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ARTICLES
Year : 1979  |  Volume : 27  |  Issue : 1  |  Page : 18-20

Tuberculosis of the maxillary antrum and of the orbit


S.M.S. Medical College, Jaipur, India

Correspondence Address:
M R Jain
K-4 A, Fatehtiba, Adarsh Nagar Road, Jaipur-4
India
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Source of Support: None, Conflict of Interest: None


PMID: 500174

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How to cite this article:
Jain M R, Chundawat H S, Batra V. Tuberculosis of the maxillary antrum and of the orbit. Indian J Ophthalmol 1979;27:18-20

How to cite this URL:
Jain M R, Chundawat H S, Batra V. Tuberculosis of the maxillary antrum and of the orbit. Indian J Ophthalmol [serial online] 1979 [cited 2020 Jun 5];27:18-20. Available from: http://www.ijo.in/text.asp?1979/27/1/18/31538

Till date in the world literature only 42 cases of tuberculosis of maxillary antrum have been reported [5],[7],[8] and its orbital involve­ment has been reported only sporadically[1],[2],[4],[9]. It is reckoned by most of the workers that orbital involvement is mostly as an extension to sinus involvement and in some cases it may be secondary to some distant focus, mostly pulmonary tuberculosis or some other site like spine[3] or root of a tooth[6]. The case described below merits its reporting due to the extreme rarity of this manifestation, the classical clinical features and its successful management.


  Case Report Top


A-30 years young male presented with a gradually increasing painless swelling at the lower nasal part of the orbital region. This swelling was associated with moderate epiphora and on examination revealed a diffuse non-tender swelling of varying consistency (soft to moderately firm) located between the globe and the orbital margin and measuring about 1.5 cm. in diameter. The swelling appeared to be fixed to the floor of the orbit with freely mobile skin over it. The physio­anatomy of the lacrimal passage and the fundus picture were normal.

Investigations

Blood T L.C -4800 per cumm., D.L.C.-P.60, L.36, M.2, E.2, E.S.R. 10 mm. 1-st hour Westergren. Skiagram of the paranasal sinuses showed haziness of the right antrum. The antrum wash showed clear fluid. It was, however, not submitted for culture study. X-ray chest showed slightly enlarged hilar glands. Mantoux test was 10 mm positive­.

Management

Patient was put on broad Spectrum antibiotics and steroids for 10 days but there was no response and hence it was decided to have surgical exploration of the orbit in collaboration with E.N.T. surgeon.

An incision 2.5 cm long was given along the inferior orbital margin through the skin, subcutaneous tissue and septum orbitale and the swelling was explored. A greyish brown blood stained granulating mass was seen when the eye ball with its extraocular appendages was retracted. The mass appeared to be adherent to the floor of the orbit with no attachment to the eye ball, An attempt to remove the growth enmass failed and the growth could only be removed in multiple small friable pieces without much tendency to bleed. It was then observed that in addition to erosion of the neighbouring bone there was an opening in the floor of the orbit and the growth appeared to have an extension into the maxillary antrum.

The Caldwell-Luc operation was performed and the maxillary antrum was seen to have large extension of the growth. This growth was like a cauliflower and appeared to arise from the mucous membrane of the sinus. The growth had exactly the same characteristics as that of the orbit and an attempt was made to remove the growth as much as possible. Involvement of the bone was quite evident. The wound was closed in a routine way and the tissue from the orbit and the antrum was sent for histopathological examination.

Both specimens revealed loose granular tissue with giant cell formation and caseation. There was also infiltration by lymphocytes and plasma cells suggestive of tuberculosis.

Post-operative recovery was uneventful. Patient was put on Streptomycin 1 gm. and Isonex 100 mg. three times a day for one month and thereafter the doses were gradually reduced. Patient has been observed for six months after the surgery and he is perfectly normal. Skiagram of the sinuses has revealed no recurrence of the disease.


  Comments Top


Inspite of positive Mantoux test and enlarged hilar glands which, however, are common findings even in healthy persons in this subcontinent, the probable diagnosis of tuberculosis was only made after surgical exploration of the growth and confirmed after its histopathological examination ; this is due to the rarity of the tuberculous involvement of the antrum and more so the extreme rarity of orbital involvement. Most of the workers[6],[7],[9] think that tuberculous in­volvement of the sinuses is usually associated with pulmonary or extrapulmonary tube­rculosis which reaches the maxillary sinus by way of blood stream or by direct extension into the sinuses. The same theory holds good for the orbital involvement.

It is very difficult to make definite com­ment as to whether the case described above had first involvement of the antrum or the orbit but it is presumed that antrum is involved first due to its proximity to respiratory system.

The presumption is strengthened by the observation of Sinha[9], where he found that maxillary tuberculosis leads to erosion of the floor of the orbit leading to development of a diffuse soft, non-tender swelling below the eye over the fronto-nasal process of the maxilla.

Mainly two types of tuberculous lesions of the antrum have been described. First type occurs less frequently and in this, there is an infection of the mucosa where the antrum is filled with a polypoidal thickened mucosa which presents boggy and pale appearance. The other type which has a tendency to spread shows bony erosion, fistula formation and caseation. Both types have tendency to be symptom free till the lesion is very much advanced. In cases with orbital involvement the only symptom may be epiphora and vision may be affected when the condition is very much advanced. The case described had all the features of second type and it is reck­oned that if such a growth is not diagnosed and treated in time, the patient may die of meningitis.

It is suggested that in hazy antrum cases even with clear lavage saline, the saline must be submitted for culture and guinea pig inno­culation studies to exclude tuberculosis of the antrum. Further any growth on the floor of the orbit with soft to firm consistency and leading to erosion and fistula formation in the bone should be suspected as tuberculous and not cancerous, since fistula formation is not a common feature of cancerous lesion[6].


  Summary Top


A case of tuberculous lesion of the maxill­ary antrurn and the orbit in a 30 years male is described. The growth was removed at one sitting by orbitotomy and Caldwell-Luc operation and diagnosed by histopathological examination. The recurrence was successfully checked by antitubercular treatment.

 
  References Top

1.
Abrol, B.M., 1970, Proc. All India Ophthal. Soc., 31, 67.  Back to cited text no. 1
    
2.
Duke Elder, S., 1954, Text Book of Ophthal., Henry Kimpton, London. 5, 5458.  Back to cited text no. 2
    
3.
Hara, H.J. and Crane, W.E., 1948, Annals of Otology, Rhinology and Laryngology, 57, 1077.  Back to cited text no. 3
    
4.
Hogan, M.J. and Zimmerman, L.E., 1962, Ophthalmic Pathology. 2nd Ed. W.B. Saunders Co. London. 728.  Back to cited text no. 4
    
5.
Kukreja, H.K., Sacha, B.S. and Joshi, K.C., 1977, Ind. Jour. of Otolary., 29, 27.  Back to cited text no. 5
    
6.
Myerson, M.C., 1944, Tuberculosis of the Ear, Nose and Throat, Charles, Co., Thomas Maryland, 197.  Back to cited text no. 6
    
7.
Page, J.R. and Jash. D.K., 1974, Jour. of Laryn. and Otology, 88, 579.  Back to cited text no. 7
    
8.
Shukla, G.K., Dayal, D. and Chandra, D.K., 1972, Jour. of Laryn. and Otology, 86, 747.  Back to cited text no. 8
    
9.
Sinha, S.N., 1969, The Eye, Ear, Nose and Throat monthly, 48, 289.  Back to cited text no. 9
    



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