A 56-year-old man who was previously healthy presented with a history of episodic pain and numbness over the left cheek for a month followed by inability to open mouth fully for a week. He also complained of left eye swelling with drooping of eyelid and reduced vision for 1 week. He initially visited a general practitioner for his pain and later consulted a neurosurgeon as his symptoms got worsened. He was treated for left trigeminal neuralgia by the neurosurgeon and then referred to us to evaluate further for his cheek pain and numbness. He did not have nasal blockage, rhinorrhoea, epistaxis, anosmia or constitutional symptoms like fever, loss of appetite and loss of weight. He did not have a previous infection with tuberculosis and could not recall any contact history. There was no history of nasal or sinus surgery. On examination, he had severe trismus with just a finger breadth of mouth opening. Perception to light touch was impaired on his left cheek at V2 (maxillary division) region. There was mild proptosis and ptosis of his left eye; however, eye movements were normal and full range. Other cranial nerve examinations were normal. There was no obvious swelling on his left cheek or facial asymmetry except for the mild proptosis and ptosis. Neck examination revealed no palpable lymph nodes. Anterior and posterior rhinoscopic examinations did not reveal any sinus pathology and other physical examinations were normal.
Blood investigation showed white blood cell (WBC) 10.9 x 103/dL, and differential counts were normal. Erythrocyte sedimentation rate (ESR) was 9 mm in the first hour. Blood for anti-HIV was non-reactive. Sputum for AFB x 3 was negative. Chest X-ray did not reveal any lung pathology. CT (computed tomography) scan of the paranasal sinuses showed soft tissue lesion in the left anterior ethmoid sinus and maxillary antrum (Figure 1) with erosions of the medial and lateral walls of the maxillary sinus.
The lesion was extending into the inferomedial aspect of the left orbit displacing the orbit anteriorly (Figure 2). Malignancy in the maxillary antrum involving the anterior ethmoid and orbit was our initial impression.
Endoscopic left medial maxillectomy and anterior ethmoidectomy was performed which revealed soft fluffy and necrotic mass at the left maxillary antrum and ethmoidal cells with a bit of pus. The mass was cleared off and sent for histopathological examination and acid-fast bacilli. Histopathological examination was reported as necrotic tissue composed of reactive multinucleated giant cells, many of Langhan's type and aggregates of epithelioid histiocytes admixed with a predominantly chronic inflammatory infiltrate forming coalescent granuloma compatible with tuberculous granuloma (Figure 3(a)-(c)).
No AFB or fungi were detected on special stains and no malignant cells were seen. We diagnosed him as a case of tuberculous granuloma of left maxillary and ethmoid sinus involving the orbit. The patient was started on a 6-month course of standard antituberculous treatment (ATT), that is, isoniazid, rifampicin, pyrazinamide and ethambutol for 2 months in the intensive phase and isoniazid and rifampicin for 4 months in the continuation phase. His trismus improved to two fingers breath on post-operative day 3 and almost normal by 2 weeks. His left eye vision also improved from 6/30 preoperatively to 6/18 on post-operative day 7. He was doing well on follow-up at 6 months and nasal endoscopy was clear.