A 50-year-old patient reported to the hospital outpatient department with a complaint of swelling of the face and painful, mobile upper right posterior teeth for 3 weeks. The patient is from a lower socioeconomic background and works with the local law enforcement unit. He further gave a history of Type II Diabetes and in under medication. On examination, a diffuse swelling was present over the right periorbital area, infraorbital region extending up to the upper lip and right alar margin and posteriorly up to the right tragus of the ear [Figure 1]. The facial/extraoral tissues were indurated on palpation with fluctuation elicited in the right maxillary buccal sulcus in the region of the right maxillary molars. The right maxillary second and third molars were tender and intraoral periapical radiograph revealed destructive periodontitis with an abscess. A provisional diagnosis of the right buccal and canine space infection secondary to periodontitis/apical infection involving the maxillary molars was made. The patient had a history of Type II diabetes with fluctuating glycemic control in spite of medication. The patient was then advised admission, and routine hematological investigations were carried out, with the administration of empirical antibiotics. An incision and drainage through a buccal sulcus approach and extraction of the mobile maxillary second and third molars was planned and performed under local anesthesia. Scanty purulent pus was drained and sent for culture and sensitivity testing which yielded negative growth after 72 h.
The patient was discharged on the third postoperative day with relief from pain and mild resolution of the facial swelling and was advised to continue the course of antibiotics for 1 week. On follow-up after a week, the extraction and incision sites were healing well however, the extraoral facial swelling persisted, and the patient complained of postnasal discharge and blockade of the right nasal passage and pain in the Paranasal sinus on the right side. An orthopantomograph done at this time revealed a hazy right maxillary sinus suggestive of chronic inflammatory right maxillary sinusitis. Diagnostic magnetic resonance imaging (MRI) was performed to determine the source and extent of the persistent facial soft-tissue swelling, which revealed mucosal thickening with polyposis involving the right maxillary, frontal, ethmoidal and sphenoidal sinuses with destruction of anterior and posterior walls of the right maxillary sinus and the hard palate, with involvement of the right orbit, infratemporal fossa and superior orbital fissure [Figures 2-4].
A differential diagnosis of a fungal infection or malignancy involving the right maxillary sinus was made. A PPD Mantoux test was positive. Through a diagnostic transnasal endoscopic approach, the right maxillary sinus was viewed which revealed a brownish granular mass [Figure 5]. A biopsy specimen was obtained through the endoscopic approach and was sent for histopathological evaluation which revealed stroma containing numerous granulomas composed of epithelioid histiocytes and Langhan's giant cells surrounded by lymphocytes and plasma cells with areas of caseation necrosis being seen, that confirmed the diagnosis of tubercular involvement of the right maxillary sinus. Further, Ziehl-Neelsen, AB-PAS and Grocott's special staining were carried out to diagnose tuberculosis and rule out fungi infection [Figures 6 and 7]. A routine posterior-anterior view chest radiograph was taken which showed no evidence of pulmonary involvement leading to the inference that with the presenting features and histopathological examination, the Maxillary sinus could be the primary site of involvement.
The patient was then started on standard anti-tuberculosis treatment with drug combinations of rifampicin, pyrazinamide, ethambutol, isoniazid and streptomycin (adapted from the WHO regimes). The patient was reviewed after 1 month when there was the total resolution of the facial swelling, clearance of the nasal blockage and absence of any postnasal discharge.