Para-Nasal Sinus Tuberculosis

Topic Name Introduction Clinical Features Anatomical Considerations Diagnosis Differential Diagnosis Management Complications Special Cases

Introduction

Paranasal sinus tuberculosis is a rare form of extrapulmonary tuberculosis affecting the sinonasal tract. It represents approximately 1% of all extrapulmonary TB cases in children. Understanding its presentation and management is crucial due to its proximity to vital structures.

Key Points

• Prevalence: Rare in immunocompetent children
• Age distribution: Most common in school-age children
• Primary involvement: Maxillary sinus (60%), followed by ethmoid sinus
• Association with pulmonary TB: Present in 40-50% cases

Pathophysiology

• Routes of Infection:
  • Direct inoculation through nasal mucosa
  • Hematogenous spread
  • Contiguous spread from adjacent structures
  • Lymphatic spread
• Tissue Response:
  • Mucosal inflammation
  • Granuloma formation
  • Caseous necrosis
  • Bone erosion in chronic cases

Clinical Features

Early Manifestations

• Nasal Symptoms:
  • Nasal obstruction (90% cases)
  • Rhinorrhea
  • Epistaxis
  • Hyposmia
• Sinus Symptoms:
  • Facial pain or pressure
  • Postnasal drip
  • Chronic sinusitis
• Constitutional Symptoms:
  • Low-grade fever
  • Weight loss
  • Night sweats
  • Fatigue

Advanced Manifestations

• Local Signs:
  • Facial swelling
  • Nasal deformity
  • Palatal perforation
  • Orbital complications
• Examination Findings:
  • Mucosal hypertrophy
  • Granulation tissue
  • Crusting
  • Polyp formation

Anatomical Considerations

Sinus Involvement Patterns

• Maxillary Sinus:
  • Most commonly affected
  • Presents with cheek pain
  • Risk of oral-antral fistula
• Ethmoid Sinus:
  • Second most common
  • Risk of orbital complications
  • Association with skull base involvement
• Frontal Sinus:
  • Less commonly affected
  • Risk of intracranial spread
  • Presents with frontal headache
• Sphenoid Sinus:
  • Rarest involvement
  • Risk of cavernous sinus thrombosis
  • Complex surgical access

Diagnosis

Clinical Assessment

• History Taking:
  • Duration of symptoms
  • Pattern of progression
  • TB contact history
  • Previous treatments
• Physical Examination:
  • Anterior rhinoscopy
  • Nasal endoscopy
  • Facial inspection and palpation
  • Cervical lymph node examination

Laboratory Investigations

• Basic Tests:
  • Complete blood count
  • ESR and CRP
  • Mantoux test
  • IGRA testing
• Microbiological Studies:
  • Nasal swab for AFB
  • Culture from tissue biopsy
  • GeneXpert MTB/RIF
  • PCR for MTB DNA
• Histopathological Examination:
  • Granulomas
  • Caseous necrosis
  • Langhan's giant cells
  • Epithelioid cells

Imaging Studies

• CT Scan:
  • Primary imaging modality
  • Shows bone erosion
  • Identifies extent of disease
  • Guides surgical planning
• MRI:
  • Soft tissue delineation
  • Intracranial extension
  • Orbital involvement
  • Differentiation from malignancy

Differential Diagnosis

• Infectious Conditions:
  • Chronic bacterial sinusitis
  • Fungal sinusitis
  • Atypical mycobacteria
  • Wegener's granulomatosis
• Neoplastic Conditions:
  • Sinonasal tumors
  • Lymphoma
  • Rhabdomyosarcoma
• Inflammatory Conditions:
  • Sarcoidosis
  • Allergic fungal sinusitis
  • Rhinoscleroma

Management

Medical Management

• Anti-tubercular Therapy:
  • Intensive Phase (2-3 months):
    • Isoniazid (10 mg/kg)
    • Rifampicin (15 mg/kg)
    • Pyrazinamide (35 mg/kg)
    • Ethambutol (20 mg/kg)
  • Continuation Phase (4-7 months):
    • Isoniazid
    • Rifampicin
• Supportive Treatment:
  • Nasal decongestants
  • Saline nasal irrigation
  • Pain management
  • Nutritional support

Surgical Management

• Indications:
  • Diagnostic biopsy
  • Extensive disease
  • Complications
  • Failed medical treatment
• Procedures:
  • Endoscopic sinus surgery
  • Debridement
  • Drainage of collections
  • Reconstruction if needed

Complications

• Local Complications:
  • Orbital involvement
  • Facial deformity
  • Chronic sinusitis
  • Osteomyelitis
• Intracranial Complications:
  • Meningitis
  • Brain abscess
  • Cavernous sinus thrombosis
• Long-term Sequelae:
  • Chronic rhinitis
  • Nasal stenosis
  • Persistent discharge
  • Cosmetic deformity

Special Cases

Immunocompromised Children

• Higher risk of dissemination
• Atypical presentation
• More aggressive disease course
• Need for prolonged therapy

Multidrug-Resistant Cases

• Need for drug sensitivity testing
• Modified treatment regimens
• Extended duration of therapy
• Close monitoring required

Follow-up Care

• Regular endoscopic examination
• Monitoring of treatment response
• Assessment for complications
• Long-term surveillance

Disclaimer

The notes provided on Pediatime are generated from online resources and AI sources and have been carefully checked for accuracy. However, these notes are not intended to replace standard textbooks. They are designed to serve as a quick review and revision tool for medical students and professionals, and to aid in theory exam preparation. For comprehensive learning, please refer to recommended textbooks and guidelines.