|Year : 2014 | Volume
| Issue : 1 | Page : 50-52
Primary nasal tuberculosis following blunt trauma nose
Kaushik Saha, Mrinmoy Mitra, Arnab Saha, Pratik Barma
Department of Pulmonary Medicine, Burdwan Medical College, Burdwan, West Bengal, India
|Date of Web Publication||10-Dec-2013|
Rabindra Pally, 1st Lane, P.O. - Nimta, Kolkata - 700 049, West Bengal
Source of Support: None, Conflict of Interest: None
Primary nasal tuberculosis is a rare disease with nearly 40 cases reported. Our patient was a young male presented with left sided nasal obstruction, anosmia and occasional epistaxis for last 7 weeks after 6 months of blunt trauma nose. Contrast enhanced computed tomography of the para nasal sinuses showed increased soft-tissue density with contrast enhancement in the left maxillary antrum with extension through left osteomeatal foramen to the left nasal cavity along with further extension through choana to nasopharynx resulting in partial obliteration of the nasopharyngeal airway. Nasal endoscopy revealed a sessile polypoidal pinkish mass arising from the left osteomeatal foramen. Histopathological examination of excisional biopsy of that area showed caseating granuloma. Our patient diagnosed as primary nasal tuberculosis following trauma and treated with anti-tubercular chemotherapy.
Keywords: Nasal tuberculosis, primary, trauma
|How to cite this article:|
Saha K, Mitra M, Saha A, Barma P. Primary nasal tuberculosis following blunt trauma nose. Med J DY Patil Univ 2014;7:50-2
| Introduction|| |
Tuberculosis can involve almost every organ in the body and it manifests itself in various forms. Tuberculosis of nose, nasopharynx and para nasal sinuses is extremely rare even in countries where the incidence of tuberculosis is very high.  Nasal tuberculosis remains silent and asymptomatic until advanced. It can occur as primary or secondary either to pulmonary tuberculosis or to lupus vulgaris of facial skin. Primary nasal tuberculosis is very rare with only 40 cases reported world-wide until date.  In this article, we report a new case of primary nasal tuberculosis in the light of relevant literature. Patient's consent had been taken for publishing the case.
| Case Report|| |
A 26-year-old immunocompetent male patient presented with left sided nasal obstruction, anosmia and occasional epistaxis for last 7 weeks. He had a history of blunt trauma of his nose followed by bleeding 6 month before. A nasal pack was given inside the left side of his nasal cavity at that time and it remained for 2 days. Examination of external nose revealed a polypoidal lesion in the medial side of the left nasal cavity almost obliterating it [Figure 1]. His general condition and systemic examination was normal. His erythrocyte sedimentation rate was 30 mm/h by Westergren's method (normal: <15 mm/h). Renal and liver function tests were normal. His two consecutive sputum smear were negative for acid-fast bacilli, as were subsequent cultures. X-ray of the para nasal sinuses showed increased soft-tissue density and mucosal thickening in left maxillary antrum [Figure 2]a. The contrast enhanced computed tomography of the para nasal sinuses showed increased soft-tissue density with contrast enhancement in the left maxillary antrum with extension through left osteomeatal foramen to the left nasal cavity along with further extension through choana to nasopharynx resulting in partial obliteration of the nasopharyngeal airway [Figure 2]b. The bony wall was appeared to be normal. Findings of the chest X-ray were normal. Nasal endoscopy also revealed that a sessile polypoidal pinkish mass arising from the left osteomeatal foramen that extended to the left nasal cavity in the anterior aspect and it had also further extension through choana to the nasopharynx in the posterior portion. The lesion was not friable or bleeding. It was also non-compressible and non-pulsatile. The mucosa over the septum and adjacent mucosa over the turbinate was thickened and inflamed. The lesion was endoscopically biopsied under local anesthesia and the specimen was sent for histopathological and microbiological examination. Histopathological examination performed from the lesion showed caseating epithelioid granuloma with the presence of Langhans giant cell [Figure 3]. Tissue section was negative for Ziehl-Neelsen staining for acid fast bacilli as well as 10% KOH staining for fungus. These findings suggested a diagnosis of tuberculosis and as no other focus of the disease was identified, a diagnosis of primary nasal tuberculosis was established. In accordance with Revised National Tuberculosis Control Program of India the patient was put on anti-tubercular medication with alternate day regimen consisting of isoniazid 600 mg, rifampicin 450 mg, ethambutol 1200 mg and pyrazinamide 1500 mg for 2 months followed by isoniazid 600 mg and rifampicin 450 mg for 4 months.  Patient underwent regular follow-up including nasal endoscopy and presently he remains disease-free at 10 months follow-up.
|Figure 1: External nose examination showing a polypoidal lesion in medial side of the left nasal cavity almost obliterating it|
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|Figure 2: X-ray of the para nasal sinuses showing increased soft-tissue density and mucosal thickening in left maxillary antrum (a) and contrast enhanced computed tomography of the para nasal sinuses showing increased soft-tissue density with contrast enhancement in the left maxillary antrum with extension through left osteomeatal foramen to the left nasal cavity along with further extension through choana to nasopharynx resulting in partial obliteration of the nasopharyngeal airway (b)|
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|Figure 3: Histopathological examination of the polypoidal mass from the left nasal cavity showing caseating epithelioid granuloma with presence of Langhans giant cell suggestive of tuberculosis|
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| Discussion|| |
In general, extra pulmonary tuberculosis occurs in 15% of all tuberculosis patients. However for last two decades, the incidence of extra pulmonary tuberculosis is gradually increasing due to human immunodeficiency virus co-infection.  Despite the increase in extra pulmonary tuberculosis, nasal tuberculosis is extremely rare.  The first case of nasal tuberculosis was reported in 1761 by Giovanni Morgani.  Nasal tuberculosis occurs either secondary to pulmonary tuberculosis or primary, that is no prior evidence of pulmonary tuberculosis. The rarity of the disease is due to protective nasal ciliary movement, bactericidal action of nasal secretions and inherent resistant of the nasal mucosa to mycobacterial growth.  Primary disease is caused by either inhalation of infected particles or traumatic inoculation. Traumatic lodgments of bacilli over the nasal mucosa make it susceptible to tuberculosis as the protective mechanism of mucosa and cilia is breeched. In our case, there was a history of trauma over the nose followed by nasal packing 6 months before. Nasal tuberculosis commonly occurs in females and the median age of occurrence is mid 40 years. Our case was a male and he was below the average median age. Nasal tuberculosis is usually unilateral as in our case, but in one-third cases it is bilateral.  The lesion can be proliferative, infiltrative or ulcerative.  In our case, the disease is proliferative. The most common presenting symptom of the disease is nasal obstruction that is followed by nasal discharge, nasal discomfort, epistaxis, crusting, eye watering, postnasal discharge, recurrent nasal polyps and ulceration.  Our case had the presenting symptoms of nasal obstruction, anosmia and epistaxis. Nasal endoscopy has an important role in diagnosis of the disease as it helps in thorough examination of the nasal cavity and also facilitates tissue sampling from suspected areas.  Differential diagnosis includes Wegner's granulomatosis, sarcoidosis, fungal infection, leprosy, foreign bodies, carcinoma, NK-T cell lymphoma, midline malignant reticuloma. Definite diagnosis of nasal tuberculosis is made by isolating Mycobacterium tuberculosis from that site as in other extra pulmonary tuberculosis. In our case, we failed to demonstrate bacilli in the lesion. However, the typical caseating epithelioid granuloma with Langhans' giant cell in the lesion and the patient's response to the treatment clearly indicate the disease. Anti-tubercular therapy is the mainstay of treatment. In our case, the patient completed anti-tubercular treatment and he was symptomatically improved and the size of the lesion also decreased.
| Conclusion|| |
We believe that though nasal tuberculosis is a rare clinical entity, it should be considered as one of the differential diagnosis of patients with granulomatous lesion of the nose. High degree of suspicion is the key to diagnose the disease. The disease can be managed effectively with proper combination of anti-tubercular drugs.
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[Figure 1], [Figure 2], [Figure 3]