The Journal of Laryngology and Otology June 1979. Vol. 93, pp. 597-600.
Radiological changes in the paranasal sinuses in lepromatous leprosy By R. P. E. BARTON
Introduction
THE nasal mucous membrane in untreated lepromatous leprosy is involved in a chronic granulomatous process caused by Mycobacterium leprae; over 95 per cent of patients are affected, and the symptoms, clinical signs and pathology of leprous rhinitis have been reported previously (Barton et al, 1973; Barton, 1974, 1975, 1976). However, there has been little investigation of the paranasal sinuses in leprosy, and the classical radiological and osteological studies of Moller-Christensen (1952, 1961) were confined to the bony nasal skeleton. In view of the high incidence of nasal involvement in lepromatous leprosy and the production of a highly infectious discharge from the nasal mucosa, it seemed pertinent to investigate the paranasal sinuses whose lining greatly increases the surface area of mucous membrane in the upper respiratory tract. Material and Methods
At Victoria Hospital, Dichpalli, South India, 16 patients previously untreated and attending for the first time were diagnosed, clinically and bacteriologically, as having lepromatous leprosy. Nasal involvement was confirmed in all patients by anterior rhinoscopy. Microscopy of a stained specimen of the nasal discharge was positive for M. leprae in 14/16 patients. Sinus radiographs were taken of all 16 patients in the occipito-mental (OM) and occipito-frontal (OF) projections. Control films were also taken on a patient with tuberculoid leprosy and a normal nose, as the radiographer had not previously used the available equipment for sinus radiographs. These control films showed normal sinuses. Results
All 16 patients showed radiological abnormalities, and these are summarized in Tables I, II, and III. The quality of the radiographs was generally excellent, and, in all instances where mucosal thickening was recorded, this was a definite finding. The most constant finding was mucosal thickening of the maxillary antra on the OM film (Fig. 1). All 16 (100 per cent) showed this at least unilaterally, and 14/16 (87-5 per cent) had bilateral mucosal thickening. The ethmoid and frontal sinuses were shown less well in some patients, and in 3 sets of radiographs the OF films were not of diagnostic quality. However, in addition to those with mucosal 597
598
R. P. E. BARTON TABLE I MAXILLARY SINUSES
Mucosal thickening Opaque Normal
Right
Left
14(87-5%) 0 2(12-5%)
16(100%) 0 0
TABLE II ETHMOID SINUSES
Mucosal thickening Opaque Normal Uncertain
Right
Left
7(44%) 1 (6%) 5 (31 %) 3(19%)
6(37-5%) 1 (6%) 6(37-5%) 3 (19%)
TABLE HI FRONTAL SINUSES
Right Mucosal thickening Opaque Normal Uncertain
5(31%) 2(13%) 8 (50%) 1 (6%)
Left 4(25%) 0 11 (69%) 1 (6%)
thickening of these sinuses, there appeared to be 2 patients with complete opacity of the frontal sinus and one patient with bilateral ethmoid opacity. Complete opacity was not seen in the maxillary sinuses nor was bone erosion noted in this series. Discussion A new awareness of the significance of the nasal involvement in lepromatous leprosy has arisen during the present decade. The transmission of leprosy, previously attributed to 'prolonged skin to skin contact', now appears to be dependent upon the dissemination of the highly bacilhferous nasal discharge of lepromatous leprosy by direct or indirect means (Rees, 1975). Although such matters are perhaps of more importance to the leprologist than to the ENT surgeon, the latter should certainly be aware of the nasal component of lepromatous infection. In endemic areas lepromatous leprosy is the most common cause of persistent nasal symptoms, such as obstruction, crusting or bleeding, and, with current patterns of migration and travel, patients with leprosy may present in almost any part of the world. It has been reported previously how simple clinical examination or bacteriological analysis of nasal mucus or, alternatively, scraping of the nasal mucosa will help in the diagnosis of lepromatous involvement of the
RADIOLOGICAL CHANGES IN THE PARANASAL SINUSES
599
FIG. 1 Mucosal thickening of maxillary antra in leprous sinusitis.
nasal mucosa (Barton, 1975). This present study shows that the mucosa of the paranasal sinuses, particularly the maxillary antra, is also involved in lepromatous leprosy. That this involvement is lepromatous infiltration and not merely non-specific mucosal thickening due to mechanical obstruction of the sinuses by lepromatous infiltration within the nasal cavity itself, was confirmed histologically. Biopsies of maxillary sinus mucosa from 2 patients in the series showed typical lepromatous infiltration and the presence of M. leprae. The significance of this is twofold. First, for the leprologist or bacteri-
600
R. P. E. BARTON
ologist it provides further evidence as to why the nasal discharge is the most important route of exit of M. leprae from the body, for the paranasal sinuses greatly increase the area within the upper respiratory tract from which M. leprae are discharged. Second, the presence of mucosal thickening in the sinuses of patients with chronic crusting, bleeding or obstruction of the nose—particularly if they have lived in or visited areas where leprosy is endemic—should alert the ENT surgeon to the possibility of leprosy being the cause of these symptoms. If the diagnosis is suspected, nasal mucus or a scraping of the mucous membrane of the anterior end of the inferior turbinate (Davey and Barton, 1973) should be examined for M. leprae. Sinus X-rays, while not diagnostic for leprosy, may give, therefore, additional information. Acknowledgements
My grateful thanks are due to Dr. Colin McDougall for histological reports on specimens of sinus mucosa: also to the Wellcome Trust and the Order of Charity who gave financial support. REFERENCES BARTON, R. P. E. (1974) A clinical study of the nose in lepromatous leprosy. Leprosy Review, 45, 135. BARTON, R. P. E. (1975) The importance of the nasal lesions in leprosy. Annals of the Royal College of Surgeons in England, 57, 309. BARTON, R. P. E. (1976) Clinical manifestations of lepromatous rhinitis. Annals of Otology, Rhinology and Laryngology, 85, 74. BARTON, R. P. E., DAVEY, T. F., MACDOUGALL, A. C , REES, R. J. W., and WEDDELL, A. G. M.
(1973) Clinical and histological studies of the nose in early lepromatous leprosy. 10th International Leprosy Congress, Bergen, Paper 6/47. DAVEY, T. F., and BARTON, R. P. E. (1973) Multiple nasal smears in early lepromatous leprosy. Leprosy in India, 45, 54. Reprinted Leprosy Review (1974) 45, 158. M0LLER-CHRISTENSEN, V. (1961) Bone changes in leprosy. Copenhagen. M0LLER-CHRISTENSEN, V., BAKKE, S. N., and WILSON, R. S. (1952) Changes in the anterior nasal spine and alveolar process of the maxillary bone in leprosy. International Journal of Leprosy, 20, 355. REES, R. J. W. (1975) Editorial, Leprosy Review, 46, 255. ENT Department, St. Mary's Hospital, Praed Street, London W2.
Radiological changes in the paranasal sinuses in lepromatous leprosy By R. P. E. BARTON
Introduction
THE nasal mucous membrane in untreated lepromatous leprosy is involved in a chronic granulomatous process caused by Mycobacterium leprae; over 95 per cent of patients are affected, and the symptoms, clinical signs and pathology of leprous rhinitis have been reported previously (Barton et al, 1973; Barton, 1974, 1975, 1976). However, there has been little investigation of the paranasal sinuses in leprosy, and the classical radiological and osteological studies of Moller-Christensen (1952, 1961) were confined to the bony nasal skeleton. In view of the high incidence of nasal involvement in lepromatous leprosy and the production of a highly infectious discharge from the nasal mucosa, it seemed pertinent to investigate the paranasal sinuses whose lining greatly increases the surface area of mucous membrane in the upper respiratory tract. Material and Methods
At Victoria Hospital, Dichpalli, South India, 16 patients previously untreated and attending for the first time were diagnosed, clinically and bacteriologically, as having lepromatous leprosy. Nasal involvement was confirmed in all patients by anterior rhinoscopy. Microscopy of a stained specimen of the nasal discharge was positive for M. leprae in 14/16 patients. Sinus radiographs were taken of all 16 patients in the occipito-mental (OM) and occipito-frontal (OF) projections. Control films were also taken on a patient with tuberculoid leprosy and a normal nose, as the radiographer had not previously used the available equipment for sinus radiographs. These control films showed normal sinuses. Results
All 16 patients showed radiological abnormalities, and these are summarized in Tables I, II, and III. The quality of the radiographs was generally excellent, and, in all instances where mucosal thickening was recorded, this was a definite finding. The most constant finding was mucosal thickening of the maxillary antra on the OM film (Fig. 1). All 16 (100 per cent) showed this at least unilaterally, and 14/16 (87-5 per cent) had bilateral mucosal thickening. The ethmoid and frontal sinuses were shown less well in some patients, and in 3 sets of radiographs the OF films were not of diagnostic quality. However, in addition to those with mucosal 597
598
R. P. E. BARTON TABLE I MAXILLARY SINUSES
Mucosal thickening Opaque Normal
Right
Left
14(87-5%) 0 2(12-5%)
16(100%) 0 0
TABLE II ETHMOID SINUSES
Mucosal thickening Opaque Normal Uncertain
Right
Left
7(44%) 1 (6%) 5 (31 %) 3(19%)
6(37-5%) 1 (6%) 6(37-5%) 3 (19%)
TABLE HI FRONTAL SINUSES
Right Mucosal thickening Opaque Normal Uncertain
5(31%) 2(13%) 8 (50%) 1 (6%)
Left 4(25%) 0 11 (69%) 1 (6%)
thickening of these sinuses, there appeared to be 2 patients with complete opacity of the frontal sinus and one patient with bilateral ethmoid opacity. Complete opacity was not seen in the maxillary sinuses nor was bone erosion noted in this series. Discussion A new awareness of the significance of the nasal involvement in lepromatous leprosy has arisen during the present decade. The transmission of leprosy, previously attributed to 'prolonged skin to skin contact', now appears to be dependent upon the dissemination of the highly bacilhferous nasal discharge of lepromatous leprosy by direct or indirect means (Rees, 1975). Although such matters are perhaps of more importance to the leprologist than to the ENT surgeon, the latter should certainly be aware of the nasal component of lepromatous infection. In endemic areas lepromatous leprosy is the most common cause of persistent nasal symptoms, such as obstruction, crusting or bleeding, and, with current patterns of migration and travel, patients with leprosy may present in almost any part of the world. It has been reported previously how simple clinical examination or bacteriological analysis of nasal mucus or, alternatively, scraping of the nasal mucosa will help in the diagnosis of lepromatous involvement of the
RADIOLOGICAL CHANGES IN THE PARANASAL SINUSES
599
FIG. 1 Mucosal thickening of maxillary antra in leprous sinusitis.
nasal mucosa (Barton, 1975). This present study shows that the mucosa of the paranasal sinuses, particularly the maxillary antra, is also involved in lepromatous leprosy. That this involvement is lepromatous infiltration and not merely non-specific mucosal thickening due to mechanical obstruction of the sinuses by lepromatous infiltration within the nasal cavity itself, was confirmed histologically. Biopsies of maxillary sinus mucosa from 2 patients in the series showed typical lepromatous infiltration and the presence of M. leprae. The significance of this is twofold. First, for the leprologist or bacteri-
600
R. P. E. BARTON
ologist it provides further evidence as to why the nasal discharge is the most important route of exit of M. leprae from the body, for the paranasal sinuses greatly increase the area within the upper respiratory tract from which M. leprae are discharged. Second, the presence of mucosal thickening in the sinuses of patients with chronic crusting, bleeding or obstruction of the nose—particularly if they have lived in or visited areas where leprosy is endemic—should alert the ENT surgeon to the possibility of leprosy being the cause of these symptoms. If the diagnosis is suspected, nasal mucus or a scraping of the mucous membrane of the anterior end of the inferior turbinate (Davey and Barton, 1973) should be examined for M. leprae. Sinus X-rays, while not diagnostic for leprosy, may give, therefore, additional information. Acknowledgements
My grateful thanks are due to Dr. Colin McDougall for histological reports on specimens of sinus mucosa: also to the Wellcome Trust and the Order of Charity who gave financial support. REFERENCES BARTON, R. P. E. (1974) A clinical study of the nose in lepromatous leprosy. Leprosy Review, 45, 135. BARTON, R. P. E. (1975) The importance of the nasal lesions in leprosy. Annals of the Royal College of Surgeons in England, 57, 309. BARTON, R. P. E. (1976) Clinical manifestations of lepromatous rhinitis. Annals of Otology, Rhinology and Laryngology, 85, 74. BARTON, R. P. E., DAVEY, T. F., MACDOUGALL, A. C , REES, R. J. W., and WEDDELL, A. G. M.
(1973) Clinical and histological studies of the nose in early lepromatous leprosy. 10th International Leprosy Congress, Bergen, Paper 6/47. DAVEY, T. F., and BARTON, R. P. E. (1973) Multiple nasal smears in early lepromatous leprosy. Leprosy in India, 45, 54. Reprinted Leprosy Review (1974) 45, 158. M0LLER-CHRISTENSEN, V. (1961) Bone changes in leprosy. Copenhagen. M0LLER-CHRISTENSEN, V., BAKKE, S. N., and WILSON, R. S. (1952) Changes in the anterior nasal spine and alveolar process of the maxillary bone in leprosy. International Journal of Leprosy, 20, 355. REES, R. J. W. (1975) Editorial, Leprosy Review, 46, 255. ENT Department, St. Mary's Hospital, Praed Street, London W2.
