INTERNATIONAL JOURNAL OF LEPROSY Volume 60, Number 3Printed in the U.S.A.

Maxillary Antrum Involvement in MultibacillaryLeprosy: A Radiologic, Sinuscopic, and

Histologic Assessment'Cecilia Z. Hauhnar, S. B. S. Mann, Vinod K. Sharma,

Surrinder Kaur, S. Mehta, and B. D. Radotra 2

Leprosy primarily affects the peripheralnerves and skin. The other tissues affectedare the mucous membrane of the upper re-spiratory tract, the anterior chamber of theeye and the testis, especially in the multi-bacillary forms of the disease. Involvementof the upper respiratory tract has been welldocumented in various autopsy series ( 8 .1and during life ( 5). Leprosy affects the mu-cosa of the nose, nasopharynx, and larynx.Leprous infiltration of the mucosa is char-acterized by the accumulation of histiocytescontaining large numbers of leprosy bacilli.

Inadequate and ill-planned studies havebeen carried out regarding the involvementof the paranasal sinuses in leprosy. A de-tailed study of this aspect of leprosy is im-portant since involvement of the paranasalsinuses may act as a reservoir of infection,as is known to occur in other forms of rhi-nitis, and this is of immense epidemiolog-ical importance. Involvement of the para-nasal sinuses and the ensuing destructioncontributes to unsightly deformities of thenose and part of the face in leprosy leadingto social stigma and is important from arehabilitation point of view. The presentstudy was undertaken to ascertain involve-ment of the maxillary antrum in multiba-cillary leprosy by radiology, sinuscopy andhistology, and to correlate the clinical, ra-

' Received for publication on 20 March 1992; ac-cepted for publication on 8 May 1992.

= C. Z. Hauhnar, M.S., Senior Resident; S. B. S. Mann,M.S., M.N.A.M.S., Additional Professor; S. Mehta,M.S., Dip. N.B.E., Pool Officer, Department of Oto-rhinolaryngology; V. K. Sharma, M.D., Assistant Pro-fessor; S. Kaur, M.D., F.A.M.S., Professor and Head,Department of Dermatology; B. S. Radotra, M.D., As-sistant Professor, Department of Pathology, Postgrad-uate Institute of Medical Education and Research,Chandigarh 160012, India.

Reprint requests to Dr. Sharma.

diological and histological findings with di-rect sinuscopy.

MATERIALS AND METHODSSeventy consecutive lepromatous leprosy

patients attending the Leprosy Clinic of theDepartment of Dermatology attached to theNehru Hospital, Postgraduate Institute ofMedical Education and Research, Chandi-garh, India, were recruited for this study.Diagnosis was based on clinical examina-tion, slit-skin smear for Mycobacterium lep-rae from six sites, and a skin biopsy. TheRidley-Jopling classification ( 10) of leprosywas followed.

All patients had X-rays of the paranasalsinuses (Water's view) to look for involve-ment of the maxillary antrum in the formof haziness, fluid level, or thickened antralmucosa. Thirty patients with radiologicalabnormalities were subjected to completeotorhinolaryngological examination andmaxillary antrum sinuscopy after obtaininginformed consent.

The maxillary antrum was approached bythe canine fossa route. The procedure wasperformed with the patient in a semirecum-bent position. A biopsy was taken from themaxillary sinus mucosa by sinus endoscopy.The sinuscopic examination was performedusing 70° and 30° Storz sinuscopes. The bi-opsy was taken from apparently abnormalmucosa showing ulceration, nodularity, andgranuloma. The biopsy material was sub-jected to histopathological examination fol-lowing hematoxylin and eosin (H&E) andZiehl-Neelsen (ZN) staining for acid-factbacilli (AFB).

RESULTSThe present report is confined to data from

30 patients with radiological abnormality inthe maxillary antrum who were subjected

390

FIG. 1. Right side localized opacity of maxillaryantrum. FIG. 2. Bilateral haziness of maxillary antra.

60, 3^Ilauhnar, et al.: Maxillary Antrum in MB Leprosy^391

TABLE 1. Nasal cavityjindings in 30 mul-tibacillary leprosy patients.

Findings No. pa-tients

Per-centage

Musocal oedema 11 36.7Mucosal infiltration 15 50.0Mucosal ulceration 18 60.0Perforation of septum 6 20.0Atrophy of inferior turbinate 15 50.0Normal mucosa 5 16.7

to sinus endoscopy and histopathology; 22(73.3%) males, 8 (26.7%) females. All of thepatients had lepromatous leprosy (LL) witha mean bacterial index (BI) of 4+ and amorphological index (MI) of 4%. At the timeof recruitment into the study, the symptomswere of 2-3 years' duration; most patients(50%) had symptoms of more than 3 years'duration. The commonest nasal complaintwas crusting in 23 patients (76.7%) followedby obstruction in 16 patients (53.5%), epi-staxis in 12 patients (40%), and anosmia in11 (36.7%) patients.

Twenty patients (66.7%) had external na-sal pyramid deformity. The nasal cavityfindings are summarized in Table 1. The

TABLE 2. Radiological observation ofmaxillary antrum in multibacillary leprosypatients.

Observation No. si-nuses

Per-centage

Diffuse opacity 14 33.3Localized mucosal thickening 12 28.6Generalized mucosal thickening 16 38.1Total 42 100.0

commonest finding was mucosal ulcerationin 18 (60%) patients. Septal perforation waspresent in 6 (20%) patients.

Eighteen patients (60%) had unilateral ra-diological involvement of the maxillary an-trum, while 12 patients (40%) had bilateralinvolvement. The most common radiolog-ical change was mucosal thickening in 28(66.7%) patients (Fig. 1) followed by diffuseopacity in 14 (33.3%) patients (Fig. 2). Themucosal thickening was localized in 12(28.6%) patients, and generalized in 16(38.1%) patients (Table 2).

Sinus endoscopy showed inflamed mu-cosa in 40%, frank mucosa ulceration in26.7%, and granular mucosa in 10% of thepatients. However, in 23.3% the mucosa was

392^ International Journal of Leprosy^ 1992

FIG. 3. Appearance of antral mucosa at maxillarysinuscopy. A = normal mucosa; B = granular mucosa;C = mucosal ulceration.

normal (Fig. 3 A, B, C). The biopsy materialshowed involvement of the antral mucosain 21 patient (70%), with diffuse infiltrationof mucosa by foam cells and AFB (Fig. 4).Similar changes were seen in the nasal bi-opsies in 90% of the patients. There wasclose correlation in the sinuscopic obser-vations of antral mucosa and histopatho-logical findings (Table 3).

Good correlation was seen in sinuscopicabnormalities and external nasal deformity.

TABLE 3. Correlation between the sinu-scopic findings and histopathological in-volvement of antral mucosa in multibacil-lary leprosy patients."

11 istopathologySinuscopic findingof antral mucosa No. patients

volved in-volved

Normal 7 (23.1%) 7Inflamed mucosa 12 (40.0%) 10 _2Ulcerated mucosa 8 (26.7%) 8 —Granulomatousmucosa 3 (10.0%) 3 —

Total 30 (100%) 21 9

x 2 value fbr: normal vs inflamed mucosa = 12.186,p < 0.01: normal vs ulcerated mucosa = 14,961,p < 0.01; normal vs gran ulomatous mucosa = 10.000,p < 0.01.

All patients with evidence of granuloma inthe sinus had nasal deformity (p < 0.05)(Table 4).

Patients having an average BI above 3+invariably had sinuscopic involvement ofthe antral mucosa (Table 5).

DISCUSSIONInvolvement ofthe upper respiratory tract

in multibacillary leprosy is well known.Leprosy affects the mucosa of the nose, tur-binates, nasopharynx, and larynx ( 12 ). AFBhave occasionally been demonstrated frombronchial secretions and involvement of thebuccal mucosa, palate, tongue, and gumshas been demonstrated ( 5 . 6 ). Involvementof the paranasal sinuses, especially the max-illary antrum, is expected because of its con-tinuity with the nasal mucosa, but this hasbeen scantily documented (4. I I. 12) .

TABLE 4. Correlation between sinuscopyand external nasal pyramid deformity inmultibacillary leprosy patients."

Nasaldeformity Nor- Inflam- Ulcer- Granu- Total

mal oration ation^loma

Present^2^8^7^3^20Absent^5^4^1^—^10Total^

7^12^8^3^30

x 2 = 5979, p < 0.05.

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60, 3^Hauhnar, et al.: Maxillary Antrum in MB Leprosy^393

FIG. 4. Photomicrographs of antral mucosa showing (A) macrophage granuloma (1-1&E x 100) with (B) acid-fast bacilli (Fite-Faraco x 1000).

In our study, a male preponderance(73.3%) (22) over female patients (26.7%)(8) was noted. Miller ( 7) also reported sim-ilar findings (male : female ratio = 2:1).

Around three fourths (86.7%) of our pa-tients were between the ages of 20 and 40years (13.3% of our patients were in theirtwenties). Soni ('') also reported similarfindings. Miller (') found 20% of his casesoccurring in children under 10 years of age.

Mucosal ulceration was the most com-mon finding (60%) in the nasal cavity, fol-lowed by mucosal infiltration (50%), andmucosal edema (36.7%). Atrophic changeswere seen in 50% of the patients; septal per-foration was noted in 20%. Normal mucosawas found in 16.7% of the cases. Barton (' - 2 )found that over 95% of the patients withlepromatous leprosy have involvement ofthe nasal mucosa, and all of the featuresnoted in the present study have been doc-umented by him.

Soni ("), in a radiological study of theparanasal sinuses in lepromatous leprosy,showed that 18 (60%) out of 30 patients hadinvolvement of the maxillary sinus of which7 (38.9%) were bilateral and 11 (61.1 %) were

unilateral. However, Barton ( 3), in a studyof 16 patients with untreated lepromatousleprosy, found radiological abnormality in100% of the cases.

We found that mucosal thickening wasthe commonest radiological abnormality(66.7%) with 16 sinuses showing general-ized mucosal thickening and 12 othersshowing localized mucosal thickening in the

TABLE 5. Correlation between sinuscopyand nasal bacterial index (131) in multiba-ciliary leprosy."

Sinuscopic findings131^Nor- Inflam- Ulcer- Granu- Total

mal^mation ation^loma

1+2+3+^4^I^

54+^7^1

^10

5+^1^4^5^10

6+^ 3^

3^

5Total^

7^12^8^

3^30

X' for 3+ vs 4+ = 5.000, p < 0.05; x 7 for 3+ vs5+ = 7.325, p < 0.01; x 7 for 3+ vs 6+ = 6.667, p <0.01.

394^ International Journal of Leprosy^ 1992

form of patchy opacity. Diffuse opacity wasobserved in the remaining sinuses (33.3%).Barton and McDougall (4) also reported mu-cosal thickening of the maxillary antrum asthe most constant radiological abnormality.

Maxillary sinuscopy revealed inflamedmucosa to be the most common abnor-mality (40%), while in 26.7% the mucosashowed ulceration and in 10% the mucosawas granulomatous. Normal mucosa wasencountered in 7 cases (23.3%). Soni (n), inan antroscopic study of the maxillary an-trum in 12 lepromatous leprosy patients,observed similar findings.

The mucosa biopsies at sinuscopy sub-jected to histopathological examination werepositive for AFB in 21 cases (70%) in thepresent study, while in the remaining 9 (30%)patients sinus mucosa biopsies were nega-tive for AFB and granuloma. Soni ( 12 ) per-formed sinus mucosal biopsy at antroscopyonly in patients whose mucosa was visiblyabnormal and found a positive biopsy in allnine cases. Barton ( 3) performed sinus mu-cosal biopsy in two patients and found his-topathological involvement with AFB.

We noted that 66.6% (20) of the patientshad a deformed external nasal pyramid;whereas Barton ( 2) observed nasal defor-mity in 47.4% of the patients in his series.The presence of clinical nasal deformity wasassociated with a significant chance of en-countering abnormal sinus mucosa [90% inpatients with nasal deformity as comparedto 50% in those with external nasal defor-mity (p < 0.05)].

The nasal mucous membrane is involvedin over 95% of lepromatous leprosy pa-tients. In view of such high incidence as-sociated with a highly infectious discharge,there is an increased possibility of the spreadof leprosy from the maxillary antrum withthe maxillary sinuses being frequently af-fected (70% in the present study). The sur-face area of the antral mucous membraneis estimated to be between 67 and 200 sq.cm . (4) and a constant flow of secretion maycontribute significantly to the shedding ofMycobacterium leprae into the nose andthence into the environment. The involve-ment of paranasal sinuses in leprosy pa-tients may take a long time to respond toantileprosy therapy, and a constant re-in-fection of the nose from the maxillary an-trum may occur. It would be interesting to

further observe the paranasal sinuses andnoses of those patients in our present studyafter completion of their antileprosy treat-ment.

SUMMARYThirty patients having lepromatous lep-

rosy (22 males, 8 females) and showing ra-diological involvement of the maxillary an-trum were subjected to sinuscopy, biopsy,and histopathological examination. Radio-logical observations showed diffuse opacityin 33.3% of the sinuses, localized mucosalthickening in 28.6%, and generalized thick-ened mucosa in 38.1%. Sinuscopy revealedinflamed mucosa as the most common find-ing (40%), followed by ulcerative (26.7%)and granulomatous (10%) lesions of the mu-cosal lining. The mucosal thickening (lo-calized or generalized) evident on radiologywas always associated with granuloma for-mation and acid-fast bacilli in the histology.The presence of an external nasal deformityindicated a statistically significant chance ofencountering mucosal involvement on sin-uscopy and histopathology (p < 0.05). Therewas more chance of finding positive sinus-copic lesions in those patients with a bac-terial index above 3+.

RESUMENTreinta pacientes con lepra lepromatosa (22 hom-

bres y 8 mujeres) que mostraron alteraciones radio-letgicas del antrum maxilar, se sometieron a senoscopia,biopsia y examen histopatholevico. Las observacionesradiolOgicas mostraron opacidad di fusa en el 33.3% delos senos, engrosamiento mucosal localizado en el28.6%, y engrosamiento mucosal generalizado en el38.1%. La senoscopia revele) una mucosa in flamada enel 40% de los casos, lesiones ulcerativas en mucosa enel 26.7%, y lesiones granulomatosas en cl 10%. El en-grosamiento mucosal, localizado o generalizado, evi-dente por radiologia, estuvo siempre asociado con Iaformaciem de granulomas y la presencia de bacilos aci-do resistentes en Ia histologia. La presencia de algunadeformaciem nasal externa indicO una probabilidad es-tadisticamente significativa de encontrar alteracionesmucosales en Ia senoscopia y en la histopatologia (p <0.05). Hubieron mas probabilidades de encontrar le-siones senoscopicas en aquellos pacientes con un indicebacteriano mayor de 3+.

RESUME

Trente patients presentant une lêpre lepromateuse(22 hommes et 8 femmes) et montrant une atteinteradiologique do l'antre maxillaire ont subi une sinus-copie, one biopsie, et un examen histopathologique.

60, 3^Ilaithnar, ct al.: Maxillary Antrum in MB Leprosy^395

Les observations radiologiques ont montre une opacitediffuse dans 33.3% des sinus, un epaississement localisede Ia muqueuse dans 28.6%, et un epaississement ge-neralise de la muqueuse dans 38.1%. La sinuscopie amontre une inflammation de Ia muqueuse comme ob-servation la plus frequence (40%), suivie par des lesionsulcercuses (26.7%), Cl granulomateuses (10%) du re-vetement muqueux. L'epaississement muqueux (lo-calise ou generalise) evident ft la radiologie emit tou-jours associe a une formation granulomateuse et desbacilles acido-resistants d l'histologie. La presence (runedeformation nasals externe indiquait une probabilitestatistiquenient significative de rencontrer un envahis-sement muqueux la sinuscopie et ft l'histopathologie(p < 0.05). II y avail plus de chances de trouver deslesions sinuscopiques positives chci les patients pre-sent un index bacterien superieur ft 3+.

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