[Primary nasal and lachrymal tuberculosis:a case report].

[Primary nasal and lachrymal tuberculosis:a case report].:

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[Primary nasal and lachrymal tuberculosis:a case report].

Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2019 Aug 07;54(8):620-621

Authors: Zhao Y, Xue K, Zhao C, Li S, Wang ZG

PMID: 31434380 [PubMed - indexed for MEDLINE]



The patient, 55 years old, was admitted to the hospital on August 7, 2015 due to "left eye tears for half a year". The patient had no obvious cause of left eye tears six months ago, occasionally purulent secretions, with intermittent nasal congestion, no nasal pain, fever, night sweats, flushing, no cough, cough, no eye pain, diplopia, vision Decline, no tinnitus, hearing loss, not taken seriously. Self-administered "levofloxacin" eye drops, no significant improvement. No history of tuberculosis. Physical examination: body temperature 36.5 °C, pulse rate 80 times / min, breathing 18 times / min, blood pressure 118 / 78 mmHg (1 mmHg = 0.133 kPa). The left eye was slightly red and swollen, the left eye was overflowing with tears, and there was a purulent discharge from the area of ​​the lacrimal sac. The nasal mucosa was pale and edematous, and no secretions were found in the nasal passages. Sinus CT: Thickened soft tissue shadows were seen around the left lacrimal sac area and bilateral maxillary sinus sinus walls (Fig. 1). Electronic nasopharyngoscopy: The left nasal mucosa is slightly rough and pale, and the surface is covered with dryness. Pathology (outpatient clinic of our hospital, July 30, 2015): squamous epithelial hyperplasia of the left inferior turbinate and nasal septum, a large number of inflammatory cell infiltration in the epithelium and epithelium, and granulomatous inflammation accompanied by a small amount of necrosis . In the outpatient department, the lacrimal passage flushed and the sac was raised in the lacrimal sac area, and the flushing liquid returned from the punctum. Admission diagnosis: dacryocystitis (left). On August 11, 2015, under general anesthesia, the endoscopic left nasal lacrimal sac ostomy was performed. During the operation, the left nasal mucosa was pale, and the purulent secretion was excreted after the lacrimal sac was cut. The lacrimal sac and the surrounding mucosa Pale and crisp. Postoperative pathology: a large number of lymphocytes infiltrated in the mucosa of the left inferior turbinate and the lacrimal ostomy, and chronic granuloma tissue was formed, and necrotic tissue was seen. Postoperative nasal glucocorticoid nasal spray, antibiotic eye drops, left eye, nasal irrigation and other treatment. The patient's left eye tears still appear intermittently. After 2.5 years, the left eye tears are aggravated, and the lacrimal passage is ineffective. He was admitted to the hospital on July 4, 2018. Electronic nasopharyngoscopy: There is a white pseudomembrane attached to the left side of the nasal septum, and no new organisms are seen in the left lower nasal passage and the middle nasal passage. Sinus CT: A small thickened soft tissue shadow was seen around the bilateral ethmoid sinus and maxillary sinus wall. There was no obvious abnormality in chest CT. Admission diagnosis: dacryocystitis (left). Endoscopic left nasal lacrimal ostomy was performed under general anesthesia. During the operation, the left inferior turbinate, nasal septum, and anterior pharyngeal mucosa were pale and edematous, and the surface was slightly rough and erosive. The left maxillary frontal mucosa was pale and edematous (Fig. 2A). The mucosa around the lacrimal sac was sticky and easy to smash. (Fig. 2B), the first operation of the lacrimal sac is open, and the mucosa in the lacrimal sac is smooth and slightly pale (Fig. 2C). Postoperative pathology: (on the left nasal lacrimal sac stoma) Chronic granulomatous inflammation was seen in the mucosal tissue with a small amount of necrosis, excluding tuberculosis (Figure 3). The patient was immediately referred to the tuberculosis hospital, tuberculin 24 h experiment (-), tuberculin 72 h experiment (+), clinical diagnosis: primary nasal lacrimal sac tuberculosis. Give rifampicin, isoniazid, ethambutol and pyrazinamide once a day, orally in the morning. One month after oral administration, the patient had no tears, and the electronic nasopharyngoscopy was repeated: the mucosa around the nasal cavity and the left lacrimal sac was smooth, and there was no erosive necrosis. Now 4 months after surgery, the electronic nasopharyngeal examination: smooth nasal mucosa, open mouth of the lacrimal sac (Figure 4).



患者女，55岁，因"左眼溢泪半年"于2015年8月7日入院。患者半年前无明显诱因出现左眼溢泪，偶有脓性分泌物，伴左侧间断性鼻塞，无鼻痛、发热、盗汗、潮红，无咳嗽、咳痰，无眼痛、复视、视力下降，无耳鸣、听力下降，未予重视。自行给予"左氧氟沙星"滴眼治疗，未见明显好转。既往无结核病史。体格检查：体温36.5 ℃，脉率80次/min，呼吸18次/min，血压118/78 mmHg（1 mmHg=0.133 kPa）。左眼睑略红肿，左眼溢泪，按压泪囊区域有脓性分泌物溢出。鼻黏膜苍白、水肿，鼻道内未见分泌物。鼻窦CT：左侧泪囊区及双侧上颌窦窦壁周围可见增厚的软组织影（图1）。电子鼻咽镜：左侧鼻黏膜略粗糙苍白，表面有干痂覆盖。病理（我院门诊，2015年7月30日）：左侧下鼻甲前端及鼻中隔鳞状上皮增生，上皮内及上皮下有大量炎性细胞浸润，并见有肉芽肿性炎，伴有少量坏死。门诊行泪道冲洗见泪囊区隆起，冲洗液自泪点返出。入院诊断：泪囊炎（左）。于2015年8月11日全身麻醉下行鼻内镜下左侧鼻腔泪囊造口术，术中见左侧鼻黏膜苍白，切开泪囊后有脓性分泌物流出，泪囊及周围黏膜苍白质脆。术后病理：左侧下鼻甲前端、泪囊造口处黏膜内见大量淋巴细胞浸润，有慢性肉芽肿组织形成，并见坏死组织。术后给予鼻用糖皮质激素喷鼻、抗生素滴眼液滴左眼、鼻腔冲洗等治疗。患者左眼溢泪症状仍间断出现，术后2.5年左眼溢泪加重，泪道冲洗无效，于2018年7月4日再次入院。电子鼻咽镜：鼻中隔左侧前份有白色伪膜附着，左侧下鼻道、中鼻道均未见新生物。鼻窦CT：双侧筛窦、上颌窦窦壁周围可见少许增厚的软组织影。胸部CT未见明显异常。入院诊断：泪囊炎（左）。再次在全身麻醉下行鼻内镜下左侧鼻腔泪囊造口术。术中见左侧下鼻甲、鼻中隔、钩突前份黏膜苍白水肿，表面略粗糙糜烂，左侧上颌骨额突处黏膜苍白水肿（图2A），泪囊口周围黏膜触之质脆、易糜烂（图2B），第一次手术泪囊口开放好，泪囊内黏膜光滑略苍白（图2C）。术后病理：（左侧鼻腔泪囊造口处）黏膜组织内见慢性肉芽肿性炎，带少量坏死，不除外结核（图3）。患者立即就诊于结核医院，结核菌素24 h实验（-），结核菌素72 h实验（+），临床确诊：原发性鼻腔泪囊结核。给予利福平、异烟肼、乙胺丁醇及吡嗪酰胺，1次/d，晨起口服。口服药物1个月后患者无溢泪，电子鼻咽镜复查：鼻腔及左侧泪囊造口周围黏膜光滑，无糜烂坏死。现为术后4个月，电子鼻咽镜复查：鼻腔黏膜光滑，泪囊造口开放良好（图4）。