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Year : 2010  |  Volume : 20  |  Issue : 1  |  Page : 6-10
Pictorial essay: Orbital tuberculosis


Department of Radiodiagnosis, Lady Hardinge Medical College and Associated Smt. Sucheta Kriplani and Kalawati Hospitals, New Delhi - 110 001, India

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Date of Web Publication6-Feb-2010
 

   Abstract 

Tuberculosis of the orbit is rare, even in places where tuberculosis is endemic. The disease may involve soft tissue, the lacrimal gland, or the periosteum or bones of the orbital wall. Intracranial extension, in the form of extradural abscess, and infratemporal fossa extension has been described. This pictorial essay illustrates the imaging findings of nine histopathologically confirmed cases of orbital tuberculosis. All these patients responded to antituberculous treatment.

Keywords: Computed tomography; lacrimal gland; orbital tuberculosis

How to cite this article:
Narula MK, Chaudhary V, Baruah D, Kathuria M, Anand R. Pictorial essay: Orbital tuberculosis. Indian J Radiol Imaging 2010;20:6-10

How to cite this URL:
Narula MK, Chaudhary V, Baruah D, Kathuria M, Anand R. Pictorial essay: Orbital tuberculosis. Indian J Radiol Imaging [serial online] 2010 [cited 2019 Nov 14];20:6-10. Available from: http://www.ijri.org/text.asp?2010/20/1/6/59744

   Introduction Top


Tuberculosis is a major cause of morbidity and mortality in the third-world countries. [1],[2] Orbital tuberculosis is rare, even in endemic areas. [3] Malignancy, developmental anomalies, and nontuberculous infections are the common orbital lesions noted in children. [4] Orbital tuberculosis is relatively more common in children, girls more likely to be affected than boys. [5] The disease is usually unilateral and slowly progressive. It has an insidious onset, with patients reporting that symptoms had been present for months to years. The left orbit is more commonly involved than the right. [5]


   Discussion Top


The primary tuberculous focus is commonly pulmonary, but extrapulmonary sites, such as cervical lymphadenopathy or abdominal disease, may be present. [5] Hematogenous spread from a primary tubercular focus or contiguous spread from paranasal sinuses may affect the orbit. [6] Orbital tuberculosis usually presents with destruction of bone (most commonly the frontal and sphenoid bones), with or without sclerosis, extraconal inflammation/abscess formation, extension into the infratemporal fossa, or intracranial (usually extradural) extension. Lacrimal gland involvement (enlargement/abscess) is also a common presentation. Involvement of the lateral wall suggests a hematogenous source of infection. [6] Involvement of the medial wall of the orbit is suggestive of spread of infection from an adjacent paranasal sinus. Orbital tuberculosis may present only with ocular lesions. [7]

The radiological features of orbital tuberculosis have been reported in only a few studies. Here, we describe the imaging features of nine cases of orbital tuberculosis (ages 1-15 years; seven boys and two girls) who presented with painless/painful orbital and/or lid swelling, proptosis, and ophthalmoplegia. In all the patients, routine laboratory investigations, chest radiographs, and orbital USG followed by CT scan were performed. The imaging findings were correlated with clinical and histopathological findings.

Although we did not use MRI as an imaging modality, the multiplanar capability and lack of bony artefacts makes MRI an excellent modality in the evaluation of orbital masses. It differentiates between different types of masses and also determines the extent of the lesion involving the lacrimal gland fossa and the brain. The use of fat suppression techniques combined with post contrast sequences significantly improves the visualization of subtle masses. [8]

Bony involvement

Orbital tuberculosis usually involves the bones of the orbital wall, viz. the orbital plate of the frontal bone, the sphenoid, or the zygomatic bone. Sphenoidal extension has been described but is rare. [5] Zygoma involvement associated with lower lid tuberculosis has also been reported. [9] Tuberculous periostitis is the usual manifestation of tuberculous infection and usually affects the outer margin of the orbit. [10] Bony involvement can also be seen in the form of cortical irregularity and destruction [Figure 1]a, d,[Figure 2]a,c,[Figure 3]a, and [Figure 4]b. Bony thickening and sclerosis are seen in long-standing cases [Figure 3]b, c, [Figure 5]b, c, and [Figure 6]a- c. Other causes of orbital bone destruction in the pediatric age-group are neuroblastoma, which normally does not have an associated abscess and Ewing sarcoma, which usually shows a spiculated periosteal reaction with a soft tissue mass.

Extraconal orbital inflammation/abscess

Orbital abscess/inflammation is usually seen in the extraconal compartment [Figure 1]b, [Figure 7]a-c, [Figure 5]a, b, [Figure 4]a-d, and [Figure 8]a-d.

Intracranial extension

Coexistence of ocular and central nervous system tuberculosis is known, [11] but orbital tuberculosis extending into the cranium has also been reported. [3],[12],[13] Intracranial extension is usually seen in the form of extradural abscesses [Figure 1]d, [Figure 7]b-d, [Figure 5]b, and [Figure 6]b.

Infratemporal fossa extension

Extension of orbital tuberculosis into the infratemporal fossa has also been described. [3] [Figure 7]b-d, [Figure 2]c, d, and [Figure 6]a.

Lacrimal gland involvement

Isolated involvement of the lacrimal gland has been described. [14] It may be seen either in the form of lacrimal gland enlargement [Figure 5]c, [Figure 9]a, and b or abscesses [Figure 1]c, [Figure 7]b, [Figure 2]b, d, and [Figure 3]a. Other causes of lacrimal gland enlargement include lymphoma and sarcoid; however, these conditions are usually bilateral and do not show orbital abscess or bony destruction.

Preseptal thickening

The inflammation may extend to the preseptal tissues causing thickening [Figure 1]c, [Figure 7]b, [Figure 2]d, [Figure 5]b, [Figure 4]a, and [Figure 8]a.


   Conclusion Top


Tuberculosis of the orbit is rare. It is usually seen in the pediatric age-group. The disease is usually unilateral. The common presentations are proptosis, nontender or mildly painful orbital/lid swelling, and sinus formation. The predominant imaging features of orbital tuberculosis are involvement of the orbital bony wall and lacrimal gland, with soft tissue inflammatory mass/abscess formation. Intracranial and infratemporal extension is not uncommon. Patients presenting with isolated preseptal thickening need to be thoroughly investigated for presence of local disease and any underlying systemic focus. Although malignancy, developmental anomalies, and nontuberculous infections are much commoner causes of proptosis in childhood, tuberculosis should always be considered in the differential diagnosis of orbital masses. The clinician should have a high index of suspicion as orbital tuberculosis has probably been underdiagnosed in the past.

 
   References Top

1.Helm CJ, Holland GN. Ocular tuberculosis. Surv Ophthalmol 1993;38:229-56.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Schlernitzauer DA, Hodges FJ, Bagan M. Tuberculoma of the left optic nerve and chiasm. Arch Ophthalmol 1971;85:75-8.  Back to cited text no. 2      
3.Aggarwal D, Suri A, Mahapatra AK. Orbital tuberculosis with abscess. J Neuroophthalmol 2002;22:208-10.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Oakhill A, Willshaw H, Mann JR. Unilateral proptosis. Arch Dis Child 1981;56:549-51.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Sen DK. Tuberculosis of the orbit and lacrimal gland: A clinical study of 14 cases. J Pediatr Ophthalmol Strabismus 1980;17:232-8.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Khalil M, Lindley S, Matouk E. Tuberculosis of the orbit. Ophthalmology 1985;92:1624-7.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Raina UK, Jain S, Monga S, Arora R, Mehta DK. Tubercular preseptal cellulitis in children: A presenting feature of underlying systemic tuberculosis. Ophthalmology 2004;111:291-96.8  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Jackson A, Sheppard S, Johnson AC, Annesley D, Laitt RD, Kassner A. Combined fat- and water- suppressed MR imaging of orbital tumors. Am J Neuroradiol 1999;20:1963-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Pillai S, Malone TJ, Abad JC. Orbital tuberculosis. Ophthal Plast Reconstr Surg 1995;11:27-31.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Duke ES, editor. The ocular adnexa: Lacrimal, orbital and paraorbital diseases. Vol. 13, Part 2. In system of ophthalmology. London: Henry Kimpton; 1974. p. 902-5.  Back to cited text no. 10      
11.De Castro CC, De Barros NG, De Sousa Campos ZM, Cerri GG. CT Scan of cranial tuberculosis. Radiol Clin North Am 1995;33:753-69.  Back to cited text no. 11      
12.Gupta V, Angra P. Orbital tubercular abscess with intracranial extension. Curr Ophthalmol 1995 Proc DOS Annu Conf Ophthalmol Update. New Delhi: 1995. p. 201-3.  Back to cited text no. 12      
13.Dewan T, Sangal K, Premsagar IC, Vashishth S. Orbital tuberculoma extending into the cranium. Ophthalmologica 2006;220:137-9.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Mortada A. Tuberculoma of the orbit and lacrimal gland. Br J Ophthalmol 1971;55:565-7.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Mahender K Narula
Department of Radiodiagnosis, Lady Hardinge Medical College and associated hospitals, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.59744

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

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