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Otorhinolaryngology Otorhinolaryngology |
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Rhinology Case
You are an Otolaryngology Head and Neck (ENT) surgeon and a 54 year old woman sees you complaining of nasal obstruction.
MCQ 1
MCQ 2
Below are two pictures of endoscopic views obtained from just inside the nasal vestibule (i.e. the anterior nasal cavity).
They both show the right nasal cavity.
In the left hand picture (normal): on the right is the nasal septum and on the left is the inferior turbinate. Further posteriorly, the middle turbinate can be seen.
In the right hand picture (allergic rhinitis): the mucosa of the septum and inferior turbinate is very swollen - consistent with inflammation.
When you examine the 54 year old patient, you find the anterior nasal cavity on both sides examines like the right-hand picture above.
With flexible nasendoscopy, you find the following:
Jot down a couple of points regarding what you are seeing.
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- The pale, sac-like lesions are polyps.
- The fact they are present on both sides indicate that the likely diagnosis is chronic sinusitis with polyps (CRS).
- If the polyps were unilateral, you would be more suspicious of a malignant aetiology.
- This patient has evidence of inflammation and polyps, therefore the working diagnosis is chronic sinusitis with polyps.
The next step is educating the patient regarding the disease, namely that is it incurable but treatable.
We treat it by prescribing a short course of oral steroids followed by topical steroids in an ongoing fashion. In addition we prescribe a one-month course of antibiotics (tetracycline or macrolide) and sinus rinse.
The patient is then reviewed following the course of treatment.
- If the patient has has a good response and is happy with the symptoms: ongoing sinus rinse and topical steroid spray is prescribed and the patient reviewed.
- If the patient has a poor response then surgical management is considered - this is called Functional Endoscopic Sinus Surgery (FESS).
- A CT is obtained prior to surgery.
A normal CT is shown on the left (for reference) and the patient's CT is shown on the right.
Write down any thoughts you have regarding the normal and abnormal scan.
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The normal CT shows:
- Well-aerated sinuses (you may need to review the anatomy on the introduction page for the rhinology section).
- There is a good airway around the inferior turbinate bilaterally.
The patient's CT shows:
- A "white-out," where all the visible sinuses are full of soft tissue and fluid (as a result of the CRS).
- The airway is severely obstructed by swollen/inflamed mucosa and polyps.
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