Thread: Ent cases[no31-35]

Case 31: A 25 year old female is complaining of bilateral nasal obstruction of 5 years duration. She gave a history of attacks of sneezing, lacrimation and watery nasal discharge that may be clear or yellowish green. On examination her nasal cavities were blocked by smooth glistening pedunculated nasal masses with a clear nasal discharge


[HIDE]CASE 31



Diagnosis & reasons



Nasal allergy (history of sneezing, watery nasal discharge) with allergic nasal polypi (smooth glistening pedunculated nasal masses)



Explain the following manifestations



Lacrimation: most cases of allergic rhinitis are accompanied by conjunctival spring catarrh causing lacrimation
Yellowish green nasal discharge: may be due to secondary bacterial infection or the allergy itself as the dischage is rich in eosinophils that give the yellowish green color
Glistening pedunculated nasal masses: due to the allergy the nasal mucosa is edematous and the lining mucosa of the sinuses is prolapsed like bags filled with water and hence they are pedunculated and glistening – the common sinuses to cause this are the ethmoid because of the large surface area of the mucosa as they are multiple sinuses



Further examination &/or investigations



• CT scan to visualize the extent of nasal polypi
• Skin allergy tests
• Radioallergosorbent test RAST
• Serum IgE level


Treatment




Remove nasal polypi by endoscopic nasal surgery
Treatment of allergy by avoidance of the cause of allergy, hyposensitization
Treatment of allergy by medical treatment: steroids, local steroids, antihistamines
Avoid non-steroidal antiinflammatory drugs as aspirin in all forms as it leads to the exacerbation of allergy and leads to the formation of nasal polypi (aspirin triade)[/HIDE]

Case 32: A 50 year old male complained of a swelling in the upper right side of the neck of 2 months duration. The swelling was firm and non-tender and progressively increasing in size. The patient mentioned that he has been suffering from right side offensive blood stained nasal discharge of 6 months duration. Now he has diplopia, right side nasal obstruction and looseness of the teeth of the right side of the upper jaw


[HIDE]CASE 32



Diagnosis & reasons


Right cancer maxilla (right side offensive blood stained nasal discharge in a 50 year old) with right upper deep cervical lymph node metastasis (firm non-tender swelling in the right upper neck)



Explain the following manifestations


Firm non-tender swelling in the right upper neck: malignant lymph node matastasis is firm and usually non-tender but may be tender in some cases
Right side offensive blood stained nasal discharge: due to the presence of the malignant tumor in the nasal cavity destroying the nasal mucosa with subsequent infection of the necrotic tissue
Diplopia: double vision due to orbital extension by the tumor causing proptosis
Looseness of the teeth of the right upper jaw: due to destruction of the roots of the teeth in the alveolus



Further examination &/or investigations


• Endoscopic examination of the nose and biopsy
• CT scan to show the extent of the tumor, metastasis and involvement of the big vessels of the neck
• Ophthalmic examination
• Dental examination


Treatment

Surgical radical maxillectomy to remove the maxilla and the metastatic lymph nodes
Radiotherapy for selected cases
Chemotherapy
Palliative management for inoperable cases[/HIDE]

Case 33: A 30 year old female had a common cold 6 weeks ago. This was followed by right forehead pain, upper eyelid edema and a temperature of 38.5 C. Later her fever rose to 40.5 C, the lid edema increased and she started to complain of double vision. On examination the eye showed a downward and lateral proptosis. She now presented to the emergency room with decreased level of consciousness and marked neck rigidity


[HIDE]CASE 33



Diagnosis & reasons


Common cold complicated by right frontal sinusitis (forehead pain, upper eye lid edema and temperature 38.5 C) complicated further by subperiosteal orbital abscess (high fever 40.5 C, increased lid edema, proptosis) finally complicated by meningitis (marked neck ridgidity and decreased level of consiousness)


Explain the following manifestations


Right forhead pain: due to acute suppurative frontal sinusitis with inflammation of the mucosal lining of the frontal sinus
Downward and lateral proptosis: due to the formation of a subperiosteal orbital abscess in the upper medial corner of the orbital cavity which displaces the globe from its position and leads to diplopia
Neck ridgidity: due to inflammation of the meninges



Further examination &/or investigations



• Endoscopic nasal examination
• CT scan with contrast
• Ophthalmic examination with fundus examination
• Lumbar puncture


Treatment


Antibiotics that cross the blood brain barrier
Surgical drainage of the subperiosteal orbital abscess either through the orbit or through the nose by the nasal endoscope
Treatment of the underlying frontal sinusitis to prevent recurrence[/HIDE]

Case 34: A 25 year old farmer has been complaining of nasal obstruction, greenish nasal discharge and nasal deformity of one year duration. On examination the nose was broad and contained a lobulated firm mass that may bleed on touch. Also, there was a hard swelling below the medial canthus of the right eye. One week ago, he noticed a change in his voice that was followed by respiratory distress. On examination there was marked stridor and laryngeal examination showed a subglottic laryngeal web

[HIDE]CASE 34



Diagnosis & reasons



Rhinoscaleroma (greenish nasal dischage, nasal deformity, broad nose, lobulated firm mass that may bleed on touch) with dacrscleroma of the lacrimal sac (hard swelling below the medial canthus of the right eye) with laryngoscleroma (change of voice, respiratory distress, stridor, subglottic web)



Explain the following manifestations


Greenish nasal dischage: characteristic of the infection caused by the Klebsiella rhinoscleromatis
Nasal deformity: due to the fibrosis that accompanies scleroma
Hard swelling below the medial canthus of the right eye: due to involvement of the right lacrimal sac by the scleroma tissue which is fibrous and hard the swelling may be cystic and fluctuant in other situations when there is only a nasolacrimal duct obstruction without involvement of the sac with the scleroma tissue
Subglottic laryngeal web: scleroma when involving the larynx is commonly in the subglottic region as it is an extension of trahceal scleroma this web is the cause of respiratory distress and stridor



Further examination &/or investigations


• Endoscopic nasal examination and biopsy that wil show Mickulicz cell, Russel body and othe chronic inflammatory cells especially the active cell in scleroma the fibroblast
• CT scan of the nose
• CT scan of the larynx and trachea to assess the degree of the subglottic stenosis


Treatment


Medical treatment with Rifampscin
Surgical treatment in the form of tracheostomy to relieve respiratory obstruction
Laser excision of the subglottic web
Removal of the mass in the lacrimal sac and dacrocystorhinostomy[/HIDE]

Case 35: Following a common cold a 30 year old male started to complain of left forehead pain and edema of the upper eyelid. One week later, his general condition became worse, there was a fever 40 C and rigors. On examination there was right eye proptosis with conjunctival chemosis and paralysis of eye movement. Also, there was a small red, hot tender swelling in the vestibule of the right nasal cavity.


[HIDE]CASE 35




Diagnosis & reasons


Common cold caused two conditions first left frontal sinusitis (left forehead pain, edema of the left upper eye lid) second right nasal furuncle (small red hot tender swelling in the right nasal vestibule) the second condition is complicated by cavernous sinus thrombosis (fever 40 C and rigors, right eye proptosis, conjunctival chemosis, and paralysis of eye movement)



Explain the following manifestations


Fever 40 C and rigors: spread of infection to the blood in the cavernous sinus causes high fever and rigors
Proptosis: thrombosis of the retrobulbar veins leads to retrorbital edema that pushes the eye forwards
Conjunctival chemosis: which means edema and congestion of the conjunctive due to occlusion of the venous drainage
Paralysis of eye movement: due to affect of the 3, 4, 6 cranial nerves related to the cavernous sinus
Swelling in the nasal vestibule: furuncle always occurs in relation to a hair follicle or sebaceous gland those are present in the nasal vestibule as it is lined by skin



Further examination &/or investigations


• Fundus examination
• CT scan of the nose
• Blood picture (leusocytic count)
• Blood culture


Treatment

Intravenous antibiotics
Anticoagulants
Treatment of the underlying cause furuncle by antibiotic ointment and drainage as it has already caused cavernous sinus thrombosis so there is no fear of such a complication
Treatment of frontal sinusitis[/HIDE]

thank you very much

thanks a lot