Thread: ENT cases (Continue)

Case 11:

A 30 year old female has been suffering from seasonal nasal obstruction for the last few years. A watery nasal discharge and attacks of sneezing accompanied this nasal obstruction. 2 weeks ago she had an attack of common cold, she refused to have medical treatment and 2 days later she began to develop pain over the forehead and a mild fever. She did not receive any treatment and so recently developed severe headache with a high fever (40 C) and became severely irritable and could not withstand light. On examination there was marked neck and back stiffness.

Answer

[hide]Diagnosis & reasons

Nasal allergy (seasonal, watery nasal discharge, sneezing and nasal obstruction) complicated by acute frontal sinusitis (mild fever, and pain over the forehead) and later complicated by meningitis (high fever, irritability, can not withstand light and neck and back stiffness)


Explain the following manifestations

Watery nasal discharge: due to edematous fluid of nasal allergey that pours from the nose after accumulating in the nasal mucosa
Pain over the forehead: due to inflammation of the frontal sinus it could be a continuous pain of the inflammation or a morning vacuum headache
Could not withstand light: photophobia that occurs with meningitis


Further examination &/or investigations

• Lumbar puncture: increased pressure of turbid pus containing CSF
• CT scan to diagnose frontal sinusitis
• Complete blood picture to show leucocytosis
• Fundus examination
• After management of acute condition investigations for allergy (skin tests, RAST, …..)


Treatment

Treatment of meningitis (antibiotics, lower intracranial tension by repeated lumbar puncture diuretics mannitol 10%)
Treatment of frontal sinusitis (functional endoscopic sinus surgery or open surgery)
Treatment of underlying predisposing cause which is nasal allergy (avoid the cause of allergy, hyposensitization, pharmacotherapy by local or systemic steroids, antihistamines, mast cell stabilizers, …….)[/hide]

Case 12:

A 25 year old patient had been complaining from severe acute rhinitis. On the fifth day he started to get severe headache, mild fever and marked pain over the left forehead. The patient did not receive any treatment and on the tenth day started to get repeated rigors and became severely ill. On examining the patient the following signs were detected:
• A large red tender swelling in the right nasal vestibule.
• Marked edema of both upper and lower right eye lids.
• Chemosis of the conjunctive in the right eye.
• Forward proptosis of the right eyeball.

Answer
[hide]Diagnosis & reasons

Acute rhinitis complicated by two conditions: left frontal sinusitis (pain over the left forhead and mild fever) the second condition is right nasal furuncle due to excessive nasal secretions leading to fissures and bacterial infection in the nasal vestibule (a large tender swelling in the right nasal vestibule) the furuncle on the tenth day is complicated by cavernous sinus thrombosis (rigors, severely ill, edema of the right eye lids, chemosis of the conjunctive, proptosis of the right eyeball)


Explain the following manifestations

Rigors: is an indication that infection has reached the blood stream
Chemosis of the conjunctiva: congestion and edema of the conjunctiva due to obstruction of the orbital veins that drain into the cavernous sinus
Proptosis of the right eyeball: due to obstruction of the venous drainage of the eye via the retrorbital veins that drain into the cavernous sinus


Further examination &/or investigations

CT scan
Blood culture
Leucocytic count
Fundus examination will show engorged retinal veins
Treatment Hospitalization
Intravenous antibiotics
Anticoagulants
Local antibiotic ointment to help furuncle to drain
Treatment of frontal sinusitis[/hide]

Case 13:

An 18 year old male patient complained of dull aching pain over the forehead for the last 3 years. This pain increased in the morning and decreased in the afternoons, together with intermittent nasal discharge. 10 days ago the pain became very severe with complete nasal obstruction and fever 38 C the patient did not receive the proper treatment and by the tenth day became drowsy with some mental behavioral changes, also there was vomiting and blurred vision.

Answer
[hide]Diagnosis & reasons

Chronic frontal sinusitis (3 years duration, typical vacuum morning headaches) complicated recently (10 days ago, complete nasal obstruction, fever 38 C) the latest complication is a frontal lobe abscess (drowsy, mental behavioral changes, vomiting and blurred vision)


Explain the following manifestations

Morning headache: due to obstruction of the opening of the frontal sinus when the patient sleeps the opening is tightly closed due to edema and the air in the sinus is absorbed creating a negative pressure that causes headache in the morning when the patient stands up the edema is somewhat relieved and air enters the sinus and so the headache disappears or decreases in the afternoon
Mental behavioral changes: the abscess causes pressure on the centers in the frontal lobe of the brain that is responsible for behavior
Blurred vision: increased intracranial tension by the abscess causing vomiting and papilledema


Further examination &/or investigations

• Tenderness over the frontal sinus
• CT scan with contrast to locate the abscess and diagnose the frontal sinusitis
• Leucocytic count important after administering treatment for prognosis
Treatment Neurosurgical excision or drainage of the abscess
Treatment of frontal sinusitis both medically by antibiotics and surgically to drain the frontal sinus[/hide]

Case 14:

A 52 year old male started to develop right sided progressively increasing nasal obstruction 6 months ago. This was followed by blood tinged nasal discharge from the right side as well. Due to looseness of the right second upper premolar tooth, the patient consulted a dentist who advised extraction, this resulted in an oroantral fistula. On examination there was a firm tender swelling in the right upper neck.

Answers
[hide]Diagnosis & reasons

Cancer of the right maxillary sinus (right blood tinged nasal discharge, looseness of right upper second premolar tooth, swelling in the right upper neck)


Explain the following manifestations

Blood tinged nasal discharge: common early manifestation of cancer of the paranasal sinuses due to the presence of necrotic infected nasal mass
Looseness of the right upper second premolar tooth: due to destruction of the root of the tooth by the malignant tumor as this tooth and the first molar are very close to the floor of the maxillary sinus
Oroantral fistula: due to destruction of the alveolus and the palate by the malignant tumor leading to escape of saliva food and drink from the mouth to the maxillary antrum and then back out of the nose
Firm tender swelling in the right upper neck: lymph node metastasis from the primary maxillary tumor it could be tender or not tender


Further examination &/or investigations


• Other symptoms include: orbital manifestations as diplopia, blindess and pain; headache and trigeminal neuralgic pain; swelling of the cheek; Horner's syndrome due to spread of malignancy from the retropharyngeal lymph node of Rouviere to the upper cervical sympathetic ganglion
• CT scan: to diagnose, study the extent of the malignant lesion and its relation to the big blood vessels of the neck and look for other lymph node metastasis
• Nasal endoscopy and biopsy to prove malignancy prior to treatment and to know the pathological type of the malignant tumor before deciding on the modality of treatment
• General investigations to assess condition of the patient



Treatment


Surgical excision by maxillectomy (partial, total or radical according to tumor extent)
Radiotherapy for extensive inoperable lesions
Radical neck dissection for lymph node metastases
Chemotherapy for inoperable tumors that do not respond to radiotherapy
Palliative treatment for inoperable terminal cases[/hide]

Case 15:

A 40 year old female has been complaining of nasal troubles of a long duration in the form of bilateral nasal obstruction, anosmia and nasal crustation. 2 months ago she developed mild stridor that necessitated a tracheostomy later on. She received medical treatment for her condition, but 1 month later developed severe to profound hearing loss that necessitated the use of a hearing aid.

Answers
[hide]Diagnosis & reasons


Rhinolaryngoscleroma (nasal crustations of long duration, stridor)


Explain the following manifestations


Nasal obstruction: due to the presence of a scleroma mass or crustation or nasal synechia
Stridor: laryngoscleroma causes subglottic stenosis and fibrosis causing biphasic stridor
Profound hearing loss that necessitated a hearing aid: an old antibiotic used for the treatment of scleroma was streptomycin that was ototoxic causing sensorineural hearing loss now rifampscin is used with no such side effect



Further examination &/or investigations



• Examination of the nose shows crusts, nasal mass, offensive discharge
• Examination of the larynx will show an area of subglottic stenosis may be in the form of a web
• Biopsy: will show a chronic inflammatory process with endarteritis obliterans and two diagnostic structure the Mickulicz cell and the Russel body; the active cell the fibroblast is also seen



Treatment


Medical: Rifampscin 300mgm daily twice daily before meals
Surgical: recanalization of the nose to relieve nasal obstruction
Laser excision of the subglottic web to relieve dyspnea and stridor
Follow up the condition until complete cure[/hide]

thank you