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MaxillarMaxillary y

SinusitiSinusitissDr. ZahoorDr. Zahoor

House Surgeon, House Surgeon,

E.N.T DepartmentE.N.T Department

Capital HospitalCapital Hospital

Case Presentation

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CASE NO:CASE NO: 11

Acute on Chronic Maxillary Acute on Chronic Maxillary SinusitisSinusitis

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PERSONAL DATAPERSONAL DATA

NameName :: Mehboob Mehboob HussainHussain

F/OF/O :: CDA Employee.CDA Employee.

AgeAge :: 66 Years male66 Years male

BedBed :: OSW 22/2OSW 22/2

D.O.AD.O.A :: 9.6.20039.6.2003

D.O.DD.O.D :: 18.6.200318.6.2003

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HISTORYHISTORY

MAIN COMPLAINTS:MAIN COMPLAINTS: Pain over cheeks and forehead – 1 yearPain over cheeks and forehead – 1 year

HISTORY OF PRESENTING ILLNESS:HISTORY OF PRESENTING ILLNESS: Pain:Pain: According to the patient, he was According to the patient, he was

alright a year back when he started alright a year back when he started developing pain over the cheeks and developing pain over the cheeks and forehead, which developed gradually forehead, which developed gradually and slowly so much so that he started to and slowly so much so that he started to have severe pain on bowing his head have severe pain on bowing his head down for sajda during prayers. He got down for sajda during prayers. He got some medical treatment off and on with some medical treatment off and on with little improvement. Now he has severe little improvement. Now he has severe pain over the cheeks for last 15 days for pain over the cheeks for last 15 days for which he agreed to get admitted at which he agreed to get admitted at capital hospital. capital hospital.

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PAST HISTORY-PAST HISTORY- Patient has past Patient has past history of maxillary sinus wash but details history of maxillary sinus wash but details are not available. are not available.

FAMILY HISTORY-FAMILY HISTORY- Not significant.Not significant.

PERSONAL HISTORY-PERSONAL HISTORY- Smoker (1 Smoker (1 pack per day for last 20 years) pack per day for last 20 years) with with normal bowel habits.normal bowel habits.

……HISTORYHISTORY

Contd.

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DRUG HISTORY-DRUG HISTORY- Had been taking antibiotics Had been taking antibiotics for sinusitis off and on. No history of any drug for sinusitis off and on. No history of any drug allergy.allergy.

SOCIOECONOMIC HISTORY-SOCIOECONOMIC HISTORY- Belongs to Belongs to lower middle class.lower middle class.

……HISTORYHISTORY

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GENERAL GENERAL PHYSICAL PHYSICAL

EXAMINATIONEXAMINATION

A old man sitting anxiously in bed, A old man sitting anxiously in bed, well oriented to time, place and well oriented to time, place and person.person.

AnaemiaAnaemia JaundiceJaundice ClubbingClubbing Absent Absent CyanosisCyanosis Palpable NodesPalpable Nodes

Contd.

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Temp:Temp: AfebrileAfebrile

Pulse:Pulse: 80 beats per min. Regular,80 beats per min. Regular,

BP:BP: 140/90 mm Hg.140/90 mm Hg.

……GENERAL PHYSICAL GENERAL PHYSICAL EXAMINATIONEXAMINATION

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SYSTEMIC SYSTEMIC EXAMINATIONEXAMINATION

Resp. System:Resp. System: CVS:CVS: NAD NAD CNS:CNS: GIT:GIT:..

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E.N.T E.N.T EXAMINATIONEXAMINATION

NASAL EXAMINATIONNASAL EXAMINATION

Inspection:Inspection: Anterior Rhinoscopy: Swollen inferior Turbinates Anterior Rhinoscopy: Swollen inferior Turbinates

with some mucopus along the nasal floor.with some mucopus along the nasal floor. Posterior Rhinoscopy: NADPosterior Rhinoscopy: NAD

PalpationPalpation: Tenderness over cheeks: Tenderness over cheeks

EXAMINATION OF THROATEXAMINATION OF THROAT Poor oral hygienePoor oral hygieneGingivitisGingivitis

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EXAMINATION OF EARSEXAMINATION OF EARS

Inspection:Inspection: Surrounding area, pinnae, Surrounding area, pinnae, EAM, EAC, T.M normal. EAM, EAC, T.M normal.

Palpation:Palpation: NADNAD Hearing Test: Hearing Test: Hears forced wisper at ear Hears forced wisper at ear

levellevel Tunning Fork Tests:Tunning Fork Tests:

Rinne’sRinne’s :: Positive on both sidesPositive on both sides WeberWeber :: CentralCentral ABC ABC :: Reduced by 5 seconds both sides.Reduced by 5 seconds both sides.

Contd.

……E.N.T EXAMINATIONE.N.T EXAMINATION

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PROVISIONAL PROVISIONAL DIAGNOSISDIAGNOSIS

Acute on Chronic Maxillary Acute on Chronic Maxillary SinusitisSinusitis

With Gingivitis & Mild SNHLWith Gingivitis & Mild SNHL

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INVESTIGATIONSINVESTIGATIONS

CP:CP: Within normal limits. Within normal limits. ESR:ESR: 05 mm within 1st hr. 05 mm within 1st hr. Renal Profile:Renal Profile: Within Normal Limits Within Normal Limits Blood Sugar (Random):Blood Sugar (Random): 90 mg/dl 90 mg/dl

Contd.

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……INVESTIGATIONSINVESTIGATIONS

X-Ray PNS (OM View):X-Ray PNS (OM View): Rt. Max. Sinus is Hazy, Lt. Rt. Max. Sinus is Hazy, Lt.

hazy but less compared to Rt.hazy but less compared to Rt. Both Middle and inf. turbinates Both Middle and inf. turbinates

Swollen with obliteration of Swollen with obliteration of both nasal spaces.both nasal spaces.

X-Ray chest :X-Ray chest :

NormalNormal..

Contd.

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TREATMENTTREATMENT

MEDICAL TREAMENTMEDICAL TREAMENT Inj. Ampicillin 500 mg I/V TDSInj. Ampicillin 500 mg I/V TDS Xynosine nasal spray tdsXynosine nasal spray tds Steam inhalations tds.Steam inhalations tds. Tab. Flagyl 400mg tds.Tab. Flagyl 400mg tds. Gargalene dil. mouth wash.Gargalene dil. mouth wash.

Drugs Advised by Medical Drugs Advised by Medical Department.Department.

Tab. Lexillium 3 mg 1 x HSTab. Lexillium 3 mg 1 x HS Tab. Capace 25 ½ X BDTab. Capace 25 ½ X BD

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Patient was much relieved of his Patient was much relieved of his symptoms at the time of discharge symptoms at the time of discharge and a check X-Ray revealed and a check X-Ray revealed improvement improvement

RESULTS & FOLLOW RESULTS & FOLLOW UPUP

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CASE

2

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Fungal Sinusitis with Fungal Sinusitis with PolypiPolypi

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PERSONAL DATAPERSONAL DATA

NameName :: DoniaDonia

D/OD/O :: Muhammad Farid - CDA Muhammad Farid - CDA Employee.Employee.

AgeAge :: 22 Years, Female22 Years, Female

BedBed :: F.10, E.N.T Dept. Capital F.10, E.N.T Dept. Capital Hospital Hospital

D.O.AD.O.A :: 05.05.200305.05.2003

D.O.DD.O.D :: 30.05.200330.05.2003

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HISTORYHISTORY

MAIN COMPLAINTS:MAIN COMPLAINTS: Nasal BlockageNasal Blockage -- 5 months5 months HeadacheHeadache -- 5 months5 months

HISTORY OF PRESENTING ILLNESS:HISTORY OF PRESENTING ILLNESS: Nasal Obstruction:Nasal Obstruction: According to the patient she According to the patient she

was alright 5 months back when she slowly was alright 5 months back when she slowly developed difficulty breathing through nose, so developed difficulty breathing through nose, so much so that now she can hardly breath and much so that now she can hardly breath and has to keep her mouth open during night. She has to keep her mouth open during night. She said that this nasal obstruction is also said that this nasal obstruction is also associated with some facial disfiguration associated with some facial disfiguration especially prominence of eye balls. especially prominence of eye balls.

Headache:Headache: Nasal obstruction was also Nasal obstruction was also accompanied by headache on the forehead, accompanied by headache on the forehead, which is mild in intensity. which is mild in intensity.

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PAST HISTORY-PAST HISTORY-

FAMILY HISTORY-FAMILY HISTORY-

PERSONAL HISTORY-PERSONAL HISTORY-

……HISTORYHISTORY

Contd.

Nothing significantNothing significant..

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DRUG HISTORY-DRUG HISTORY- Had been taking antibiotics Had been taking antibiotics and other drugs as prescribed by different G.P’s. and other drugs as prescribed by different G.P’s. No history of any drug allergy.No history of any drug allergy.

SOCIOECONOMIC HISTORY-SOCIOECONOMIC HISTORY- Belongs to Belongs to lower middle class.lower middle class.

……HISTORYHISTORY

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GENERAL GENERAL PHYSICAL PHYSICAL

EXAMINATIONEXAMINATION

A young girl sitting anxiously in bed, with A young girl sitting anxiously in bed, with proptosed eyes and well oriented to time, proptosed eyes and well oriented to time, place and person.place and person.

AnaemiaAnaemia JaundiceJaundice ClubbingClubbing Absent Absent CyanosisCyanosis Palpable NodesPalpable Nodes

Contd.

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Temp:Temp: AfebrileAfebrile

Pulse:Pulse: 86 beats per min. Regular,86 beats per min. Regular,

BP:1BP:1 130/70 mm Hg.130/70 mm Hg.

……GENERAL PHYSICAL GENERAL PHYSICAL EXAMINATIONEXAMINATION

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SYSTEMIC SYSTEMIC EXAMINATIONEXAMINATION

Resp. System:Resp. System: CVS:CVS: N0RMAL N0RMAL CNS:CNS: GIT:GIT:..

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E.N.T EXAMINATIONE.N.T EXAMINATION

NASAL NASAL EXAMINATIONEXAMINATION

Inspection:Inspection:

Proptosis more on right Proptosis more on right side.side.

TelecanthusTelecanthus Swelling over the right Swelling over the right

cheekcheek Anterior Rhinoscopy: Anterior Rhinoscopy:

Bilateral polypoidal mass Bilateral polypoidal mass with some cheesy material & with some cheesy material & mucopus.mucopus.

PalpationPalpation: Firm swelling : Firm swelling

over right cheek which was over right cheek which was tender.tender.

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EXAMINATION OF THROATEXAMINATION OF THROAT

NADNAD

EXAMINATION OF EARSEXAMINATION OF EARS

NADNAD

Contd.

……E.N.T EXAMINATIONE.N.T EXAMINATION

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C.N I - XIIC.N I - XII Intact.Intact.

EXAMINATION OF EXAMINATION OF CRANIAL NERVESCRANIAL NERVES

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INVESTIGATIONSINVESTIGATIONS CP:CP:

TLC:TLC: 9.0 Thsd/Cu mm9.0 Thsd/Cu mmDLC:DLC: N-69%N-69%

L-29%L-29%

M-01%M-01%

E-01%E-01%

ESR:ESR: 38 mm within 1st hr. 38 mm within 1st hr. B.T:B.T: 2 min 30 sec.2 min 30 sec. C.T:C.T: 5 min 50 sec.5 min 50 sec. Renal Profile:Renal Profile:

Urea: 29 mg/dlUrea: 29 mg/dl

Creatinine: 0.8 mg/dlCreatinine: 0.8 mg/dl

LFT’s:LFT’s: Normal Normal

Contd.

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……INVESTIGATIONSINVESTIGATIONS

X-Ray PNS (OM View):X-Ray PNS (OM View): Hazy maxillary and ethmoid Hazy maxillary and ethmoid

sinusessinuses Also nasal cavity appears Also nasal cavity appears

obliterated.obliterated.

X-Ray chest :X-Ray chest :

NormalNormal..

Contd.

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……INVESTIGATIONSINVESTIGATIONS

C-T Scan (Nose and PNS)C-T Scan (Nose and PNS) Obliteration of the nasal cavity, Rt. Obliteration of the nasal cavity, Rt.

Maxillary sinus, ethmoids with little Maxillary sinus, ethmoids with little extension into anterior cranial fossa. extension into anterior cranial fossa. Lt. maxillary sinus is minimally Lt. maxillary sinus is minimally affected.Destruction of Rt. Medial affected.Destruction of Rt. Medial orbital wall is also noted with little orbital wall is also noted with little extension into orbit. extension into orbit.

Likely lesion could be Nasal Likely lesion could be Nasal polyposis, fungus. However polyposis, fungus. However malignancy cannot be excluded. malignancy cannot be excluded.

Contd.Coronal Views

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Axial Views

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PROVISIONAL PROVISIONAL DIAGNOSISDIAGNOSIS

Fungal Sinusistis with polypiFungal Sinusistis with polypi

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SURGICAL TREATMENTSURGICAL TREATMENTAfter thorough preoperative preparation on After thorough preoperative preparation on 17.5.2003 at 10.00 a.m following surgical 17.5.2003 at 10.00 a.m following surgical procedure was performed under general procedure was performed under general G/A with oro-trachial intubation through G/A with oro-trachial intubation through oral cavity and throat packing. oral cavity and throat packing.

1.1. Bilateral polypectomyBilateral polypectomy2.2. Cald well Luc’s operation on right side Cald well Luc’s operation on right side

including transantral ethmoidectomy and including transantral ethmoidectomy and antrostomy.antrostomy.

3.3. Left sided transnasal ethmoidectomy. Left sided transnasal ethmoidectomy. BIPP & clotrim imprenated packing done in BIPP & clotrim imprenated packing done in antrum and nasal cavity. antrum and nasal cavity.

TREATMENTTREATMENT

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……TREATMENTTREATMENT

MEDICAL TREAMENTMEDICAL TREAMENT

Inj. Ceftim 1 gm i/v BDInj. Ceftim 1 gm i/v BD for 5 daysfor 5 days Followed by Cap.Kefril 500 mg TDSFollowed by Cap.Kefril 500 mg TDS 1 wk.1 wk. Inj. Chymoral 1 amp I/M TDS Inj. Chymoral 1 amp I/M TDS 2 days2 days Xynosine nasal spray tdsXynosine nasal spray tds Myconil drops tdsMyconil drops tds Liquid Paraffin drops tds.Liquid Paraffin drops tds. Steam inhalations tds.Steam inhalations tds. Inj. Dicloran 1 amp. I/M SOSInj. Dicloran 1 amp. I/M SOS Tab. Brufen tds. Tab. Brufen tds. Tab. Diflucan 200 mg ODTab. Diflucan 200 mg OD 4 4

weeks.weeks.

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FOLLOW UPFOLLOW UP

Nasal pack removed on 2nd post operative day.

Antral pack (BIPP) removed over 1 week.

Follow up on 15th post operative day showed normal nasal patency and markedly reduced disfiguration

Monthly followup till Dec. was satisfactory, however was advised to repeat scan.

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Thank you!

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