CASE PRESENTATION
Dr. Sachana Adhikari
Junior Resident
Department of ORL and HNS,
BPKIHS
Patient’s Particulars
• Name: Ms. Mahato
• Age/Sex: 19 years /female
• Address: Siraha
• Occupation: Student
• Religion : Hindu
• Informant: Self
• Reliability: Good
Chief Complaint
Right sided nasal obstruction for 1 year
Right sided nasal discharge since last 4 months
Right Sided Nasal Obstruction
insidious onset
gradually progressive in nature to reach present state
continuous
increases during expiration and while lying down
no diurnal variation
aggravated by cold weather
not relieved on using nasal drops
Right sided Nasal discharge
insidious in onset
mucoid type
non foul smelling
non blood stained
associated with discomfort in swallowing
No History of
• loss of smell sensation
• recurrent episodes of runny nose,watering of eyes,sneezing
• bleeding from nose
• snoring, mouth breathing
• chronic irritation in throat and throat clearing
• change in voice
• ear complaints
• visual Disturbances/Loss of vision/Double vision
• protrusion of eyes
• loosening of tooth
• facial Swelling/Cheek Swelling
• Altered sensation over face/hard palate
• Neck Swelling,
• Headache, nausea, vomiting
• Loss of consciousness
• Significant weight loss
Past History
• Similar history in the past (2075) for which she underwent
Endoscopic Sinus Surgery in another center
• No history of bronchial asthma,DM,HTN,TB
• No history of malignancies, previous irradiations
Family History
No h/o similar illness in family member
No h/o HTN/PTB/DM/Bronchial asthma
No History of surgeries or Malignancy
Personal History:
-student
- Consumes mixed diet
-Bowel/bladder-Normal
-Sleep /appetite - Normal
-does not bath in ponds
-does not smoke
Drug History
H/o use of nasal decongestant drops
Allergic History
No h/o allergy to drugs or known substances.
GENERAL PHYSICAL EXAMINATION
General examination
Patient is conscious, cooperative, and well oriented to time, place
and person
Blood Pressure: 120/70 mm Hg, right arm sitting position,
Pulse: 90 bpm, regular, normal in rate, rhythm, volume and
character, no RR or RF delay, all peripheral pulses palpable.
Respiratory Rate: 16/ minute, thoracoabdominal
Temp: Afebrile
• Pallor
• Icterus
• Lymphadenopathy
• Clubbing Absent
• Cyanosis
• Edema
• Dehydration
Systemic Examination
CNS : Grossly intact
CN I-XII function intact
Respiratory:
B/L Normal vesicular breath sounds
No added sounds
CVS: S1, S2 heard, No murmur
Abdomen:
Soft, non tender
No organomegaly
Bowel sound heard
LOCAL EXAMINATION
• NOSE
– Skin overlying:
• Root
• Dorsum
• Supratip
• Tip WNL
• Columella
• Osteocartilagenous Framework: No obvious deformity/ deviation
Local Examination (NOSE)
Examination Area Right Left
Mucoid discharge
Vestibule Normal
present
Paranasal Sinuses No No
(Palpation) fullness/tenderness tenderness
Anterior Rhinoscopy Right Nasal Cavity Left Nasal Cavity
Normal mucosa, no
Roof Normal
masses
Midline, no
Septum Midline, normal
deviation/perforation
Middle Turbinate Normal Normal
Middle Meatus No purulence/polyps Normal
Not visualized. Occupied
by a solitary pale,
Inferior Turbinate Normal, mucosa intact
glistening polypoidal
mass
Inferior Meatus Obstructed by mass Patent
Floor Normal Normal
Palpation Findings (Right Nasal Mass)
• Surface: Smooth, glistening.
• Consistency: Soft, mobile, non-friable.
• Sensitivity: Insensitive to touch.
• Bleeding: No bleeding on probing.
• Decongestant Test: No shrinkage
• Probe Test: Can be passed around the mass
Posterior Rhinoscopy
Anatomical Site Right Side Left Side
Pinkish mass filling
Posterior the space,
Patent, normal
Choanae obscuring
septum/turbinates
Normal torus
Eustachian Tube
tubarius, no Normal
Opening
obstruction
Fossa of Normal, no
Obscured by mass
Rosenmüller masses
• Functional test
Test Right Side Left Side
Normal
Cold Spatula Test Decreased misting
misting
Normal
Cotton Wool Test Reduced movement
flutter
No
Cottle's Test No improvement
improvement
Smell Test Present Present
Eye examination
Examination Right Eye Left Eye
Visual Acuity 6/6 6/6
Proptosis/Exophthalmos Absent Absent
Extraocular Movements Full (all gazes) Full
Conjunctiva/Sclera No injection/chemosis Normal
Pupillary Reflexes RAPD absent Normal
Lacrimal System No epiphora Normal
Oral Cavity
– Lips/ Vestibule A pinkish, cylindrical mass
– Teeth/Gums protruding from nasopharynx
– Tongue/Floor of the mouth into the oropharynx, insensitive
– Hard/soft palate to touch, did not bleed on
– probing
Bilateral buccal mucosa
– Bilateral gingivobuccal sulcus
– Bilateral Retromolar Trigone
– Bilateral tonsilolingual sulcus
– Uvula
– Anterior and posterior tonsillar pillar
– Bilateral Tonsils
– Posterior pharyngeal wall
Indirect Laryngoscopy
• Base of Tongue
• Vallecula
• Median/lateral glossoepiglottic fold
• Epiglottis
• Aryepiglottic Fold
• B/L Arytenoids
• Interarytenoid region
• B/L TVC
• B/L FVC
• Anterior commissure
• Posterior commisure
• B/L pyriform fossa
NECK
– No mass/swelling
– No scar/sinus
– No Tenderness
– Laryngeal framework- wnl
– Laryngeal crepitus- present
– Lymphadenopathy- absent
– B/L carotid pulsations palpable
– Trachea- central
Ear
Examination Area Right Left
Normal shape, size, Normal shape, size,
Pinna
symmetry, position symmetry, position
No No
Pre-Auricular
scar/sinus/swelling/discha scar/sinus/swelling/disch
Region
rge/tenderness arge/tenderness
No No
Post-Auricular
scar/sinus/swelling/discha scar/sinus/swelling/disch
Region
rge/tenderness arge/tenderness
Retroauricular
Well-defined (WNL) Well-defined (WNL)
Groove
Tragal tenderness: B/L Absent
Circumduction test: B/L Negative
3 finger test: B/L absent
External Auditory Meatus
B/L Patent
No Discharge
External Auditory Canal: without / with Speculum
Right Left
Roof
Anterior wall WNL
WNL
Posterior wall
Floor
Otoscopy
Tuning Fork Test ( 512Hz)
Right Left
Rinne’s : +ve + ve
(AC>BC) (AC>BC)
Weber’s : Not lateralized
ABC: Not decreased Not decreased
Fistula test: B/L Negative
Nystagmus: B/L Absent
Facial Nerve
Clinically Intact
Tests for Balance
• Romberg’s Test : Negative
• Gait: Normal
• Dysdiadokinesia: absent
• Finger Nose Test: Normal
Provisional Diagnosis:
Recurrent right Antrochoanal Polyp
Differential Diagnosis
• Allergic Fungal Rhinosinusitis
• Rhinosporidiosis
• Inverted papilloma
• Meningoencephalocele
• Inferrior tubinate hypertrophy
• Rhinolith
• Foreign body
Investigation
• DISCHARGE C/S
• DNE
• XRAY/CT NOSE AND PARANASAL SINUS
• ROUTINE BLOOD INVESTIGATIONS
Plan
• Endoscopic sinus surgery under GA
Intraoperative Finding
• Pale, polypoidal tissue of size ~10*5*4 cm right maxillary sinus ostium
entirely covering the right nasal cavity extending posteriorly upto the
choana and nasopharynx with mucosal thickening in left maxillary sinus
Thank You
