2. July 27, 2014 2
MaxillaryMaxillary
SinusitisSinusitis
Dr. ZahoorDr. Zahoor
House Surgeon,House Surgeon,
E.N.T DepartmentE.N.T Department
Capital HospitalCapital Hospital
Case Presentation
3. July 27, 2014 3
CASE NO:CASE NO: 11
Acute on Chronic Maxillary SinusitisAcute on Chronic Maxillary Sinusitis
4. July 27, 2014 4
PERSONAL DATAPERSONAL DATA
NameName :: Mehboob HussainMehboob Hussain
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
5. July 27, 2014 5
HISTORYHISTORY
MAIN COMPLAINTS:MAIN COMPLAINTS:
Pain over cheeks and forehead – 1 yearPain over cheeks and forehead – 1 year
HISTORY OF PRESENTINGHISTORY OF PRESENTING
ILLNESS:ILLNESS:
Pain:Pain: According to the patient, he was alright aAccording to the patient, he was alright a
year back when he started developing pain overyear back when he started developing pain over
the cheeks and forehead, which developedthe cheeks and forehead, which developed
gradually and slowly so much so that he startedgradually and slowly so much so that he started
to have severe pain on bowing his head downto have severe pain on bowing his head down
for sajda during prayers. He got some medicalfor sajda during prayers. He got some medical
treatment off and on with little improvement.treatment off and on with little improvement.
Now he has severe pain over the cheeks for lastNow he has severe pain over the cheeks for last
15 days for which he agreed to get admitted at15 days for which he agreed to get admitted at
capital hospital.capital hospital.
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PAST HISTORY-PAST HISTORY- Patient has past historyPatient has past history
of maxillary sinus wash but details are notof maxillary sinus wash but details are not
available.available.
FAMILY HISTORY-FAMILY HISTORY- Not significant.Not significant.
PERSONAL HISTORY-PERSONAL HISTORY- Smoker (1Smoker (1
pack per day f or last 20 years)pack per day f or last 20 years) withwith
normal bowel habits.normal bowel habits.
……HISTORYHISTORY
Contd.
7. July 27, 2014 7
DRUG HISTORY-DRUG HISTORY- Had been taking antibiotics forHad been taking antibiotics for
sinusitis off and on. No history of any drug allergy.sinusitis off and on. No history of any drug allergy.
SOCIOECONOMIC HISTORY-SOCIOECONOMIC HISTORY- Belongs to lowerBelongs to lower
middle class.middle class.
……HISTORYHISTORY
8. July 27, 2014 8
GENERAL PHYSICALGENERAL PHYSICAL
EXAMINATIONEXAMINATION
A old man sitting anxiously in bed, well orientedA old man sitting anxiously in bed, well oriented
to time, place and person.to time, place and person.
AnaemiaAnaemia
JaundiceJaundice
ClubbingClubbing AbsentAbsent
CyanosisCyanosis
Palpable NodesPalpable Nodes
Contd.
9. July 27, 2014 9
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 PHYSICALGENERAL PHYSICAL
EXAMINATIONEXAMINATION
10. July 27, 2014 10
SYSTEMICSYSTEMIC
EXAMINATIONEXAMINATION
Resp. System:Resp. System:
CVS:CVS: NADNAD
CNS:CNS:
GIT:GIT:..
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E.N.T EXAMINATIONE.N.T EXAMINATION
NASAL EXAMINATIONNASAL EXAMINATION
Inspection:Inspection:
Anterior Rhinoscopy: Swollen inferior Turbinates with some mucopusAnterior Rhinoscopy: Swollen inferior Turbinates with some mucopus
along the nasal floor.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 hygiene
GingivitisGingivitis
12. July 27, 2014 12
EXAMINATION OF EARSEXAMINATION OF EARS
Inspection:Inspection: Surrounding area, pinnae, EAM, EAC,Surrounding area, pinnae, EAM, EAC,
T.M normal.T.M normal.
Palpation:Palpation: NADNAD
Hearing Test:Hearing Test: Hears forced wisper at ear levelHears forced wisper at ear level
Tunning Fork Tests:Tunning Fork Tests:
Rinne’sRinne’s :: Positive on both sidesPositive on both sides
WeberWeber :: CentralCentral
ABCABC :: Reduced by 5 seconds both sides.Reduced by 5 seconds both sides.
Contd.
……E.N.T EXAMINATIONE.N.T EXAMINATION
13. July 27, 2014 13
PROVISIONAL DIAGNOSISPROVISIONAL DIAGNOSIS
Acute on Chronic Maxillary SinusitisAcute on Chronic Maxillary Sinusitis
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 LimitsWithin Normal Limits
Blood Sugar (Random):Blood Sugar (Random): 90 mg/dl90 mg/dl
Contd.
15. July 27, 2014 15
……INVESTIGATIONSINVESTIGATIONS
X-Ray PNS (OMX-Ray PNS (OM
View):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. turbinatesBoth Middle and inf. turbinates
Swollen with obliteration ofSwollen with obliteration of
both nasal spaces.both nasal spaces.
X-Ray chest :X-Ray chest :
NormalNormal..
Contd.
16. July 27, 2014 16
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 Department.Drugs Advised by Medical 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 symptomsPatient was much relieved of his symptoms
at the time of discharge and a check X-Rayat the time of discharge and a check X-Ray
revealed improvementrevealed improvement
RESULTS & FOLLOW UPRESULTS & FOLLOW UP
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Fungal Sinusitis with PolypiFungal Sinusitis with Polypi
20. July 27, 2014 20
PERSONAL DATAPERSONAL DATA
NameName :: DoniaDonia
D/OD/O :: Muhammad Farid - CDA Employee.Muhammad Farid - CDA Employee.
AgeAge :: 22 Years, Female22 Years, Female
BedBed :: F.10, E.N.T Dept. Capital HospitalF.10, E.N.T Dept. Capital Hospital
D.O.AD.O.A :: 05.05.200305.05.2003
D.O.DD.O.D :: 30.05.200330.05.2003
21. July 27, 2014 21
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 was alrightAccording to the patient she was alright
5 months back when she slowly developed difficulty5 months back when she slowly developed difficulty
breathing through nose, so much so that now she canbreathing through nose, so much so that now she can
hardly breath and has to keep her mouth open duringhardly breath and has to keep her mouth open during
night. She said that this nasal obstruction is also associatednight. She said that this nasal obstruction is also associated
with some facial disfiguration especially prominence ofwith some facial disfiguration especially prominence of
eye balls.eye balls.
Headache:Headache: Nasal obstruction was also accompanied byNasal obstruction was also accompanied by
headache on the forehead, which is mild in intensity.headache on the forehead, which is mild in intensity.
22. July 27, 2014 22
PAST HISTORY-PAST HISTORY-
FAMILY HISTORY-FAMILY HISTORY-
PERSONAL HISTORY-PERSONAL HISTORY-
……HISTORYHISTORY
Contd.
Nothing significantNothing significant..
23. July 27, 2014 23
DRUG HISTORY-DRUG HISTORY- Had been taking antibiotics and otherHad been taking antibiotics and other
drugs as prescribed by different G.P’s. No history of any drugdrugs as prescribed by different G.P’s. No history of any drug
allergy.allergy.
SOCIOECONOMIC HISTORY-SOCIOECONOMIC HISTORY- Belongs to lowerBelongs to lower
middle class.middle class.
……HISTORYHISTORY
24. July 27, 2014 24
GENERAL PHYSICALGENERAL PHYSICAL
EXAMINATIONEXAMINATION
A young girl sitting anxiously in bed, with proptosed eyesA young girl sitting anxiously in bed, with proptosed eyes
and well oriented to time, place and person.and well oriented to time, place and person.
AnaemiaAnaemia
JaundiceJaundice
ClubbingClubbing AbsentAbsent
CyanosisCyanosis
Palpable NodesPalpable Nodes
Contd.
25. July 27, 2014 25
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 PHYSICALGENERAL PHYSICAL
EXAMINATIONEXAMINATION
26. July 27, 2014 26
SYSTEMICSYSTEMIC
EXAMINATIONEXAMINATION
Resp. System:Resp. System:
CVS:CVS: N0RMALN0RMAL
CNS:CNS:
GIT:GIT:..
27. July 27, 2014 27
E.N.T EXAMINATIONE.N.T EXAMINATION
NASALNASAL
EXAMINATIONEXAMINATION
Inspection:Inspection:
Proptosis more on right side.Proptosis more on right side.
TelecanthusTelecanthus
Swelling over the right cheekSwelling over the right cheek
Anterior Rhinoscopy: BilateralAnterior Rhinoscopy: Bilateral
polypoidal mass with somepolypoidal mass with some
cheesy material & mucopus.cheesy material & mucopus.
PalpationPalpation: Firm swelling over: Firm swelling over
right cheek which was tender.right cheek which was tender.
28. July 27, 2014 28
EXAMINATION OF THROATEXAMINATION OF THROAT
NADNAD
EXAMINATION OF EARSEXAMINATION OF EARS
NADNAD
Contd.
……E.N.T EXAMINATIONE.N.T EXAMINATION
29. July 27, 2014 29
C.N I - XIIC.N I - XII Intact.Intact.
EXAMINATION OF CRANIALEXAMINATION OF CRANIAL
NERVESNERVES
30. July 27, 2014 30
INVESTIGATIONSINVESTIGATIONS
CP:CP:
TLC:TLC: 9.0 Thsd/Cu mm9.0 Thsd/Cu mm
DLC: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: NormalNormal Contd.
31. July 27, 2014 31
……INVESTIGATIONSINVESTIGATIONS
X-Ray PNS (OMX-Ray PNS (OM
View):View):
Hazy maxillary and ethmoidHazy maxillary and ethmoid
sinusessinuses
Also nasal cavity appearsAlso nasal cavity appears
obliterated.obliterated.
X-Ray chest :X-Ray chest :
NormalNormal..
Contd.
32. July 27, 2014 32
……INVESTIGATIONSINVESTIGATIONS
C-T Scan (Nose andC-T Scan (Nose and
PNS)PNS)
Obliteration of the nasal cavity, Rt.Obliteration of the nasal cavity, Rt.
Maxillary sinus, ethmoids with littleMaxillary sinus, ethmoids with little
extension into anterior cranial fossa.extension into anterior cranial fossa.
Lt. maxillary sinus is minimallyLt. maxillary sinus is minimally
affected.Destruction of Rt. Medialaffected.Destruction of Rt. Medial
orbital wall is also noted with littleorbital wall is also noted with little
extension into orbit.extension into orbit.
Likely lesion could be NasalLikely lesion could be Nasal
polyposis, fungus. Howeverpolyposis, fungus. However
malignancy cannot be excluded.malignancy cannot be excluded.
Contd.
Coronal Views
34. July 27, 2014 34
PROVISIONAL DIAGNOSISPROVISIONAL DIAGNOSIS
Fungal Sinusistis with polypiFungal Sinusistis with polypi
35. July 27, 2014 35
SURGICAL TREATMENTSURGICAL TREATMENT
After thorough preoperative preparation on 17.5.2003After thorough preoperative preparation on 17.5.2003
at 10.00 a.m following surgical procedure wasat 10.00 a.m following surgical procedure was
performed under general G/A with oro-trachialperformed under general G/A with oro-trachial
intubation through oral cavity and throat packing.intubation through oral cavity and throat packing.
1.1. Bilateral polypectomyBilateral polypectomy
2.2. Cald well Luc’s operation on right side includingCald well Luc’s operation on right side including
transantral ethmoidectomy and antrostomy.transantral ethmoidectomy and antrostomy.
3.3. Left sided transnasal ethmoidectomy.Left sided transnasal ethmoidectomy.
BIPP & clotrim imprenated packing done in antrumBIPP & clotrim imprenated packing done in antrum
and nasal cavity.and nasal cavity.
TREATMENTTREATMENT
38. July 27, 2014 38
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.