ENT Clinic Note

Patient's Name: Mrs. Eleanor Vance Reason for Visit: Chronic rhinosinusitis with nasal polyps. Mrs. Eleanor Vance, a 58-year-old female, presents with a chief complaint of chronic nasal congestion, facial pressure, and reduced sense of smell for the past two years. Her symptoms are constant, worsening with seasonal allergies, and significantly impact her quality of life, particularly her enjoyment of food and social interactions. She reports frequent headaches and occasional post-nasal drip. Over-the-counter decongestants and antihistamines provide minimal temporary relief. She has previously tried a course of oral steroids from her GP, which offered short-term improvement but her symptoms recurred. There is no known family history of nasal polyps, but her mother had chronic sinusitis. Physical examination revealed significant bilateral nasal mucosal oedema and multiple grade 2 nasal polyps obstructing both nasal passages. Transillumination of the maxillary sinuses was reduced bilaterally. The remainder of the ENT examination, including otoscopy and pharyngoscopy, was unremarkable. No cervical lymphadenopathy was noted. A detailed discussion of treatment options was conducted. Given the chronic and recurrent nature of her symptoms and the presence of significant nasal polyps, endoscopic sinus surgery (ESS) was proposed. The procedure involves the removal of nasal polyps and enlargement of sinus drainage pathways to improve ventilation and drainage. The benefits include improved nasal breathing, reduced facial pressure, restoration of smell, and decreased frequency of sinus infections. Risks associated with ESS include bleeding, infection, cerebrospinal fluid leak (rare), orbital complications (rare), and recurrence of polyps. Post-operative care will involve saline nasal rinses, topical nasal steroids, and regular follow-up appointments. The recovery timeline is typically 2-4 weeks for initial healing, with full recovery taking several months. We aim to schedule the procedure for late November, with the exact date to be confirmed by the surgical coordinator. Referring Clinician: Dr. Sarah Davies, MBChB, MRCP (GP)