ENT Consultation

**Diagnosis:** 1. Chronic Rhinosinusitis with Nasal Polyposis (ICD-10: J33.8) 2. Eustachian Tube Dysfunction, bilateral (ICD-10: H69.8) **Management:** 1. Start a 3-month course of oral Doxycycline 100mg once daily. 2. Continue with daily nasal saline rinses and Fluticasone propionate nasal spray. 3. Patient information regarding chronic sinusitis sent via email. **History of Presenting Complaint:** This is a follow-up consultation for Mr. David Miller, who initially presented with persistent nasal congestion, facial pressure, and reduced sense of smell. He reports that his primary concerns remain the persistent blockage of his nose and a sensation of fullness in both ears. Mr. Miller describes the nasal congestion as a constant obstruction, worsening at night, which has been present for approximately 18 months. The ear fullness is intermittent but has become more frequent over the last six months, occurring daily and sometimes accompanied by a popping sensation when swallowing. He notes that the facial pressure is localised to the bridge of his nose and under his eyes, typically a dull ache, rated 4/10 on a pain scale. He has tried over-the-counter decongestants, which provide temporary relief for nasal symptoms, but no significant improvement in ear fullness. He also attempted steam inhalation, which offered minimal benefit. There has been a slight progression of symptoms, with the ear fullness becoming more pronounced and frequent since his last visit three months ago. He also reports that his sense of smell has not improved and remains significantly diminished. Previous episodes of similar, though less severe, nasal congestion occurred sporadically in his younger years, managed with antihistamines, but these did not involve the ear symptoms he is currently experiencing. The current symptoms significantly impact his quality of life, particularly his sleep due to nasal obstruction, and his enjoyment of food due to anosmia. He finds it difficult to concentrate at work due to the persistent discomfort. Associated symptoms include mild post-nasal drip and occasional, non-productive coughing. There are no associated headaches, fever, or visual disturbances. The patient was accompanied by his wife, Mrs. Sarah Miller, during the consultation. **Past Medical History:** * Allergic Rhinitis, diagnosed 5 years ago, currently managed with Fexofenadine. * Hypertension, diagnosed 10 years ago, controlled with Ramipril 5mg daily. **Medication History:** * Ramipril 5mg once daily * Fexofenadine 180mg once daily * Fluticasone propionate nasal spray two sprays each nostril once daily (as prescribed at previous consultation) * Nasal saline rinses twice daily **Social History:** * Living situation: Lives with wife in a detached house. * Sleep quality: Poor due to nasal congestion, often wakes up feeling unrested. Experiences frequent awakenings. * Work status: Employed full-time as an accountant. **Family History:** * Mother had chronic sinusitis. * Father had hypertension. **Allergies:** No known drug allergies. **Physical Examination:** General examination revealed a well-appearing gentleman in no acute distress. The examination was performed in the presence of a female chaperone. Examination of the external ear canals was clear, and tympanic membranes were retracted bilaterally with decreased mobility on pneumatic otoscopy, consistent with Eustachian tube dysfunction. The nasal cavity showed significant bilateral oedematous mucosa and large nasal polyps almost completely obstructing the nasal passages. There was no evidence of a deviated nasal septum or external nasal deformity. The tonsils were small and not inflamed. The oropharynx was clear. Tuning fork tests (Rinne and Weber) were normal, indicating no conductive or sensorineural hearing loss. Balance tests were unremarkable. Flexible Fiberoptic Laryngoscopy was not performed during this consultation. Oral Cavity: Mucosa no lesions. Lips no masses or lesions. Oral tongue no masses or lesions, normal mobility. Dentition good. FOM without abnormality. Oropharynx: Soft palate no masses or lesions, normal elevation. Tonsils/fossae without abnormality. Symmetric posterior pharynx. Neck: Soft/flat. No cervical, supraclavicular, or auricular LAD. Trachea midline. Laryngeal framework palpable. Thyroid no masses or fullness. **Investigations:** * Completed investigations and their results: A CT scan of the paranasal sinuses performed three weeks prior revealed extensive mucosal thickening and bilateral nasal polyposis, with complete opacification of the ethmoid and maxillary sinuses. Hearing tests performed one month ago showed normal audiometry. * Previous imaging reviewed: The CT scan of the paranasal sinuses from three weeks ago was reviewed, confirming the findings of chronic rhinosinusitis with nasal polyposis. **Impression:** Diagnosis: Chronic Rhinosinusitis with Nasal Polyposis and bilateral Eustachian Tube Dysfunction. Anatomical finding and potential intervention: Extensive nasal polyposis requiring potential Functional Endoscopic Sinus Surgery (FESS) and Eustachian Tube Balloon Dilation to address symptoms. Differential diagnosis: Allergic rhinitis, fungal sinusitis. **Discussion:** The diagnosis and the treatment options are discussed with the patient in detail. Following which the patient decides to go ahead with the following plan. **Plan:** * Treatment plan: Continue Doxycycline 100mg once daily for 3 months. Continue nasal saline rinses and Fluticasone propionate nasal spray. * Investigations planned or arranged: Referral for allergy testing to further investigate potential allergic triggers for rhinosinusitis. * Previous imaging to be obtained and reviewed: Not applicable. * Conditional management steps: If symptoms of nasal obstruction and ear fullness persist or worsen after 3 months of medical therapy, discuss Functional Endoscopic Sinus Surgery (FESS) – CCSD Procedure Code: E1432 and Eustachian Tube Balloon Dilation – CCSD Procedure Code: D2240 with Dr. Thomas Kelly. * Other relevant actions: Patient counselled on the importance of adherence to medical therapy and potential surgical interventions. A referral to a dietitian for advice on potential food triggers will be considered if allergy testing is inconclusive. * Follow-up timeframe: Review in clinic in 3 months on 1 November 2024 to assess response to treatment and discuss further management. **Information for the patient:** Relevant patient information resources from the ENT UK or NHS UK website: Information leaflets on Chronic Rhinosinusitis and Eustachian Tube Dysfunction provided. **Nasal and Sinus Surgery** **Functional Endoscopic Sinus Surgery (FESS)** – _CCSD Procedure Code: E1432_ **Septoplasty** – _CCSD Procedure Code: E0360_ **Turbinate Surgery** – _CCSD Procedure Code: Not applicable_ **Specific risks (depending on procedure):** Leakage of fluid from around the brain (CSF leak), meningitis, or brain injury (rare, more likely in FESS) Loss of vision or double vision (very rare, more likely in FESS) Watery eyes Hole in the septum (septal perforation – septoplasty only) Changes in the shape of the nose (septoplasty only) Altered sensation in the nose or teeth (may be permanent) Changes in breathing or sense of smell (including possible permanent loss) **Other notes:** Symptoms may return in the future. These procedures will not cure rhinitis; ongoing medical treatment may still be needed. Turbinate surgery results are not always permanent. **Eustachian Tube Balloon Dilation** – _CCSD Procedure Code: D2240_ **Specific risks include:** Bleeding from the nose or back of the throat Infection (sinus or ear) Failure to improve symptoms Discomfort/pressure sensation during healing Very rare injury to nearby structures (internal carotid artery, skull base) **Other notes:** Improvement may be gradual over weeks to months. Some patients may need additional procedures if symptoms persist. Otorhinolaryngologist (ENT Specialist)