ENT Letter

Date of consultation: 01/11/2024 Private & Confidential Mrs. Eleanor Vance, DOB: 15/03/1975 42 Orchard Lane, Greenford, London, UB6 7PL EMPI: EV750315A Mobile No. 07700 900321 elena.vance@example.com Dr. Sarah Jenkins, Greenford Family Practice, 12 High Street, Greenford, London, UB6 0JY Consultation Record: Reason for Consultation: Chronic rhinosinusitis with nasal polyps, experiencing persistent nasal obstruction and reduced sense of smell. History of Presenting Complaint: Mrs. Vance, a 49-year-old female, presents with a 2-year history of persistent nasal obstruction, facial pressure, and hyposmia. She reports a dull, constant pressure across her forehead and cheeks, which occasionally worsens with weather changes. The nasal obstruction is bilateral and intermittent but has become more consistent in recent months, significantly impacting her sleep quality and daily activities. She denies any purulent nasal discharge or epistaxis. Patient requests improvement in breathing and sense of smell. The symptoms began insidiously, approximately two years ago, with mild nasal congestion. Over time, the congestion progressed to significant obstruction, accompanied by a gradual decline in her ability to smell and taste. She has tried various over-the-counter nasal decongestants and saline rinses, providing only temporary and minimal relief. Her general practitioner initially prescribed a course of oral antibiotics and steroid nasal sprays, which improved symptoms slightly but did not resolve the underlying issue. Symptoms are exacerbated by environmental allergens, particularly dust and pollen, and cold, dry air. She finds some relief with warm, humid air and lying down. Self-treatment has primarily involved daily saline nasal rinses and occasional over-the-counter antihistamines, which have offered limited symptomatic improvement. She has also tried an air purifier in her bedroom, which has not made a noticeable difference. The condition has steadily worsened over the past year. Initially, symptoms were episodic, but now she experiences constant nasal blockage and facial pressure. The hyposmia has also become more pronounced, affecting her enjoyment of food and ability to detect hazards like gas leaks. She notes that previously, she would have periods of relative clarity, but these are now rare. She recalls a similar, but less severe, episode of prolonged nasal congestion about five years ago, which was managed with a short course of oral steroids and resolved completely. She denies any prior diagnosis of chronic sinusitis or nasal polyps. The chronic nasal obstruction severely impacts her sleep, leading to daytime fatigue and reduced concentration at work. Her reduced sense of smell affects her quality of life and has caused her some anxiety regarding safety. She is a marketing executive and finds that her fatigue affects her professional performance. She avoids social gatherings in dusty environments. Associated symptoms include occasional post-nasal drip, mild throat irritation, and a feeling of ear fullness, particularly in her right ear. She denies fevers, chills, or significant headache. Allergies: Penicillin (rash) Dust mites (sneezing, rhinorrhoea) Past Medical History: Thyroidectomy (2010, for benign nodule) Hypertension (controlled with medication) Anxiety disorder (managed with counselling) Drug History: Amlodipine 5mg OD Levothyroxine 75mcg OD Fexofenadine 180mg OD (as needed for allergies) Social History: Lives with husband in a semi-detached house with two children. Non-smoker. Occasional alcohol use (1-2 units/week). Works full-time as a marketing executive. No significant occupational exposures. Sleep is disturbed due to nasal obstruction; often wakes up feeling unrefreshed. Family History: Mother: History of allergic rhinitis Father: History of asthma Brother: History of chronic sinusitis SNOT-22 Score: SNOT-22 total score: 45 (Moderate to severe impact) On Examination: Findings on anterior rhinoscopy including anatomical and mucosal observations: Bilateral pale, boggy turbinates. Mucosal oedema noted in both nasal passages. Small, sessile polyps visible in the anterior aspect of the middle meatus bilaterally. Clear watery discharge present bilaterally. Findings on nasal endoscopy including anatomical and mucosal observations: Extensive oedematous mucosa throughout both nasal cavities. Large, gelatinous polyps originating from the middle meatus, partially obstructing the nasal passages. Inferior turbinates appear hypertrophic. No evidence of purulent discharge or active inflammation. Septum is central with no significant deviation. Investigations: CT Paranasal Sinuses (01/10/2024): Extensive mucosal thickening and opacification of bilateral maxillary, ethmoid, and frontal sinuses. Presence of large nasal polyps filling both nasal cavities, consistent with chronic rhinosinusitis with nasal polyposis. Impression: Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP), significantly impacting quality of life due to nasal obstruction, hyposmia, and facial pressure. The extensive nature of the polyposis on CT suggests a need for surgical intervention. Plan: Endoscopic Sinus Surgery (ESS) with polypectomy and possible turbinate reduction. Proposed date to be scheduled pending pre-operative assessments. Expected outcome: improved nasal airflow, reduction in facial pressure, and potential improvement in sense of smell. Nasal steroid spray (e.g., Fluticasone Propionate) 2 sprays each nostril BD for 6 weeks post-surgery, then OD long-term. Oral Doxycycline 100mg OD for 21 days pre-operatively to reduce inflammation. Investigations ordered or arranged: Pre-operative blood tests (FBC, U&E, Coagulation screen). Previous imaging or results to be obtained and reviewed: Previous CT scan to be reviewed again prior to surgery by the surgical team. Conditional management steps: Patient to complete pre-operative blood tests and an anaesthetic review prior to surgery. Other actions including counselling provided: Discussed risks and benefits of ESS, including potential for recurrence. Provided patient with information leaflets on CRSwNP and ESS. Counseled on the importance of continued medical management post-surgery. Planned follow-up appointment details including timeframe and clinic type: 6 weeks post-operatively in ENT outpatient clinic. The specific procedure risks of endoscopic sinus surgery include but are not limited to: bleeding, infection, CSF leak, meningitis, brain injury, visual loss or double vision, watery eyes, pain, altered breathing and smell including loss of smell. You are aware that your symptoms may recur and surgery will not cure your condition, but may improve your medical management. C.C. Dr. Sarah Jenkins Priory Medical Records