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Case write up ent

  1. 1. PATIENT’S BIODATAName : Mr IRAge : 30 years oldSex : MaleRace : MalayRegistration no : AM 144046Date of presentation : 28/07/2010PRESENTING COMPLAINTElectively admitted for bilaterally tonsillectomy and CAPSO under General Anasthesia.HISTORY OF PRESENTING COMPLAINTHe first presented in the clinic November last year due to chronic snoring problem for the past 10years. It progressively worsened with increased in weight gain. The snoring problem sometimescaused him to wake up in the middle of the night due to shortness of breath (SOB) which lead tofrequent awakening at night which affected his sleeping pattern. Before November last yeasr, heseldom had sleep apneic attacks. However, since November last year, ithappened approximatelytwice in a week, thus rending him unable to sleep soundly at night.During the day, he usually will be lethargic, sleepy and weak. Thus, his work was also affected.He also had recurrent sore throat for the past 3 years with attack as frequent as once monthlywith or without fever. The sore throat episodes were usually preceded by Upper RespiratoryTract Infection. There was also cough present.However, there was no pain, altered taste, dryness, trismus, dysphagia, odynophagia, ear ache orother constituitional sypmtoms. Furthermore, there was no voice change (eg. dysarthria,hoarseness), noisy breathing (eg. snoring, stridor), cough, halitosis or repeated throat clearing.There was no loss of appetite or loss of weight.Systemic reviews of other systems were also unremarkable.
  2. 2. PAST MEDICAL AND PAST SURGICAL HISTORYUnremarkableDRUGS AND ALLERGIESHe is only allergic to seafood whereby when he took seafood he will develop ithciness all overthe skin. Otherwise, he has no other known allergies.FAMILY HISTORYHe has a positive family history of atopy. His mother has Eczema and Hypertension while hisyounger brother has childhood asthma. Otherwise, there were no other chronic medical illnesses.SOCIAL HISTORYMr. Iznal Rafa is currently single and work as an instrument service technician. His totalmonthly income are approximately RM1,800. He lives with his friend in a single storey house inCheras. He is a smoker of 7 cigarretes per day for the past 10 years. Other than that, he is a non-drinker.PHYSICAL EXAMINATIONGENERAL EXAMINATIONPatient looked obese but generally he was alert and comfortable, not pale looking or jaundice.Weight: 105 kg Height: 1.7 m BMI: 36.33Vital Signs: Pulse Rate : 86 beats/min, regular and good volume Respiratory rate : 20 breaths/min, regular Blood Pressure : 130/70 mmHg Temperature : 37 oC
  3. 3. OTORHINOLARYNGOLOGICAL SYSTEM • Oral Cavity Lips and buccal mucosal were well hydrated. Mouth opening was good. There was no halitosis. Dentition was good, no missing teeth and bledding gums. No tongue atrophy or deviation. Hard palate appeared normal. There was no cracks, ulcers or masses seen in the oral cavity. • Oropharnyx There were bilateral tonsils enlargement and they appeared erythematous. However, there was no follicles or exudate seen. (Grade 3). Uvula was slightly erythematous. Soft palate, posterior pharyngeal wall and base of tongue appeared to be normal. There was no ulcers, swelling or any other masses seen. The larynx was normal with mobile vocal cords. • Ear The pinna and external auditory meatus were normal bilaterally. The tympanic membrane appeared translucent pearly white and no abnormalities were detected on both sides. Rinne’s test was positive on both sides. Weber’s test was equal bilaterally. • Nose The nose appeared normal bilaterally. No scars, sinus, swelling or any deformities seen. On anterior rhinoscopy, the septum looked normal. Right side inferior turbinate was slightly oedematous and boggy. The left side infererior turbinate was normal. Otherwise, the mucosa appeared pink and were not pale and edematous bilaterally. Middle meatus was normal. No polyps or foreign bodies were seen. The posterior nasal space was normal. • Neck: The neck was in normal attitude. There was no noticeable swelling, discoloration, ulcer, or prominent veins. There was no temperature, tenderness, mass, or lymph node enlargement. The trachea was not deviated.
  4. 4. No nodes or masses were palpable. No abnormalities were seen.OTHER SYSTEMSThe cardiorespiratory examination revealed normal chest with vesicular breath sound and noadded ronchi or crepitation. Apex beat was not dislocated and first and second heart sound washeard with no murmur. Abdomen was soft and non tender. There was no organomegaly.SUMMARYMr IR, a 30 year old Malay gentlemen presented with history of chronic snoring for 10 years and3 years history of recurrent tonsillitis electively admitted for bilateral tonsillectomy with CAPSOunder general anesthesia. Physical examination revealed grade 3 bilateral hypertrophicerythematous tonsils with erythematous uvula.DIAGNOSISChronic Tonsillitis causing obstructive sleep apneaMANAGEMENTFollowing a complete history and physical examination, relevant baseline investigations shouldbe carried out since patient will undergo an operation under general anaesthesia. Even though hehad no other chronic medical illnesses, patient still has every possible risk especially since he isobese.INVESTIGATION 1. Full blood count Objective: - To check for and infection and Hameglobin level since he had been having recurrent tonsillitis - For pre-operation assessment
  5. 5. 2. Renal profile Objective: To assess renal function (pre operation assessment) 3. Liver function test Objective: To assess renal function (pre operation assessment) 4. Blood grouping cross match Objective: For preparation in case of any complication from the surgery which will need blood transfusion. 5. Chest x-ray Objective: To assess patient’s lung condition for pre-operation assessmentTREATMENT 1. Bilateral tonsillectomy with CAPSO under General Anasthesia.DISCUSSIONTonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterialinfection. Symptoms of tonsillitis include sore throat and fever. While viral tonsillitis mustresolve on its own, tonsillitis caused by bacteria is treatable with antibiotics, which usuallyresolves symptoms in two to three days.Chronic tonsillitis is a persistent infection in the tonsils. Since this infection is repetitive, cryptsor pockets can form in the tonsils where bacteria can store. Frequently, small, foul smellingstones (tonsilloliths) are found within these crypts that are made of high quantities of sulfur.These stones cause a symptom of a full throat or a throat that has something caught in the back.A foul breath that is characterized by the smell of rotten eggs (because of the sulfur) is also asymptom of this condition. Other symptoms that can be caused by tonsillitis that are notnormally associated with it include snoring and disturbed sleep patterns. These conditionsdevelop as the tonsils enlarge and begin to obstruct other areas of the throat. A persons voice isgenerally affected by this type of illness and changes in the tone of voice a person normally has.While a person may only become hoarse, it is possible for laryngitis to develop if the throat is
  6. 6. used too much while the tonsils are swollen or inflamed. Other uncommon symptoms that can beexperienced with tonsillitis include vomiting, constipation, a tongue that feels furry or fuzzy,difficulty opening the mouth, headaches and a feeling of dry or cotton mouth.In my patient, he presented with chronic history of snoring which affected his quality of life dueto his lack of sleep. The recurrent tonsillitis that he had been having for the past 3 years alsomade the snoring problem worse apart from his weight increment. These are two predisposingfactors for his snoring problem along with the smoking. His physical examination revealed grade3 bilateral hypertrophic tonsils which are an indication for operation apart from the monthlyattack of sore throat. Thus he was electively being admitted for bilateral tonsillectomy withCAPSO. Since the operation will be done under general anaesthesia, baseline investigationsshould be carried out especially since he is obese. The post operative complications are not to betaken lightly. The same reason goes for the complete physical examination. [1]A tonsillectomy is a 2,000 year-old surgical procedure in which the tonsils are removed fromeither side of the throat. The procedure is performed in response to cases of repeated occurrenceof acute tonsillitis or adenoiditis, obstructive sleep apnea, nasal airway obstruction, snoring, orperitonsillar abscess. Sometimes the adenoids are removed at the same time, a procedure calledadenoidectomy. Although tonsillectomy is being performed less frequently than in the 1950s, itremains one of the most common surgical procedures in children in the United States.Post operatively: • A sore throat will persist for around two weeks. Most patients do not feel like swallowing anything during the first few days after surgery. Patients should try to get as much fluid down as possible, as it will help speed recovery. Very cold drinks will help bring down swelling. Ice cream, frozen yogurt and other dairy products are not recommended because they leave a film in the mouth that is difficult to swallow. Sherbet and popsicles, on the other hand, are recommended. Additionally, Slushies are particularly helpful for sore throats, especially when sugar-free. • Pain following the procedure is significant and may include a hospital stay. [2] Recovery can take from 10 up to 20 days, during which narcotic analgesics are typically prescribed. Patients are encouraged to maintain diet of liquid and very soft foods for several days following surgery. Rough textured, acidic or spicy foods may be irritating and should be
  7. 7. avoided. Proper hydration is very important during this time, since dehydration can increase throat pain, leading to a vicious cycle of poor fluid intake.[3][4] • At some point, most commonly 7–11 days after the surgery (but occasionally as long as two weeks (14 days) after), bleeding can occur when scabs begin sloughing off from the surgical sites. The overall risk of bleeding is approximately 1%–2% higher in adults.[5] Approximately 3% of adult patients develop significant bleeding at this time. The bleeding might naturally stop quickly or else mild intervention (e.g., gargling cold water) could be needed (but ask the doctor before gargling because it might bruise the area of the skin that has been cauterized). Otherwise, a surgeon must repair the bleeding immediately by cauterization, which presents all the risks associated with emergency surgery (primarily the administration of anesthesia particularly on a patient whose stomach may not be empty).Cautery-assisted palatal stiffening operation (CAPSO) is a procedure where the surgeon useselectrocautery equipment to remove part of the soft palate and uvula. It burns the uvula causingfibrosis and consequent stiffening of the uvula thus increase the arch of palate and subsequentlyincrease the airway to reduce snoring. There are no long-term efficacy data available at present.[6]According to a study, its short-term effectiveness is rated as high at 92% and effectiveness within12 months is average at 77%.[7]REFERENCES 1. McNeill RA., RA (1 June 1960). "A History of Tonsillectomy: Two Millenia of Trauma, Hæmorrhage and Controversy". Ulser Medical Journal 29 (1): 59–63. PMID 20476427. PMC 2384338
  8. 8. 2. Graham, John M.; Glenis K. Scadding, Peter D. Bull (2008). Pediatric ENT. Springer. pp. 136. ISBN 35406993093. Timby, Barbara Kuhn; Nancy Ellen Smith (2006). Introductory medical-surgical nursing. Lippincott Williams & Wilkins. pp. 357. ISBN 0781780322.4. Pemberton, Cecilia M. (1988). Mayo Clinic diet manual. B.C.Decker. ISBN 1556640323.5. Windfuhr JP, Chen YS, Remmert S. (2005). "Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients". Otolaryngology-Head & Neck Surgery 132 (2): 281– 86. doi:10.1016/j.otohns.2004.09.0076. New and Emerging Techniques – Surgical by Royal Australian College of Surgeons7. Zachary Wassmuth, Eric Mair, Daniel Loube, David Leonard. Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome, Otolaryngology Head and Neck Surgery Jurnal. Vol 123 issue 1 page 55-60.