A 22-year-old female presented with 5 months of nasal blockage and headache. Examination found proptosis of the eyes, swelling of the right cheek, and polyps obstructing the nasal cavity. Imaging showed haziness of the sinuses and obliteration of the nasal cavity. She underwent surgery including polypectomy and Caldwell Luc procedure on the right side to address suspected fungal sinusitis with polyps.

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MaxillaryMaxillary
SinusitisSinusitis
Dr. ZahoorDr. Zahoor
House Surgeon,House Surgeon,
E.N.T DepartmentE.N.T Department
Capital HospitalCapital Hospital
Case Presentation

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CASE NO:CASE NO: 11
Acute on Chronic Maxillary SinusitisAcute on Chronic Maxillary Sinusitis

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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

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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.

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 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

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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.

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 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

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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

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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

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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.

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……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.

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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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CASE
2

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Fungal Sinusitis with PolypiFungal Sinusitis with Polypi

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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

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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.

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 PAST HISTORY-PAST HISTORY-
 FAMILY HISTORY-FAMILY HISTORY-
 PERSONAL HISTORY-PERSONAL HISTORY-
……HISTORYHISTORY
Contd.
Nothing significantNothing significant..

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 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

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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.

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 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

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SYSTEMICSYSTEMIC
EXAMINATIONEXAMINATION
 Resp. System:Resp. System:
 CVS:CVS: N0RMALN0RMAL
 CNS:CNS:
 GIT:GIT:..

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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.

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EXAMINATION OF THROATEXAMINATION OF THROAT
NADNAD
EXAMINATION OF EARSEXAMINATION OF EARS
NADNAD
Contd.
……E.N.T EXAMINATIONE.N.T EXAMINATION

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 C.N I - XIIC.N I - XII Intact.Intact.
EXAMINATION OF CRANIALEXAMINATION OF CRANIAL
NERVESNERVES

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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.

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……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.

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……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

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Axial Views

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PROVISIONAL DIAGNOSISPROVISIONAL DIAGNOSIS
Fungal Sinusistis with polypiFungal Sinusistis with polypi

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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

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……TREATMENTTREATMENT
MEDICAL TREAMENTMEDICAL TREAMENT
 Inj. Ceftim 1 gm i/v BDInj. Ceftim 1 gm i/v BD for 5 daysfor 5 days
 Followed by Cap.Kefril 500 mg TDSFollowed by Cap.Kefril 500 mg TDS 1 wk.1 wk.
 Inj. Chymoral 1 amp I/M TDSInj. Chymoral 1 amp I/M TDS 2 days2 days
 Xynosine nasal spray tdsXynosine nasal spray tds
 Myconil drops tdsMyconil drops tds
 Liquid Paraffin drops tds.Liquid Paraffin drops tds.
 Steam inhalations tds.Steam inhalations tds.
 Inj. Dicloran 1 amp. I/M SOSInj. Dicloran 1 amp. I/M SOS
 Tab. Brufen tds.Tab. Brufen tds.
 Tab. Diflucan 200 mg ODTab. Diflucan 200 mg OD 4 weeks.4 weeks.

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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.

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Thank you!

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