It case presentation

1. Case presentation
Dr: Nmarig Mohamed albushari
4/2022

2.  Name : M. A. A. A
 Age :67 years
 Sex: male
 Occupation : farmer
 Residence : Halfa

3. C/O
- Left cheek swelling 4 years
and Lt nasal obstruction
-left decrease of vision 6 months

4. HPI:
 Condition started 4 years ago with a small left side cheek swelling
which gradually increased in size ,then breached the skin anteriorly
in the last three months and developed small amount of bleeding from
the swelling, not associated with pain, and
 No facial pain or numbness .
 Also there is left side intermittent nasal obstruction , for 4 years . With
normal right side.
 No allergic symptoms (sneezing , itching or cough ) , no nasal or post
nasal discharge , no epistaxsis no nasal regurgitation , no snoring no
change of voice or SOB and no smell disorder .

5.  Six months ago the patient experience decrease
vision in the left side which was progressive till
he became completely blind before two weeks.
 No left eye protrusion, pain or epiphora.
 on the right eye, no diplopia, no blurred of
vision no pain and no vision loss.

6.  There is loss of teeth with no history of tooth extraction.
 No headache , no fever , no projectile vomiting or loss
of conciousness, no behavioral changes.
 No decrease hearing, no ear discharge bilatrally . No
tinnitus or vertigo.
 No neck swelling .
 No difficulty or pain with swallow and no hoarseness
of voice.
 Patient seen by opthalmologist , requested MRI and
referred for ENT consultation.

7. Systemic review
Cardiopulmonary:
no cough , SOB , chest pain, palpitation or
hemoptysis .
GIT :
no reflux ,epigastric pain or vomiting.
GU :
no heamturea or dysurea .
MS:
no joint pain , muscle weakness or skin lesions.

8. PMH:
 Patient known hepatitis B positive for 6 years and not
recived treatment or .
 Not known asthmatic ,diabetic or hypertensive
 No history of admission or blood transfusion
 No hx of radiotherapy.

9. Drug history
-not known allergic to any type of drugs .
-not under long term drugs .

10. FH
no similar condition , HTN , DM , bronchial
asthma or chronic cough .

11. Social history
He is a farmer, not smoker, snuffier or alcoholic
consumer
- No healthy insurance.

12. summary
 A 63yrs old male known case of hepatitis B, presented
with Lt side progressive, painless cheeck swelling
associated with ipislateral intermittent nasal
obstruction for 4 years before 3 months ago stated to
bleed , 6 months ago he developed decrease vision on
the left side ended by complete loss .
 No others nasal symptoms , no ear symptoms and no
symptoms of increase of intracranial pressure .

13. Examinations:
 Pt looks ill , not pale jaundiced or cyanosed
PR :80 /MIN Regular of good volume
RR :15 /MIN
BP : 130/80

14.  There is Lt side fungating cheek mass about 6×4cm lateral
to the nose Extended from the infraorbite to middle of the
cheek, skin over it is ulcerative in the medial side with
fleshy mass protruding through the ulcer, and normal skin
in the rest of the swelling. regular will defined edges . No
active bleeding.
 No bleeding on touch ,Firm in consistency, not tender or
hot and it attached to underlying structure.
 Bony defect in the maxillary bone below it.

16. Nasal examination:
inspection: normal nasal contour, no swelling
or previous scar.
Palpitation: no nasal or cheek tenderness
 Anterior rhinoscopy :
normal central septum with bilatral normal
mucosa and patent lumen and no ulcer,
granulation tissue dischargr or mass.
Spatula test fogging bilatrally .

17.  Oral cavity:
 there Is loss Of teeth (upper and lower incisers,
upper pre molar) with dental caries.
 Normal gengiva, normal hard palate no bony
defect or swelling .no cheek numbness
 Soft palate is mobile.
 Oropharynx:
No postnasal dripping.

18.  Posterior rhinoscopy :
No visible mass.Lt and Right Rossen Molars'
fossa is free with patent choana.
 Endoscopic examination:
Bilatrally normal turbinates , normal nasopharynx
IDL normal

19. Eye exam:
Inspection: bilateral no ptosis or proptosis
Left: cmpletely blind and difficult to assess eye movement
Right: normal eye movement, normal visual acuity and normal visual color.
Ear exam:
bilateral normal external ears, normal mobile tympanic membranes.
cranial nerves:
are intact except left optic nerve .

20. Neck exam
No palpable lymph nodes
 No thyroid enlargement.
 trachea is central. With present of Laryngeal crepitus.
Systemic examination :
Normal.

21. Radiological studies :


22. DD:
 Sinonasal tumor.
 Invasive fungal Rhinosinusitis:
• chronic
• Granulomatous
• Granulomatous disease

23. Investigations :
 CBC : normal . HGB 13.2 WBC 9.9 PLT 300
 U.G : clear .
 RFT: normal.
 ESR : 10mm/Hr .
 RBS : 125 m mol / dl .
 LFT:
ALT 87 IU/L n <40
AST 75 OU/L n <40

32. Radiological study:
 There is soft-tissue opacification homogenous
hypodense in the left maxillary sinus extending
anteriorly and destruct anterior wall of ththe
sinus.
 Also extending superiorly and destructing the
inferior orbital wall and orbital apex with
intraorbital extension and involving the optic
nerve.
 Involve also the base of the skull.

33. Patient underwent biopsy from
cheek swelling for
histopathology
Result: Aspergillus
granuloma( Aspergilloma)

35. Plan:
_ consultation for medicine department (HB+ve)
_ FESS + antifungal
_follow up

36. thanks