ENT Flashcards
Chronic Rhinosinusitis? complications? Treatment?
young woman is presenting with 6 months of progressive sinus symptoms including congestion, discharge, and change in smell, associated with the visualization of large nasal polyps on rhinoscopy. She meets the criteria for a diagnosis of chronic rhinosinusitis with nasal polyposis for which the first-line therapy is intranasal corticosteroids.
Chronic rhinosinusitis (CRS) is a common, inflammatory disorder of the paranasal sinuses that lasts 12 weeks or longer and is characterized by 4 major symptoms: mucopurulent drainage; nasal obstruction, blockage, or congestion; facial pain pressure or fullness; and a reduction of smell. Subtypes of CRS include CRS with nasal polyposis, without nasal polyposis, and allergic fungal rhinosinusitis (rare). The symptoms of CRS with and without NP are similar, aside from the findings of nasal polyps on rhinoscopy or endoscopy. The treatments are also similar. Allergic fungal rhinosinusitis is a rare condition and requires positive fungal staining of mucus and evidence of IgE-mediated allergy to fungus and is likely beyond the scope of your examination.
Nasal polyps (NP) are usually found in the middle meatus and are almost always described as being a different color than the surrounding pink sinus tissue. They can be yellow, gray, white, or translucent, usually due to a comparatively poor blood supply, and are insensate. Large polyps often lead to obstructive symptoms. Swollen turbinates can be mistaken for polyps, however, turbinates are usually pink and very tender. Nasal polyps due to CRS should be bilateral. Unilateral polyps should raise concern for papilloma or tumor.
The treatment of CRS with NP aims at reducing the size of the polyps and controlling nasal inflammation. Initial therapy should take into account prior therapy but starts with nasal saline spray and nasal corticosteroids for 1-3 months. Given this patient has already tried saline, this should be continued along with the addition of nasal steroids. If this fails, oral steroids can be tried for a short course (10-15 days) to reduce inflammation. If there is a concern for infection (signs of acute bacterial rhinosinusitis) antibiotics can be added. Refractory disease can be treated with sinus surgery or biologic agents. If the patient has significant eosinophilia, other diagnoses such as eosinophilic granulomatosis with polyangiitis (Churg-Strauss) should be considered.
What is Ménière’s disease?
This patient’s symptoms are most consistent with Meniere’s disease which is caused by an increased volume of endolymphatic fluid in the inner ear. Most common between 30 and 60 years of age, Meniere’s disease presents episodically with attacks lasting from several minutes to hours. Characterized by a constellation of symptoms including ear fullness, vertigo, tinnitus, and hearing loss, diagnosis can often be made clinically. The American Academy of Otolaryngology Head and Neck Surgery diagnosis of Meniere’s disease breaks it down based on certainty. To be classified as “definite”, there needs to be two or more episodes of rotational vertigo lasting more than 20 minutes PLUS audiometrically confirmed sensorineural hearing loss, tinnitus, aural fullness, in addition to other causes excluded. On audiometric evaluation, patients will commonly exhibit a low-frequency or combined low-high frequency sensorineural hearing impairment. Treatment includes caffeine and salt restriction, vestibular rehabilitation, intratympanic steroids and gentamicin. There are very few randomized-controlled trials to guide therapy.
