Case Presentation

Case presentation
By- Dr.lavanya
Moderator-Dr.Byra Reddy
Professor & H.O.D
Case History
 Name - Ramya
 Age - 18 yrs
 Sex - Female
 Occupation –student
 Address -Tirupattur
Chief complaints
1. Nasal obstruction since 1yr
2. Headache since 1yr and is

increased in intensity since 3
months
H/o present illness
1.H/o of nasal obstruction since 1 yr
aggravated since 1yr
 It is Rt side of nose
 It is insidious in onset
 Gradually Progressive
 Not relieved after taking medication

H/o present illness
2.H/o headache since 1 yr increased in
intensity since 3 months
 Insidious in onset, continuous type, more
during mornings
 Progressive in nature
 Headache associated with facial pain over
cheek
 No h/o nausea ,vomiting
 Relieves with medication again recurres

H/o present illness
 No h/o fever
 H/o of recurrent attacks of nasal discharge
 No h/o excessive sneezing
 No h/o itching sensation in the nose
 Pt able to perceive smell normally
 No h/o bleeding from nose
 No h/o ear complaints, No h/o change in voice

Past history
 No h/o similar complaints in the past
 Not a known diabetic , hypertensive
 No h/o asthma
 No h/o epilepsy
Family history
 No h/o allergic symptoms in the family
 No h/o bleeding tendency in the family
 No other chronic medical illness

Personal history
 No h/o taking bath in stagnant water
 No h/o excessive use nasal drops
 Sleep
 Appetite normal
 Bowel
 bladder
Treatment history
 Pt not consulted in any other hospitals
 When pt is suffering from sever headache she
took medication by her own
 In the past pt not had any allergic reactions, in the
present admission pt had doubtful allergic
reactions with inj. Taxim
 No h/o previous surgeries

General physical examination
 pt is conscious, well oriented to time, place,
person
 Moderately built and nourished
 No pallor, no cyanosis, no clubbing, no
icterus, no pedal edema, no generalized
lymphadenopathy
 vitals; temp-afebrile, BP;110/70 mm of Hg ;
Pulse; 84 beats/min ; RR; 18 cycles/min
General physical examination
 CVS ; S1 S2 +, No murmurs
 RESP: B/L NVBS +,no additional

sounds.
 P/A: soft, no organomegaly.
 CNS: NAD
Examination of nose & PNS
 External appearance of nose: Normal
 Tip test ; no caudal dislocation
 Cold Spatula test :
Rt side of nose decreased mist formation
 Vestibule ; normal
 Anterior rhinoscopy examination:
 No deviation of nasal septum
 pearly white smooth polypoidal mass noted in Rt
nasal cavity extending from middle meatus to middle
of inferior turbinate.
Anterior rhinoscopy
Contd…,
 Nasal mucosa – normal on both nasal cavities
 Lateral wall
 Rt side Lt side
 Inferior turbinate normal normal
 Inferior meatus normal normal
 Middle turbinate normal normal
 Middle meatus polyp + normal
Contd…,
 On Probe test :
 Mass can be probed around expect on lateral
side
 Mass is soft in consistency.
 Mass is relatively insensitive.
 No bleeding on touch
Posterior rhinoscopy
Anteriorly: Posterior part of septum-central
Lt choana : Normal
Rt choana : normal
Posterior ends of turbinates – nomal
Ppw – Normal
Laterally:
Eustachian tube openings –
Normal
Superiorly roof of
nasopharynx-normal
Examination of paranasal sinuses
 Inspection : Skin over the sinuses normal.

 Palpation : No sinus tenderness present.
ENT examination
 EXANINATION OF EAR
 EAR RT LT
 Pinna N N
 Pre&post
 Aricular region N N
EAC N N
 TM N N
Contd….,
 OTONEUROLOGICAL EXAMINATION
 FISTULA TEST: normal
 EXAMINATION OF FACIAL NERVE:

Normal
Tuning fork test
 Rinne”s test ; Rt ear Lt ear

 +ve +ve
 Weber's test ; centralized
 ABC test: normal with the examiner

EXAMINATION OF ORAL
CAVITY &OROPHARYNX
 Lips – Normal
 Angle of mouth - normal
 Teeth & Gums – Normal
 Tongue – Normal
 Floor of mouth – Normal
 Buccal mucosa – Normal
 Hard palate – Normal
 Soft Palate – Normal
EXAMINATION OF ORAL
CAVITY &OROPHARYNX
 Uvula –normal
 Anterior pillar- normal
 Posterior pillar-normal
 Tonsillar fossa – Normal
 PPW - Normal
EXAMINATION OF LARYNX
 INDIRECT LARYNGOSCOPY –
normal
 Neck examination – normal

 Normal laryngeal framework noted
PROVISINOAL DIAGNOSIS
 Right Antrochoanal polyp

Investigations
X-ray PNS water’s view
Diagnostic nasal endoscopy
Endoscopic polypectomy
Endoscopic polypectomy
Thank u

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Case presentation

1. Nasal obstruction since 1yr

2. Headache since 1yr and is

 Not relieved after taking medication

 Headache associated with facial pain over

 Relieves with medication again recurres

 No h/o bleeding tendency in the family

 No other chronic medical illness

 No h/o previous surgeries

 RESP: B/L NVBS +,no additional

 P/A: soft, no organomegaly.

 Inspection : Skin over the sinuses normal.

 FISTULA TEST: normal

 EXAMINATION OF FACIAL NERVE:

 Rinne”s test ; Rt ear Lt ear

 ABC test: normal with the examiner

 Neck examination – normal

 Right Antrochoanal polyp

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