A 40 year old female is complaining of attacks of lacrimation and watery nasal discharge accompanied by sneezing. She had a severe attack one spring morning that was accompanied by respiratory difficulty and she was admitted to hospital. She received the proper treatment and her condition improved. On examination she had bilateral nasal obstruction by bluish pedunculated masses that were covered by a

clear mucous discharge.

Diagnosis & reasons Allergic nasal polypi (history of nasal allergy and the presence of

bluish pedunculated masses in the nose)

Explain the following manifestations Lacrimation: nasal allergy is usually accompanied by spring catarrh

of the conjunctiva Sneezing: a reflex due to presence of edematous fluid in the nasal

mucosa and one of the symptoms of nasal allergy and occurs in the form attacks with nasal obstruction and a watery nasal discharge

Attack accompanied by respiratory difficulty: the respiratory difficulty is due to bronchial asthma a common condition associated with allergic nasal polypi as both are a type I hypersensitivity

Bluish pedunculated bluish masses: these are the nasal polypi they are bluish because of venous engorgement by the pressure from the edematous fluid in the mucosa

Further examination &/or investigations Laboratory tests for type I hypersensitivity: skin tests, RAST,

serum IgE CT scan of the nose and the paranasal sinuses to show the

extent of the nasal polypi Nasal endoscopy Chest X-ray

Treatment Polypectomy by nasal endoscopic surgery and ethmoidectomy Treatment of allergy by avoiding the cause, hyposensitization,

local and systemic steroids, antihistamines Avoid aspirin and non-steroidal antinflammatory drugs as they

aggrevate the type I hypersensitivity

A 30 year old male had an attack of left severe earache and left loss of hearing together with deviation of the angle of the mouth to the right side and failure to close the left eye. 3 days later, a swelling vesicular in nature appeared in the left external auditory meatus. The condition subsided 10 months later.

CASE 70

Diagnosis & reasons Left lower motor neuron facial paralysis (deviation of the angle of the mouth to the right side

and failure to close the left eye) due to Herpes Zoster Oticus – Ramsay Hunt Syndrome (severe earache, hearing loss, vesicular swelling in the left external auditory canal, duration of the illness is 10 months)

Explain the following manifestations Severe earache: before the appearance of the vesicles on the dermatome of the cutaneous

branch of the facial nerve the virus of herpes zoster that was dormant in the geniculate ganglion causes severe inflammation of the facial nerve leading to pain and paralysis

Hearing loss: is a sensorineural hearing loss due to affection of the vestibulocochlear nerve as it passes beside the facial nerve in the internal auditory canal

Vesicular swelling: appears in the area of the cutaneous dermatome of the facial nerve namely the posterior part of the most lateral part of the external auditory canal, the concha and parts of the auricle; once the vesicular erruption appears the pain starts to subside

Further examination &/or investigations Investigations of the facial nerve (shirmer test, acoustic reflex,

topognostic tests, electroneuronography, electromyography) CT scan to exclude other causes of facial paralysis Audiogram Viral antibody titre

Treatment Antivirals Steroids Facial nerve exploration and decompression if the

electroneuronography shows 90% degeneration of the facial nerve fibers within 3 weeks from the onset of paralysis

Care of the eye during the paralytic period to prevent lagophthalmus (drops, ointment and bandage during sleep)

ss

CARD FINAL EXAM ON 7TH DEC TOPICS

EARNOSEORAL CAVITYPHARYNXTONSIL