ENT Consultation

Diagnosis

1. Chronic rhinosinusitis without nasal polyps
2. Deviated nasal septum
3. Bilateral Eustachian tube dysfunction

Management

1. Fluticasone furoate 27.5 microgram nasal spray, two sprays into each nostril once daily for eight weeks
2. Regular isotonic saline nasal douching twice daily
3. Arrange computed tomography scan of the paranasal sinuses
4. Obtain previous magnetic resonance imaging of the internal auditory meatus from Royal Free Hospital
5. Consider Septoplasty (Clinical Coding and Schedule Development procedure code E0360), Functional Endoscopic Sinus Surgery (Clinical Coding and Schedule Development procedure code E1432), and Eustachian Tube Balloon Dilation (Clinical Coding and Schedule Development procedure code D2240) if medical therapy fails
6. Summary of consultation findings, prescription instructions, and surgical information leaflets sent to Mr Henderson by email

History of Presenting Complaint

Mr Henderson attends for a review consultation regarding persistent bilateral nasal obstruction, facial congestion, and bilateral aural fullness. He requests a definitive long-term solution as conservative measures have provided insufficient relief.

The nasal obstruction has been present for eighteen months, remaining constant throughout the day and worsening significantly overnight. The blockage affects both nasal passages, though it is markedly more severe on the left side. He describes a dull, constant pressure across the bilateral maxillary and frontal regions, graded at six out of ten in severity. The symptoms began following a severe upper respiratory tract infection and have persisted without resolution.

Symptoms are aggravated by lying flat, exposure to dust, and cold air. Over-the-counter oxymetazoline nasal spray provided temporary relief initially, but he discontinued this three months ago following advice regarding rebound congestion. Steam inhalation and oral loratadine 10 milligram tablets once daily have yielded minimal improvement.

Over the past six months, the nasal congestion has progressively worsened, and he has developed a thick, mucopurulent post-nasal drip.

Mr Henderson experienced a similar episode of prolonged sinus congestion five years ago, which resolved completely after a six-week course of mometasone furoate nasal spray prescribed by his general practitioner.

The persistent nasal blockage causes significant sleep disturbance, resulting in daytime fatigue that impairs his concentration as a chartered accountant. He is also unable to participate in his regular recreational running due to restricted nasal airflow and exercise-induced mouth breathing.

Accompanying local symptoms include reduced sense of smell, bilateral ear popping, muffled hearing, and intermittent non-pulsatile tinnitus. He denies epistaxis, visual changes, dental pain, vertigo, otorrhoea, fever, or unintentional weight loss.

Mr Henderson attended the consultation accompanied by his wife, Mrs Sarah Henderson.

Past Medical History

• Open appendicectomy, 14/05/2012, uncomplicated recovery
• Arthroscopic right anterior cruciate ligament reconstruction, 22/11/2018, managed by the orthopaedic team
• Mild intermittent asthma, diagnosed in childhood, currently well controlled on salbutamol inhaler as required with no specialist respiratory input
• Gastro-oesophageal reflux disease, managed by his general practitioner with oral proton pump inhibitor therapy

Medication History

• Omeprazole 20 milligram capsules, one capsule orally once daily (current)
• Salbutamol 100 microgram pressurised metered-dose inhaler, two puffs inhaled as required (current)
• Loratadine 10 milligram tablets, one tablet orally once daily (stopped two weeks ago)
• Oxymetazoline 0.05 percent nasal spray, two sprays into each nostril twice daily (stopped three months ago)

Social History

• Lives in a detached house with his wife and two children
• Sleep quality is poor, characterised by frequent waking, dry mouth, and non-restorative sleep secondary to nasal obstruction and snoring
• Employed full-time as a chartered accountant; non-smoker and consumes ten units of alcohol per week

Family History

• Father has late-onset asthma and nasal polyposis
• Mother has essential hypertension

Allergies

Allergic to penicillin, which causes a widespread maculopapular rash.

Physical Examination

Mr Henderson appeared comfortable at rest with normal respiratory effort, and a female chaperone, Nurse Rebecca Clarke, was present throughout the physical examination.

Otoscopy revealed intact, pearly grey tympanic membranes bilaterally, though both membranes appeared mildly retracted with reduced mobility on pneumatic otoscopy; the external auditory canals were clear and free of debris. Anterior rhinoscopy demonstrated a marked deflection of the caudal nasal septum to the left, causing significant narrowing of the left nasal valve, alongside bilateral inferior turbinate hypertrophy and mucopurulent discharge within the middle meatuses; there was no external nasal deformity, and the tonsils were symmetric and grade one.

Tuning fork assessment using a 512 Hertz fork demonstrated a Weber test that remained central, and Rinne testing was positive bilaterally, indicating air conduction was greater than bone conduction in both ears.

Balance assessment performed during the previous consultation on 10/01/2025 showed a negative Romberg's test, no significant deviation on Unterberger's stepping test, a normal head thrust test, intact cerebellar finger-to-nose testing, negative Dix-Hallpike manoeuvres bilaterally, no requirement for Epley's manoeuvre, absence of spontaneous or gaze-evoked nystagmus, normal ocular saccades, and intact cranial nerve function from two to twelve.

After verbal consent was obtained, the flexible endoscope was passed through the right naris, which appeared grossly normal anteriorly, though passage through the left naris was restricted by a severe anterior septal deviation and bilateral inferior turbinate hypertrophy, with mucopurulent secretions noted draining from both osteomeatal complexes, while no nasal polyps were seen. The nasopharynx appeared grossly normal, with no mass or lesion, although mild mucosal oedema was noted around the Eustachian tube orifices bilaterally. The posterior pharynx was symmetrical, with no mass or lesion. The base of tongue was normal and symmetrical. The vallecula was clear. The epiglottis and aryepiglottic folds were crisp, with no mass or lesion. The supraglottic inlet was unobstructed. Both true vocal folds were fully mobile and symmetrical, with no mass or lesion. The visualised subglottis was patent. The pyriform sinuses were clear, with no pooling of secretions. The patient tolerated the procedure without complication.

"Oral Cavity: The mucosa was free of lesions. The lips had no masses or lesions. The oral tongue had no masses or lesions and moved normally. Dentition was good. The floor of mouth was unremarkable. Oropharynx: The soft palate had no masses or lesions and elevated normally. The tonsils and fossae were unremarkable. The posterior pharynx was symmetrical. Neck: The neck was soft and flat. There was no cervical, supraclavicular, or auricular lymphadenopathy. The trachea was central. The laryngeal framework was palpable. The thyroid had no masses or fullness."

Investigations

Pure tone audiometry completed today demonstrated normal hearing thresholds across all frequencies bilaterally, and tympanometry revealed bilateral Type C traces consistent with negative middle ear pressure. Full blood count and total immunoglobulin E levels performed last month were within normal laboratory limits, and a Radioallergosorbent test panel was negative for common aeroallergens.

Plain sinus radiographs performed two years ago at an external clinic showed mild mucosal thickening in the bilateral maxillary antra without air-fluid levels.

Impression

Chronic rhinosinusitis without nasal polyps, left-sided deviated nasal septum, and bilateral Eustachian tube dysfunction.

Left caudal septal deflection, bilateral inferior turbinate hypertrophy, and middle meatal oedema, which may require Septoplasty, Functional Endoscopic Sinus Surgery, and Eustachian Tube Balloon Dilation if maximal medical therapy is unsuccessful.

Allergic rhinitis and non-allergic vasomotor rhinitis.

Discussion

"The diagnosis and available treatment choices are reviewed thoroughly with the patient. The patient then chooses to proceed with the plan below."

Plan

• Commence fluticasone furoate 27.5 microgram nasal spray, two sprays into each nostril once daily for eight weeks
• Commence isotonic saline nasal douching, 240 millilitres irrigated through the nasal cavities twice daily for eight weeks
• High-resolution unenhanced computed tomography scan of the paranasal sinuses arranged to evaluate the osteomeatal complexes and sinus anatomy

Obtain and review the previous magnetic resonance imaging scan of the internal auditory meatus performed at the Royal Free Hospital in 2023 within the next four weeks.

• Proceed to Septoplasty (Clinical Coding and Schedule Development procedure code E0360), Functional Endoscopic Sinus Surgery (Clinical Coding and Schedule Development procedure code E1432), and bilateral Eustachian Tube Balloon Dilation (Clinical Coding and Schedule Development procedure code D2240) under the care of Consultant Otolaryngologist Mr Alistair Vance, conditional upon persistent symptoms after eight weeks of maximal medical therapy and confirmation of sinus disease on the computed tomography scan
• Counselled Mr Henderson on correct nasal spray administration technique and the importance of regular auto-inflation exercises via the Valsalva manoeuvre
• Provided smoking and allergen avoidance advice
• Review in the outpatient clinic in eight weeks following completion of the computed tomography scan and medical therapy trial.

Information for the Patient

Provided Mr Henderson with the Ear, Nose and Throat United Kingdom patient information leaflets on Chronic Rhinosinusitis, Septoplasty, and Functional Endoscopic Sinus Surgery, alongside the National Health Service United Kingdom guidance on steroid nasal sprays.

Nasal and Sinus Surgery

(Includes Functional Endoscopic Sinus Surgery – FESS, Septoplasty, and Turbinate Surgery)

"Functional Endoscopic Sinus Surgery (FESS) – CCSD Procedure Code: E1432 Septoplasty – CCSD Procedure Code: E0360 Turbinate Surgery – CCSD Procedure Code: Not applicable

Specific risks vary with the procedure

Leakage of fluid surrounding the brain (CSF leak), meningitis, or brain injury (rare and more likely with FESS) Loss of vision or double vision (very rare and more likely with FESS) Watery eyes A hole in the septum (septal perforation – septoplasty only) A change in nasal shape (septoplasty only) Altered sensation in the nose or teeth (which may be permanent) Changes in breathing or sense of smell (including possible permanent loss)

Other points

Symptoms can recur later. These operations do not cure rhinitis, so continuing medical treatment may be necessary. The effects of turbinate surgery are not always permanent."

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Eustachian Tube Balloon Dilation

"Eustachian Tube Balloon Dilation – CCSD Procedure Code: D2240

Specific risks include

Bleeding from the nose or the back of the throat Infection involving the sinuses or ear No improvement in symptoms Discomfort or pressure during healing Very rare injury to nearby structures, including the internal carotid artery or skull base

Other points

Improvement may develop gradually over weeks or months. Further procedures may be required for some patients if symptoms continue."