ENT Consultation Letter

Date of consultation 14/05/2024

Private & Confidential

Arthur Pendelton, DOB: 12/08/1978 42 Albion Street, Manchester, M1 5GD EMPI: 8493021948 Mobile No. 07700 900456 arthur.pendelton78@email.co.uk Dr Sarah Jenkins, Highfield Medical Practice, 15 Station Road, Manchester, M20 2JG

Consultation Record

Reason for Consultation

Bilateral nasal obstruction and chronic facial pain.

History of Presenting Complaint

The patient presents with persistent bilateral nasal blockage, mucopurulent anterior rhinorrhoea, and hyposmia, referred by his GP following failed primary care medical management. He is keen to explore definitive surgical options to improve his nasal airway and sinus drainage.

Symptoms commenced approximately 18 months ago following a severe upper respiratory tract infection. The nasal congestion is constant, worse on the left side, and accompanied by a dull, pressure-like ache over the bilateral maxillary and frontal regions, rated 6/10 in severity.

Symptoms are exacerbated by exposure to cold air and leaning forward. Over-the-counter saline douches and fluticasone propionate nasal spray have provided minimal, transient relief.

The obstruction and facial pressure have progressively worsened over the past six months, transitioning from intermittent to continuous.

He experienced a similar, milder episode four years ago which resolved completely following a two-week course of oral doxycycline and topical nasal steroids.

The chronic congestion significantly impairs his concentration at work as an architect and causes chronic daytime fatigue due to disrupted sleep.

Associated symptoms include thick post-nasal drip and a reduced sense of smell, though he denies epistaxis, visual changes, or neurological deficits.

Allergies

• Penicillin (generalised maculopapular rash)
• House dust mite (rhinorrhoea and sneezing)

Past Medical History

Laparoscopic appendicectomy, 14/03/2012, uncomplicated recovery. Right ACL reconstruction, 22/09/2016, managed by Orthopaedic team. Mild intermittent asthma, managed with PRN inhaled bronchodilator under GP care. Gastro-oesophageal reflux disease (GORD), well controlled on maintenance PPI therapy.

Drug History

fluticasone furoate (Avamys®) 27.5 mcg per spray IN OD salbutamol (Ventolin®) 100 mcg INH PRN omeprazole (Losec®) 20 mg PO OD cetirizine 10 mg PO OD

Social History

• Lives in a semi-detached house with his wife and two children; carpeted throughout.
• Poor sleep quality, waking 2–3 times nightly due to obligatory mouth breathing and dry throat; snores regularly, no witnessed apnoeas.
• Ex-smoker (quit 2015, 5 pack-year history); drinks 10 units of alcohol per week; no recreational drug use; occasional exposure to building site dust via occupation.

Family History

• Atopic eczema and asthma – Mother
• Nasal polyposis – Maternal uncle

SNOT-22 Score

54 (Severe)

On Examination

• Caudal septal deflection to the left; bilateral inferior turbinate hypertrophy with pale, oedematous mucosa.
• Grade 2 nasal polyps arising from the bilateral middle meatuses; thick mucopurulent discharge visible in both osteomeatal complexes; post-nasal space clear.
• Cranial nerves II–XII intact; no palpable cervical lymphadenopathy; tympanic membranes normal bilaterally.

Investigations

• RAST (10/01/2024): Positive for Dermatophagoides pteronyssinus (IgE Grade 4); negative for grass and tree pollens.
• FBC (10/01/2024): Mild eosinophilia (0.6 × 10⁹/L), otherwise NAD.

Impression

• Chronic rhinosinusitis with nasal polyps (CRSwNP) causing mechanical obstruction of the osteomeatal complexes.
• Symptomatic left septal deviation and bilateral inferior turbinate hypertrophy contributing to airway resistance.
• Concomitant tension-type midfacial pain secondary to trigeminal sensitisation.

Plan

Bilateral functional endoscopic sinus surgery (FESS), septoplasty, and bilateral turbinoplasty (turbinate surgery), provisionally scheduled for July 2024, aiming to restore sinus ventilation, improve access for topical therapies, and correct the nasal airway. prednisolone 25 mg PO OD for 7 days betamethasone sodium phosphate (Vista-Methasone®) 0.1% nasal drops 2 drops IN BID for 4 weeks amitriptyline 10 mg PO ON for 6 months High-resolution CT scan of the paranasal sinuses (unenhanced, stealth protocol) to delineate anatomy prior to surgery.

• Obtain and review previous external MRI head from 2021 within the next 2 weeks to exclude any incidental intracranial pathology. Pre-operative assessment clinic clearance and completion of CT paranasal sinuses required prior to confirming surgical date. Advised to continue high-volume, low-pressure saline nasal irrigations twice daily. Routine follow-up in the Rhinology Outpatient Clinic in 6 weeks with CT results.

Risks specific to endoscopic sinus surgery include, but are not limited to: bleeding, infection, CSF leak, meningitis, cerebral injury, visual impairment or diplopia, watering of the eyes, pain, and changes in breathing or smell, including anosmia. You understand that symptoms can return and that surgery is not curative, although it may make medical treatment more effective.

Risks specific to septoplasty include, but are not limited to: bleeding, infection, septal perforation, a change in nasal shape, altered sensation (which can be permanent) involving the nose and teeth, and changes in breathing or smell. If a graft donor site is needed (for example, the ear may provide cartilage), that site may also have altered shape or sensation. The outcome may occasionally fall short of expectations (only a small proportion of patients require further surgery). This procedure does not cure rhinitis, so ongoing medical treatment is frequently needed.

Risks specific to turbinate surgery include, but are not limited to: bleeding, infection, changed sensation in the nose and teeth, and altered breathing or smell. The benefit may not be permanent. Turbinate surgery does not cure rhinitis, and medical treatment may still be required.

Amitriptyline: In my experience, low-dose amitriptyline is the most useful medicine for many forms of facial pain. I recommend beginning with 10 mg at night. Possible adverse effects include sleepiness, dry mouth, and constipation, and alcohol's effects may be increased. If there is no improvement after six weeks, the dose may be increased to 20 mg. After symptom control is achieved, I have advised continuing it for six months before stopping. By then, it will often have stabilised the trigeminal nucleus and further treatment may no longer be needed.

C.C.

Arthur Pendelton (Patient) Dr David Vance, Consultant Respiratory Physician, Manchester Royal Infirmary "Medical Records"