Final Diagnosis: BILATERAL SINONASAL POLYPOSIS

procedure done : FESS UNDER GA on 1/11/2022

Chief complaints:

c/o decreased sensation of smell for 6 months

C/o nasal block for 6 months

History of present illness:

The patient was apparently normal before 3 years and then she developed
episodes of watery discharge and nasal block on and off, relived with Medication , now patient
developed complete obstruction of nose for past 6 months

Complaints of decreased sensation of smell

History of mouth breathing present

Past medical history:

Not a known case of systemic hypertension, diabetes mellitus, epilepsy, bronchial asthma ,
tuberculosis

Past surgical history:

Nil

Personal History:

mixed diet

normal bowel and bladder habits

Normal regular menstrual cycle

Examination:

General condition:

Gc fair

conscious ,oriented and afebrile

No pallor, no pedal edema,

Vitals stable

Systemic examination:

CVS: S1 and S2 heard

RS: Normal vesicular breath sounds heard

Local examination:
Nose:

RIGHT LEFT

Septum normal normal

DNE findin Pale polyp noted in middle meatus extending Pale polyp noted into
gs into nasal cavity nasal cavity

Nasopharyn
normal normal
x

Ear:

RIGHT LEFT

Tympanic membrane intact intact

EAC normal normal

PTA - -

Impedance - -

Facial nerve clinically intact clinically intact

Throat:

Tonsil grade and condition normal

Oral cavity normal

Oropharynx normal

Larynx normal

Hypopharynx normal

Neck: normal

Investigations: enclosed
Course of stay: patient presented with above complaints and admitted in ENT ward with diagnosis of
bilateral sinonasal polyposis. Routine investigations done.CT PNS done which showed mucosal
thickening in bilateral maxillary , ethmoid and right sphenoid sinuses, with polypoidal growth in nasal
cavity, patient underwent FESS .post op period was uneventful, Patient improved symptomatically. Hence
discharged with following advice.

Treatment given in hospital:

INJ.CEFOTAXIME 1G IV BD
INJ.PANTOPRAZOLE 40MG IV OD
INJ.METHYLPREDINSOLONE 40MG IM STAT
T.MONTELEUKAST + LEVOCETIRIZINE 10MG+5MG HS

FLUTICASONE NASAL SPRAY 2 PUFFS BD

OPERATIVE NOTES:

IN GA , pt in supine position, nasal packing done ,

Rt uncinectomy done polyp in middle meatus removed and sent for HPE, middle meatal antrostomy
done and ostea widened, bulla ethmoidalis removed and found to be polypoidal, posterior ethmoidectomy
done,polyp in spenoethmoidal recess removed,

LT uncinectomy done, polyp in middle meatus removed sent for HPE, middle meatus antrostomy
done and ostea widened, bulla ethmoidalis removed, posterior ethmoidectomy done,

Bilateral nasal packing done with antibiotics soaked pack after achieving haemostasis, pt withstand the
procedure well

Medication advised at discharge:

Sl Formulatio Frequenc 5 Before/After

Drug Dose
No n y Days food

5
1 tablet CEFIXIME 200mg 1-0-1 after food
days

MONTELUKAST + 10 mg + 7
2 tablet 0-0-1 after food
LEVOCETRIZINE 5 mg days

3 Tablet Paracetamol 650mg Sos 6days After food

4 tablet PANTOPRAZOLE 40 mg 1-0-0 7 days before food

4 Naso wash Nasowash 1-0-1 7 days

FLUTICASONE NASAL 7
5 per nasal 2 puff 1-0-1 after food
SPRAY days

review after one week in ent opd on 8/11/2022 for further management
Precautions and danger signs

Nose
Avoid blowing of nose, sneezing.
Avoid trauma to nose.
Review in Emergency/ OPD in case of bleeding from nose/ mouth or any watery nasal discharge.

Signature & Seal of Treating Consultant

NOTE: In case of Emergency; Please Contact: 044 27528528, Toll Free No: 1800 599 0999.
அவசர உதவிக்கு தொடர்புகொள்ள வேண்டிய எண் : 044 2752 8528,
கட்டணமில்லா தொலைபேசி எண் : 1800 599 0999