Academe Learn
CBME Curriculum Preview

Page 21 of 21

EN4.{27,31-34} | Sinonasal Inflammation and Tumours — PBL Case

CLINICAL SETTING

It is a Tuesday morning at the ENT outpatient department of a district hospital in Tamil Nadu. Dr Kavitha Subramanian, ENT registrar, sees her fourth patient: Arjun, a 16-year-old student who has been brought by his parents. His mother opens the consultation with the words: 'Doctor, he's been bleeding from the nose badly — sometimes a full bucket — for the last 6 months. It stops by itself after 20–30 minutes, but it keeps coming back. And his right nostril has been completely blocked for 4 months. He failed his 10th standard board exams because he couldn't concentrate.' Arjun sits quietly. He looks pale and tired. His mother adds: 'We saw two doctors before. One said it was just bleeding from the nose because of heat — he gave iron tablets. Another doctor at a private clinic said it was some mass and he wants to do a biopsy under local anaesthesia next week. That's why we came here first — we wanted a second opinion.' On examination, Arjun has mild pallor. Anterior rhinoscopy reveals a smooth, pink, fleshy, pulsatile mass filling the right nasal cavity. There is no visible mass in the left nasal cavity.

Trigger 1: The Emergency in the Clinic

Dr Kavitha examines the mass carefully — it is smooth, pulsatile, and fills the right nasal cavity. Arjun reports it has never been painful. He denies discharge from the nose except blood. There is no cervical lymphadenopathy. His haemoglobin is 9.2 g/dL (anaemia from recurrent blood loss). The referring doctor's notes mention 'plan: biopsy under LA next week to confirm diagnosis.' Dr Kavitha recognises the clinical picture immediately. She turns to her intern and says: 'We have a problem. And it is not the mass in the nose.'

DISCUSSION POINTS

  • What is the most likely diagnosis? List the demographic, historical, and examination features in this case that support your diagnosis.
  • The referring doctor has planned a biopsy. Dr Kavitha is distressed by this. Why is biopsy absolutely contraindicated in this condition? Describe specifically what would happen if a biopsy was performed.
  • How should Dr Kavitha communicate this to Arjun's parents and to the referring doctor? What professional and ethical obligations does she have in this situation?
  • What investigation should Dr Kavitha order? What specific findings on this investigation would confirm the diagnosis and guide surgical planning?
Click to reveal Trigger 2: The Imaging Results and the Surgical Plan (discuss previous trigger first!)

Trigger 2: The Imaging Results and the Surgical Plan

Dr Kavitha orders a contrast-enhanced CT of the paranasal sinuses and nasopharynx. The report reads: 'An intensely enhancing lobulated mass is seen in the right nasal cavity and nasopharynx, extending into the right pterygopalatine fossa. There is anterior bowing of the posterior wall of the right maxillary sinus (Holman-Miller sign). No intracranial extension. No skull-base erosion. Appearances consistent with juvenile nasopharyngeal angiofibroma — Radkowski Stage IIA.' Arjun and his parents are relieved it is not cancer. But his father asks: 'Doctor, if it is benign, can it just be left alone? My son is afraid of surgery.' His mother asks: 'Is it going to grow back after surgery?' The surgical team meets to plan Arjun's management. The anaesthetist asks about blood product preparation and the interventional radiologist is requested for consultation.

DISCUSSION POINTS

  • The CT confirms JNA, Stage IIA (Radkowski classification). Explain to the team what this staging means and what surgical approach would typically be used for this stage.
  • What is the role of pre-operative embolisation in JNA surgery? Which vessel must be embolised, and how long before surgery should it be performed? What happens to blood loss if embolisation is skipped?
  • Arjun's father asks if the tumour can just be watched — 'it is benign, after all.' How would you counsel the family about the natural history of JNA if left untreated, and the risk of intracranial extension?
  • What is the recurrence rate after surgical resection of JNA, and what factor most influences recurrence? How should Arjun be followed up post-operatively?
Click to reveal Trigger 3: The Night Shift, the Polyp Patient, and the Farmer's Son (discuss previous trigger first!)

Trigger 3: The Night Shift, the Polyp Patient, and the Farmer's Son

Two months after Arjun's successful surgery (endoscopic approach, pre-operative embolisation performed, minimal blood loss), Dr Kavitha is on her ENT night duty. Two new patients arrive in the same hour. Patient 1: Mrs Geetha, 35 years old, a teacher who has had bilateral nasal obstruction and anosmia for 2 years. She uses salbutamol for asthma and has had two previous courses of nasal polyp surgery. Tonight she presents with severe right periorbital swelling, a red eye, proptosis, and restricted eye movement after a week of worsening 'sinus infection.' Her temperature is 38.9°C. CT shows opacification of the right ethmoid sinus with a lenticular hypodense collection between the periorbita and the medial orbital wall. Patient 2: Mr Suresh, 18 years old, the son of a farmer from a village 80 km away. He has bilateral progressive nasal obstruction and a saddle-nose deformity over 3 years. His nose bleeds intermittently and produces blood-stained crusts. His father says the same problem affected his paternal uncle 10 years ago, who was treated with 'strong injections' for months at a government hospital. Nasal biopsy done at a peripheral centre shows 'necrotising granulomata' without caseous necrosis. ANCA serology is pending.

DISCUSSION POINTS

  • Mrs Geetha's CT shows a subperiosteal abscess (Chandler Stage III). Why is this an ENT emergency? What is the risk to vision, and what is the risk of intracranial spread? Outline the immediate management — both non-surgical and surgical steps.
  • Mrs Geetha had bilateral nasal polyps from childhood-onset allergy, asthma, and aspirin-triggered exacerbations. Name this syndrome and explain why her polyps keep recurring despite surgery. What medical treatment would specifically target the underlying leukotriene pathway?
  • For Mr Suresh: the biopsy shows necrotising granulomata. Name the two most likely diagnoses causing this picture in an Indian patient with saddle-nose deformity. For each diagnosis, state the one investigation that would confirm or exclude it. What is the pending ANCA result likely to show if GPA (Wegener's granulomatosis) is the diagnosis?
  • Reflecting on tonight's three patients (Arjun, Mrs Geetha, and Mr Suresh): what is the single clinical sign that was most important in each case — the sign that, if missed, would have led to patient harm or incorrect management? Discuss the consequences of missing each sign.

Group Task Assignments

Group 1: JNA: Diagnosis, Investigation Pathway, and the Biopsy Rule

  • Prepare an investigation pathway for Arjun from referral to pre-operative planning — in the correct sequence, explaining what each investigation adds
  • Write the letter from Dr Kavitha to the referring doctor explaining why the planned biopsy must be cancelled, what the likely diagnosis is, and what should be done instead
  • Summarise the Radkowski staging system for JNA and explain how stage affects surgical approach and embolisation requirements

Competencies: EN4.31

Group 2: Nasal Polyps: Types, Syndromes, and Complications

  • Create a comparison table of ethmoidal polyps vs antrochoanal (Killian's) polyp: origin, laterality, patient profile, gross appearance, management
  • Explain Samter's triad (AERD): definition, mechanism (COX-1 inhibition + leukotriene pathway), and treatment implications including the role of aspirin desensitisation
  • Review the stepwise management of bilateral nasal polyps: intranasal steroids → short oral steroid course → FESS → post-surgical maintenance

Competencies: EN4.27

Group 3: Orbital Complications of Sinusitis: Chandler Classification and Management

  • Describe all five Chandler stages of orbital complication of sinusitis — for each stage, state the examination finding, CT appearance, and management
  • At what Chandler stage does surgical drainage become mandatory? What are the signs of optic nerve compromise that demand emergency intervention?
  • Design the management plan for Mrs Geetha (Stage III): IV antibiotics (name the drug and rationale), ENT surgical drainage approach, ophthalmology involvement, and monitoring parameters

Competencies: EN4.32

Group 4: Sinonasal Malignancy: Red Flags and Investigation Strategy

  • List the clinical red flags for sinonasal malignancy and explain why each is significant — specifically address the importance of unilateral symptoms in any age group
  • Describe the histological types of sinonasal malignancy and their aetiological associations (SCC, adenocarcinoma, NPC, olfactory neuroblastoma) with occupational/viral associations where relevant
  • Outline the staging workup for a patient confirmed to have sinonasal SCC — what investigations are needed, in what order, and what determines resectability?

Competencies: EN4.33

Group 5: Granulomatous Nasal Disease: Differential Diagnosis

  • Create a differential diagnosis table for Mr Suresh (saddle-nose + bilateral crusting + necrotising granulomata) — include nasal TB, GPA (Wegener's), sarcoidosis, and rhinoscleroma, with distinguishing histological features and specific diagnostic tests for each
  • What is the significance of the family history of a paternal uncle treated with 'strong injections' for months? Which granulomatous disease requires prolonged systemic drug therapy (months-to-years)?
  • Outline the treatment of GPA confirmed by ANCA serology: induction agent, maintenance agent, and ENT-specific (rhinological) management

Competencies: EN4.34

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [EN4.31] What are the clinical, demographic, and imaging features of JNA? Why is biopsy absolutely contraindicated, and what is the correct investigation and pre-operative embolisation protocol?
  2. [EN4.27] What is the difference between ethmoidal and antrochoanal polyps in terms of origin, laterality, and management? What is Samter's triad and its mechanism?
  3. [EN4.27] What is the ostiomeatal complex (OMC)? How does OMC obstruction cause CRS and polyps, and how does FESS address this anatomically?
  4. [EN4.32] Describe the Chandler classification of orbital complications of sinusitis. At which stage does surgical drainage become mandatory, and what is the emergency sign for optic nerve compromise?
  5. [EN4.32] What are the criteria distinguishing acute bacterial rhinosinusitis from viral URTI? When should antibiotics be prescribed for sinusitis, and what organism is most commonly responsible for community-acquired ABRS?
  6. [EN4.33] What clinical features should raise suspicion of sinonasal malignancy? What is the investigation of choice for diagnosis, and what are the occupational associations of common sinonasal tumours?
  7. [EN4.33] What is the aetiology of nasopharyngeal carcinoma? Why does NPC present with cervical lymphadenopathy as the first symptom, and how is it staged and managed?
  8. [EN4.34] Compare the histopathology, investigations, and treatment of nasal TB, GPA (Wegener's granulomatosis), sarcoidosis, and rhinoscleroma affecting the nose.