Lost to Follow-Up: Chronic Rhinosinusitis. Jacob Burdett, OMSIII

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1 Lost to Follow-Up: Chronic Rhinosinusitis Jacob Burdett, OMSIII

2 Abstract: Introduction: Chronic rhinosinusitis is a common illness that affects numerous people and contributes to the healthcare economic burden in the United States. Although the manifesting symptoms are often similar from one patient to another, there are many possible underlying factors that contribute to obstruction of the osteomeatal complex, and may be responsible for predisposing the patient to recurrent sinus symptomatology. Care should be taken to identify and address the root cause in all patients presenting with chronic rhinosinusitis, with a detailed history and physical examination to discover any contributing abnormalities. Treatment should be focused at the root cause, rather than simply managing the presenting symptoms of congestion, rhinorrhea, and headache. Case Presentation: We present a case of a 54-year-old diabetic male tobacco smoker who presented to the otolaryngology clinic with a two-decade history of sinus discomfort, congestion and seasonal allergies, refractory to nasal steroids, antihistamines, and multiple courses of antibiotics. He agreed to a past surgical history of a septoplasty for a deviated septum 20 years prior to the office visit, which he stated failed to improve his sinus symptomatology. Examination of the nares revealed a foreign body in the left nostril which, upon removal and inspection, was noted to be a nasal splint. On subsequent questioning, the patient reported he had missed his follow-up appointments after his septoplasty and was unaware of an object in his nostril. Conclusion: Patients may be predisposed to chronic rhinosinusitis due to underlying allergies, immunodeficiency, systemic disorders, anatomic abnormalities and exposure to irritants or ciliostatic substances such as tobacco smoke. However, the possibility of a retained foreign body should not be discounted, even in a patient who denies a history consistent with insertion of an object into the nostril. Thorough examination of the nasal passageways for polyps, anatomic abnormalities, and foreign body is necessary in all patients presenting with chronic rhinosinusitis. Introduction: Sinus pressure and congestion are some of the most common symptoms routinely found in the general population. The etiology of the symptoms can be attributed to a variety of conditions including allergies, infectious origins, and foreign body obstruction. Chronic rhinosinusitis is a protracted duration of these common symptoms with concentric thickening of the sinus mucosa and accumulation of mucosal secretions. If left unmanaged, chronic rhinosinusitis can cause significant impact on quality of life and emotional well-being of patients. Chronic rhinosinusitis should be treated in any clinical setting, addressing the underlying cause. The estimated prevalence in the United States is approximately 12 percent. (1) The economic burden in the United States was estimated to be 8.6 billion in (2) In addition to these estimations, research indicates the impact on the patient s quality of life is comparable to those with significant lung or heart disease. (3) Case presentation: Chief Complaint: I have sinus pain and congestion. HPI: A 54-year-old male presented to the otolaryngology clinic with painful pressure and fullness of the left nostril and cheek bone. Patient reported his symptoms had been present for approximately 20 years and had not been relieved by any therapy. He had tried multiple rounds of antibiotics, nasal sprays, and oral allergy preparations. He denied any exacerbating factors. Review of systems was significant for: headaches lasting hours, that were primarily located in his forehead; dull sinus pressure; non-bloody yellow-green mucous sinus drainage; some fatigue during flare-ups ; and decreased ability to smell foods. Patient denied having visual disturbances, recent changes in weight, fever, chills, nausea, vomiting, chest pain, dyspnea, or epistaxis. Pain at time of visit was rated as a constant 3/10. Past Medical History: Hypertension, Type 2 Diabetes, Seasonal allergies.

3 Past Surgical History: Nasal surgery for allergies in approximately Social History: Current smoker; 35 pack-year-tobacco history, denies current alcohol or illicit drug use Family History: Mother: HTN and Diabetes, Father: non-contributory Medications: Fluticasone two sprays each nostril daily, Allegra one pill each day, Humalog, Metformin, Enalapril. The patient reported he did not know the dosage of his medications, but takes them as prescribed by his primary care. Allergy: No drug allergy Physical Exam: Vitals: Temperature: 37ºC Brachial Pulse: 78 bpm, Blood Pressure: 128/87, Weight 297 lbs, Height: 5 10 General: The patient was sitting comfortably in the exam chair with no acute distress. Patient was alert and able to reliably answer all questions. Head: The head was normocephalic and atraumatic with male pattern baldness. Eyes: The pupils were equal, round, and reactive to light. The extraocular movements were intact bilaterally. Sclera were non-icteric without injection. Ears: Tympanic membranes were pearly grey without injection, bulging, or erythema. All anatomical landmarks were easily visualized. Nose: Frontal and maxillary sinuses were tender to light palpation bilaterally. The right nostril was patent, and mild swelling of the right turbinates was noted. There was a right septal deviation. The left nostril was not patent and had a visible clear crumpled plastic foreign body. During nasal examination, a foul odor was appreciable when the examiner was in close proximity to the patient. Mouth: The oral mucosa was pink and moist with no visible lesions. Teeth were in good repair with no acute dental abnormalities. The tonsils and pharynx were without erythema or exudates. Parotid and submandibular glands were non-tender and normal in size. Neck: The neck was supple and non-tender with no palpable lymphadenopathy. The thyroid was non-tender, mobile, midline and normal in size. Heart: Regular rate and rhythm without murmurs rubs or clicks appreciable. Lungs: Clear to auscultation in all fields bilaterally. Abdomen: The abdomen was obese, soft, non-tympanic, nontender, with no palpable organomegaly, or appreciable masses. Neurologic: Cranial nerves II-XII were grossly intact. Range of motion in all extremities was grossly intact. Reflexes were 2/4 and strength was 5/5 in all extremities. Procedures: The patient was informed of the risks and agreed to removal of the foreign body in the left nostril. Using Bayonet forceps, the foreign body was removed from the nostril. The foreign body was misshapen but recognized as a nasal splint commonly used during septoplasty procedures. Following removal of the foreign body there was a large volume of foul smelling, non-bloody, yellow-green mucous that flowed from the left nostril. The nares were suctioned to remove the additional mucus. The patient tolerated the procedure well with no bleeding or appreciable discomfort. Assessment: The current constellation of signs and symptoms seen in our patient are best described by chronic rhinosinusitis secondary to retained nasal splint with an associated right septal deviation. He also had a history of seasonal allergies that were exacerbating his sinus symptoms. The patient reported current tobacco use which was likely increasing the severity of his symptoms. The patient had a current diagnosis of essential hypertension being controlled medically with good success. He was a type 2 diabetic reporting good management with his current diabetes medications.

4 Plan: The patient was started on empiric Augmentin 500 mg twice daily for a 10 day period with instructions to return if foul discharge continued. The patient reported a history of seasonal allergies that had been managed medically with fluticasone and Allegra. The patient was encouraged to continue management of allergies with his current medications. If medication fails to manage his allergies we will consider referral for allergy sensitivity testing and immunological desensitization. (1) The patient will have a CT-scan of the nasal cavity and surrounding sinuses to investigate the need for septoplasty revision. The patient was counseled on the risks associated with tobacco use and negative contributions to his sinus condition. (1) He was encouraged to quit smoking and was offered cessation advice and medical management, which he declined at this time. The patient was instructed to return to the office in two weeks for follow-up on his imaging results. Discussion: Our patient presented with several factors that can contribute to chronic sinusitis, including chronic allergic rhinitis, diabetes, and tobacco smoking, in addition to the retained foreign body. Allergic rhinitis is one of the major contributing factors to the development of chronic rhinosinusitis. (1) While the routine treatment of allergic rhinitis is medical management, there is evidence that Osteopathic treatments may be helpful. (4) Allergic rhinitis refractory to medical management is often treated with surgical interventions, including septoplasty for anatomical derangements and turbinate reductions to reduce reactivity of nasal mucosa to allergens. The vast majority of patients respond well to surgical intervention; however, in our case the patient s noncompliance with follow up appointments to his otolaryngologist resulted in a chronically retained nasal splint. Packing of the nasal cavity or splinting of the nasal septum following septoplasty with or without other interventions is common practice in ear, nose, and throat surgery, though there is some debate, and there is evidence supporting septoplasty without the use of splints. (4,5) Idealized benefits of splinting and packing are: increased stability of the nasal structure, reduced incidence of hematoma, reduced recurrence of septal deviation, and prevention of synechiae formation. (4,5,6,7) Research studies have focused on the surgical benefits of splinting and packing, but until recent years, few have examined the discomfort related to nasal splints or differences in long-term outcomes comparing splinting versus non-splinted septoplasty procedures. There are no case reports of splints retained for decades without detection. A small number of studies (6,9,10) have compared the postoperative pain experienced by patients receiving splints or packing to those with no splint or packing after septoplasty. These studies present good data concerning pain associated with splints and packing, but report conflicting results. A variety of septal splints have been included in the study designs, which confounds the results and makes it difficult to quantify the relative morbidity of different types of splints. One study examining the level of pain reported in patients receiving silastic splints (9), was designed to have the patients report pain level relative to each nostril. A silastic splint was placed in one nostril, while the other nostril was left unsplinted. The patients were re-evaluated in the second postoperative week. In this study, only 15 of the 39 subjects (38.5%) remembered whether the nasal splint had been inserted in their left or right nostril. (9) Although this information was not the focus of the study, it does show that even during a study giving specific focus to nasal splints, a patient can forget where a splint has been placed. Provided this information, it is not as surprising that our patient was unaware he had a retained nasal splint in his nose. However, due to his chronic symptomatology, it is hard to speculate on why the nasal splint remained in his nose for such an extensive period of time without detection. A literature review for cases of asymptomatic foreign bodies in the nose revealed one case of an eighteen-year-old patient with a button battery lodged within her nose. (11) The case reported that: she could

5 not remember when she put this button battery into her nose ; and, not unlike our patient, She has been treated several times for sinusitis. (11) Even though our patient was not asymptomatic, his case highlights the importance of taking a thorough history with detailed past surgical history pertinent to the presenting complaint and performing a complete examination of the nares in a patient presenting with chronic rhinosinusitis. In addition, patients receiving surgical interventions should be provided a clear explanation of the procedure and importance of keeping recommended follow up appointments. In patients with a history of noncompliance it is reasonable to consider excluding septal splints, or placing dissolving septal implants. (12) Abbreviations: HTN hypertension CT-scan computerized tomography scan Authors Contributions: Jacob Burdett, OMS III initial case report write-up; literature review Tracy O. Middleton, D.O. literature review and review & detailed editing of report Disclosures: No disclosures are necessary for this case presentation. Acknowledgements: Special thanks to Dr. Brian Rizzo for mentoring students References: 1. Hamilos DL. Chronic rhinosinusitis: Epidemiology and medical management. J Allergy Clin Immunol. 2011;128(4): Bhattacharyya N. Incremental health care utilization and expenditures for chronic rhinosinusitis in the United States. Annals of Otology, Rhinology & Laryngology. 2011;120(7): Gliklich R, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngology - Head and Neck Surgery. 1995;113(1): Steinbauer, U, Roos, S, Amann, P, Schwerla, F, Resch, K. Do osteopathic treatments improve the symptoms of headache and/or sinus pressure in patients with chronic rhinosinusitis (CRS)? A randomized controlled trial. International Journal of Osteopathic Medicine. 2008;11(4): Tan BK, Chandra RK. Postoperative prevention and treatment of complications after sinus surgery. Otolaryngologic Clinics of North America. 2010;43(4): Cook JA, Murrant NJ, Evans KL, Lavelle RJ. Intranasal splints and their effects on intranasal adhesions and septal stability. Clinical Otolaryngology Clin Otolaryngol. 1992;17(1): Dubin MR, Pletcher SD. Postoperative packing after septoplasty: Is it necessary? Otolaryngologic Clinics of North America. 2009;42(2): Hajiioannou JK, Bizaki A, Fragiadakis G, Bourolias C. Optimal time for nasal packing removal after septoplasty. A comparative study. Rhinology. 2006;45:68 71.

6 9. Jung YG, Hong JW, Eun Y-G, Kim M-G. Objective usefulness of thin silastic septal splints after septal surgery. Am J Rhinol Allergy. 2011;25(3): Veluswamy A, Handa S, Shivaswamy S. Nasal septal clips: An alternative to nasal packing after septal surgery? Indian J Otolaryngol Head Neck Surg. 2011;64(4): Onal, M, Ovet G, Alatas N. An asymptomatic foreign body in the nose in an eighteen-year-old patient: Button battery. Case Reports in Surgery. 2015;2015: Watzinger F, Wutzl A, Wanschitz F, Ewers R, Turhani D, Seemann R. Biodegradable polymer membrane used as septal splint. International Journal of Oral and Maxillofacial Surgery. 2008;37(5):

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