M2 ANATOMY

You are a fourth-year medical student on the Family Medicine service at a large multi-specialty clinic of Michigan Medicine.  Working with a senior member of the Family Medicine faculty, you are seeing a 52-year old literature professor concerned with fever, pain over the right cheek and beneath the right eye, and slight purulent nasal discharge.  The patient relays that his symptoms began three days previously, gradually worsening up to the time of this visit.  He adds that he has been treated successfully with antibiotics and decongestants for similar episodes three times in the past year, diagnosed as having recurrent sinusitis possibly related to allergies.

The patient’s past medical history is unremarkable and he has had no prior surgeries.  He denies medication allergies, and his current medications include only atorvastatin 20 mg. per day for a mildly elevated cholesterol.  He is a lifelong non-smoker, drinks one glass of red wine each night with dinner, and runs approximately 30 miles per week.

Physical examination notes a pleasant gentleman in no distress.  Vitals are recorded as HR 68, RR 16, BP 120/80, Temperature 100.1 and Pulse Ox at 98%.  ENT examination notes that the pupils are equal and reactive to light and the conjunctiva are clear.  The external auditory canals are patent and the tympanic membranes are without erythema or deformity.  Mild purulent nasal discharge is expressed from the right nares with mild erythema of the mucosa.  Dentition is good and intraoral examination is otherwise unremarkable.  In a darkened room a penlight is shined alternately against both sinuses (transillumination test).  The left sinus appears hollow with the light shining through giving a reddish glow.  The right sinus fails to allow light to shine through and the sinus appear opaque as though blocked with a fluid density. 

You discuss the patient’s history and physical examination and diagnostic impression with the Family Medicine attending.  Your primary concern is that while bilateral sinusitis from a variety of causes is fairly common in primary care practice, recurring episodes of unilateral sinusitis with fever is not.  You express an interest in obtaining a CT of the sinuses and facial bones, and the attending physician agrees with you.  You have a discussion with the patient about your provisional diagnosis and plan for imaging, and discharge him with a follow up appointment and a prescription for antibiotics and decongestants.

A CT scan is obtained which demonstrates several large mucosal polyps in the right maxillary sinus with a surrounding fluid density which obliterates the sinus; the polyps are noted as being hypodense relative to the surrounding tissue.  Associated local benign bone erosion is suggested involving the medial wall of the sinus.  The left maxillary sinus and the remainder of the facial radiographic examination is otherwise normal.  Your final diagnosis is now recurrent exacerbations of acute sinusitis secondary to maxillary ostia obstruction due to mucosal polyps.  You refer the patient to the otolaryngology service.

The otolaryngologist agrees with your diagnosis and the patient is scheduled for surgery.  The surgeon tells you that she plans to do what is known as a Caldwell-Luc procedure to clean out the maxillary sinus.  She states this is a procedure where she will make an incision from right upper lateral incisor to the second molar tooth.  From here a flap of mucosa and periosteum will be dissected to get to the bone in the canine fossa, and the bone will be drilled through though get to the maxillary sinus, allowing an endoscope and instruments to be inserted.  The abnormal growth of mucous membrane and sinus polyps will then be removed. The patient undergoes this procedure and is discharged on a week’s course of post-operative antibiotics.  Weeks later he is well healed and healthy.