Septal Perforation 2

Take a history from this 40 year old man who has had 3 previous septorhinoplasty surgeries. He feels like his nose is blocked and sometimes whistles.

History

  • Onset

  • Duration 

  • Associated symptoms – whistling, nasal obstruction, crusting, epistaxis, saddle deformity, hyposmia/anosmia, phantosmia, parosmia, headaches

  • Predisposing events – Nasal trauma, septoplasty/rhinoplasty, exposure to chemical irritants, septal haematoma/abscess, nasal cautery

  • Constitutional symptoms – weight loss, malaise, anorexia, night sweats

  • Past Medical History – granulomatosis with polyangiitis (GPA), syphilis, sarcoidosis, lupus, nasal foreign body, leprosy

  • Drug History – nasal steroids,bevacizumab (avastin), cocaine abuse

  • Social History – smoking, alcohol, occupation

  • Family History – cancer, above listed medical conditions

  • Systems review

  • Elicit the patient’s ideas, concerns and expectations 


Conclusion

  • Summarise consultation

  • Thank patient

  • Offer appropriate differential diagnosis

Differential diagnoses to consider*

Autoimmune

  • Granulomatosis with polyangiitis

  • Sarcoidosis

Infective

  • Syphilis 

  • Septal abscess

Malignancy

  • Primary nasal tumour

Drugs

  • Cocaine abuse

  • Bevacizumab

Trauma

  • Nasal trauma

  • Nose picking

  • Excessive nasal cautery

  • Septal haematoma

*Table not exhaustive


Management


You will be asked to suggest an appropriate management plan based on your presumed diagnosis. Ensure that you offer a complete ENT examination including nasendoscopy prior to further investigations.


Further investigations will depend on the history and your examination findings. As a baseline, offer to check full blood count, urea and electrolytes and ESR. Some examples are below:-

Suspected diagnosis

The following investigations/management strategies may be indicated however you must offer based on the clinical scenario you are given

GPA

ANCA, chest x-ray, urine dip

Sarcoidosis

Angiotensin converting enzyme (ACE)

Syphilis

Venereal Disease Research Laboratory – VDRL

Nasal tumour

Biopsy

Post a comment

Leave a Comment

Your email address will not be published. Required fields are marked *