Clinical case

presentation
Department of ENT
Dhaka central international medical college & hospital
Presenter: Dr. S. M. Niazzaman
Supervisor: Asso. Prof. Dr. Raju Barua
Instructor: Dr. Sanzida Islam Mohua
Particulars of the patient

 Name: Md. Mahbubur Rashid

 Age : 15 years
 Sex: Male
 Occupation: Student
 Address :Mirpur,Dhaka
 Date of admission: 14.01.23
 Date of operation: 15.01.23
Chief complaints

 Recurrent sore throat for 3 years

 Mouth breathing for 2 years
 Recurrent common cold for 1 year
 Occasional snoring at night for 1 year
History of presenting illness
 According to the statement of the patient he was
reasonably well 3 years back. Then he developed
recurrent throat pain , difficulty in swallowing . It
occurred at least 5-6 times per year. The symptoms
resolved upon taking antibiotics, analgesics.

 His parents also complained of mouth breathing for

last 2 years which increases during common cold.
History of presenting illness cont’d

 He complained of recurrent common cold for 1

year.
 His parents further complained of occasional
snoring at night for 1 year which also increases
during common cold.
 He is normotensive, non diabetic. His bowel
bladder habit are normal.
History of past illness

 Nothing significant
Drug history

 He took multiple antibiotics, analgesics, antihistamines

for his repeated illness.
Family history

 Nothing significant
Personal history

 Nothing significant
Socioeconomic history

 He belongs to low socioeconomic status

General examination

 Appearance: Ill looking, Elongated face with hitched up lips.

 Body Built: Average
 Weight : 49 kg
 Consciousness: Conscious
 Decubitus: On choice
 Nutritional Status: Good
 Cyanosis: Absent
 Clubbing: Absent
 Koilonychia: Absent
 Leuconychia: Absent
 Anaemia: Absent
 Jaundice: Absent
 Edema: Absent
 Dehydration : Absent
 Thyroid: Not palpable
 Pulse:72beats per minute
 BP: 100/70 mm of Hg
 Temperature: 98.5*F
 Respiratory rate: 16 breaths per minute
 JVP: Not raised
 Lymph nodes: Jugulodigastric lymph nodes are palpable and
non-tender.
 Skin condition: Normal
 Hair Distribution: Normal
 ENT examination:
Throat examination:
 Oral cavity: Tongue tie, ranula absent.
 Tonsil:

 Tonsils are enlarged.

 Anterior pillar congested
 Pressing over the anterior pillar, inspissated pus
comes out.
 Jugulodigastric lymph node enlarged but non tender.
 Posterior pharyngeal wall: Granular pharyngitis.
 Earexamination: No abnormality in external
auditory canal, pre auricular or post auricular
area.
 Both tympanic membranes are intact.

 Noseexamination: No abnormality in nasal

passage, its patent.
 Nodeviation of nasal septum or hypertrophy of
turbinate's.
Salient features

 Md mahbubur rashid, 15 yrs old, normotensive, non diabetic

male, hailing from mirpur-1, dhaka was admitted into this
hospital on 14/01/23 with the complaints of recurrent throat
pain , difficulty in swallowing . It occurred at least 5-6 times
per year. The symptoms resolved upon taking antibiotics,
analgesics. He complained of recurrent common cold for 1
year.
 His parents also complained of mouth breathing for last 2
years & occasional snoring at night for 1 year which also
increases during common cold.
 On examination, Ill looking, Elongated face with hitched up
lips. Jugulodigastric lymph nodes are palpable and non-
tender.
 Tonsils are enlarged. Anterior pillar congested. Pressing over
the anterior pillar, inspissated pus comes out .
Jugulodigastric lymph node enlarged but non tender.
Pulse:72beats per minute BP: 100/70 mm of Hg
Temperature: 98.5*F.Respiratory rate: 16 breaths per minute
 Posterior pharyngeal wall: Granular pharyngitis.
 He is normotensive, non diabetic. His bowel bladder habit
are normal.
Provisional diagnosis
Provisional diagnosis:

Enlarged Adenoid with chronic tonsillitis

Differential diagnoses???
Differential diagnosis:

 Nasopharyngeal angiofibroma
 Lymphoma
Investigation :
 CBC with ESR with PBF
 CRP
 SERUM IgE
 XRAY PNS O/M VIEW
 XRAY NASOPHARYNX LATERAL VIEW
 BT,CT
 S. CREATININE
 HbsAg
 Anti HCV
 ASO Titre
 CXR P/A VIEW
 BLOOD GROUPING
X-ray PNS O/M view:
X-ray NASOPHARYNX LATERAL VIEW
Complete blood
count report
Suggestive of bilateral paratracheal
lymphadenopathy
Serum IgE Serum creatinine
 BT- 2mins 45sec  Blood group : o+
 CT- 7mins 30sec  HbsAg : Negative
Confirmatory diagnosis:

 Enlarged Adenoid with chronic tonsillitis

Treatment:

Surgery : Adenotonsillectomy under G/A

Operation note:

 With all aseptic precaution under G/A , adenoidectomy

was done by curettage method.
 Tonsillectomy was done by dissection method. Proper
hemostasis was ensured by silk ligature and diathermy.
 Post operative recovery was uneventful.
 Consultant ASSOC. PROF. DR. RAJU BARUA
 Surgeon ASSOC. PROF. DR. RAJU BARUA
 Anaesthetists DR.N.KALAM
During operation
After successful
operation
Post operative treatment:
 Position: Left lateral
 Diet: NPO for 2 hours then start with ice cold liquid ( avoid hot,
hard, spicy food)
 Tab. CEFUROXIME 250mg 1+0+1 (after meal)
 Tab. KETOROLAC 10mg 1+1+1 (after meal)
 Tab. FEXOFENADIN 60mg 0+0+1
 Cap. ESOMEPRAZOLE 20mg 1+0+1 (after meal)
 OXYMETAZOLINE 0.05% nasal drop 3 drops in each nostril 3 times
daily
 Gurgle with hydrogen peroxide 2tsf mixed with ½ glass normal water
and gurgle 4-5 times.
 Please monitor pulse, BP, respiratory rate, temperature, angle of
mouth and urine output per hourly.
Treatment on discharge with advice:
 Tab. CEFUROXIME 250mg 1+0+1 (after meal)10 days
 Tab. KETOROLAC 10mg 1+1+1 (after meal) 5 days
If pain persists
 Tab. FEXOFENADIN 60mg 0+0+1 1 month
 Cap. ESOMEPRAZOLE 20mg 1+0+1 (after meal)10 days
 OXYMETAZOLINE 0.05% nasal drop 3 drops in each nostril 3 times daily
for 7 days
 Gurgle with hydrogen peroxide 2tsf mixed with ½ glass normal water
and gurgle 4-5 times. 15 days

 Advice :
 Avoid hot, hard, spicy food.
 Ice cold liquid intake is requested
ANY QUESTIONS?