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Abstract: A 61-year-old male patient reported that half a month ago, he suddenly felt nasal congestion, loss of smell, headache, and sometimes clear runny nose, and applied nasal drops at home on his own to reduce the symptoms, but still had recurrent attacks, so he came to our hospital. After examination and diagnosis of sinusitis, he was treated with surgery and medication, and his discomfort disappeared and his condition was stable.
Basic information】Male, 61 years old
Disease Type】Sinusitis (chronic sinusitis)
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of consultation】August 2014
Treatment plan】Surgical treatment (endoscopic sinus surgery, nasal polypectomy) + medication (cefuroxime sodium for injection, levofloxacin hydrochloride capsule)
Treatment period】Inpatient treatment for 9 days, outpatient review 2 weeks after discharge
Treatment effect]: Nasal congestion, headache, loss of smell, and clear runny nose disappeared, and the condition was stable.
I. Initial consultation
The patient complained of nasal congestion, headache, decreased sense of smell, and sometimes clear runny nose without nausea, panic and palpitations since half a month ago. On examination, the patient’s nasal mucosa was found to be swollen and pale, with a small amount of viscous secretions inside, and the bilateral nasal common tract was filled with grayish, translucent noon, soft to touch, with no pressure pain in the bilateral sinus areas. After combining the patient’s symptomatic manifestations and laboratory test results, the patient was initially diagnosed with sinusitis (chronic sinusitis) with nasal polyps and admitted to the hospital for treatment.
II. Treatment history
I informed the patient that the recent physical discomfort was due to sinusitis, and since the disease had a relatively large impact on the patient’s breathing and his condition was somewhat severe, I suggested that surgery be performed to treat sinusitis along with nasal polypectomy and postoperative medication, and the patient also expressed his cooperation. After the patient was under general anesthesia, the endoscopic guidance was used to directly locate the focal point in the nose and remove the sinus and polyp tissue, and the patient’s incision site was bandaged with pressure after the surgery. Since the patient suffered from sinusitis due to bacterial infection and should also be treated with postoperative anti-infection therapy, cefuroxime sodium for injection was given intravenously and levofloxacin hydrochloride capsule was given orally. After 1 week, no relevant complications appeared and discharge could be arranged.
III. Treatment effect
The patient had nasal congestion, headache, and decreased sense of smell with clear runny nose before treatment. After 7 days of nasal endoscopic surgery as well as the above mentioned medication, the patient reported that the symptoms of nasal congestion, headache and clear runny nose subsided and the sense of smell was restored. The patient was discharged from the hospital one week later, and was found to have an intact nasal mucosa, no mucous secretions, and no soft tissue density foci filling in the nasal cavity bilaterally.
IV. Notes
I am very happy that the patient’s condition has improved. For patients with sinusitis, in addition to active medication, it is also necessary to strengthen their own management in life, usually to do the following.
1, 1 week after discharge from the hospital need to review the recovery of the disease, during the period if there is discomfort in time to seek medical attention.
2, patients should be light diet, avoid spicy and irritating food intake, such as chili, fatty meat, etc., and pay attention to quit smoking and limit alcohol.
3, living indoor to keep the air flowing, wear a mask when going out, to reduce car exhaust, second-hand smoke, dust and other adverse stimuli.
4. In the early postoperative period, be careful not to perform irritating operations such as digging nostrils and plucking nasal hairs to avoid affecting postoperative recovery.
V. Personal insight
For patients suffering from sinusitis, they should take allopathic and symptomatic treatment, so as to better control the disease and promote its improvement. Like the 61-year-old male patient in this case, the condition was better controlled after anti-infective drugs and nasal endoscopic surgery were given. Sinusitis starts with nasal congestion, runny nose, smell disturbance, nasal bleeding, and local pain. Once such symptoms appear, one should be alert to the occurrence of sinusitis and seek medical attention in a timely manner.