Brief Answer:
CRS. BSP, RF, OSAS

Detailed Answer:
Hi,

Thank you for your query.

1. I must appreciate the amount of clinical data presented by you.

2. Your CT PNS Scans show Chronic Rhinosinusitis (CRS). There are varying images of Pansinusitis in the comparative scans. Almost all sinuses are involved in the various scans at various points of time. Mucosal thickening and secretions are present. Since medical management of CRS has failed, surgical options must be explored.

3. Given your medical history, fungal infection is common and the bony walls of the sinuses often appear thinned out due to the density of the fungal debris, but in reality at the time of surgery are usually not eroded.

4. The appearance of the pituitary in the MRI is of no concern. There is the likely-hood of pituitary imbalance as the pituitary is the master gland of the body. However your blood tests show good control of your medical conditions and are fairly within acceptable limits.

5. Since you have Obstructive Sleep Apnea Syndrome, and a BMI of 45, and the above medical conditions, I recommend the following:
a. Balloon Sinuplasty (BSP) and Radiofrequency (RF) volume reduction of the Inferior nasal turbinates can be done under Local Anesthesia.
b. Right Nasal Concha Bullosa can be removed under Local Anesthesia
c. Avoid Septoplasty at the age of 56 years.
d. Keep FESS (Functional Endoscopic Sinus Surgery) which will require General Anesthesia as the last resort.
e. The nasal valve area needs to be reassessed.
f. A flexible nasopharyngoscopy and Dynamic MRI for the OSAS is required.

Hope I have answered your query. If you have any follow up queries, I will be available to answer them.

Regards.

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Brief Answer:
Detailed follow up answer:

Detailed Answer:
Hi,

Thank you for writing back.

1. It is good to hear that your BMI has decreased.

2. Taking such long courses of antibiotics will cause fungal overgrowth.

3. I believe you have been kept on a wait list against cancellation for earlier surgery.

4. In regard to the fungal sinusitis, I need to put certain facts into perspective:
a. If the age of the Earth (4.6 billion years) is considered as a 12 hour clock, the first fungus appeared at 8 o'clock (about 2 billion years ago).
b. Humans in comparison have been on this planet since 11:56 (about 4 minutes). c. It is estimated that there are 8-10 tonnes on fungus as against each person in this World.
d. Hence fungii are omnipresent.
e. Fungal sinusitis in humans has a wide variation with Allergic Fungal Rhino Sinusitis (AFRS) on one end of the spectrum where the fungus is in the sinus but outside the body, yet it causes an allergic reaction. The efficacy of oral anti-fungals is doubtful in such cases. At the other end of the spectrum is Invasive Fungal Sinusitis which is the most severe form. All the other conditions mentioned by you lie in between.
f. Hence there is no need for further tests. Penicillium spp are common. After the sinuses are opened, cleaned and ventilated, the fungus load will fall and your fungal allergy will decrease.
g. Uncontrolled diabetes and other conditions which cause lower immunity help the fungus cause more severe disease.

5. Yes, I do many such surgeries in XXXXXXX I have performed the first Spin Balloon Sinuplasty cases in XXXXXXX as National Live Surgical Faculty at ‘Sinus Saga’, a Live Surgical demonstration on 23rd February 2014 at BJMC and Civil Hospital in XXXXXXX Gujrat.

6. Your headaches may be Rhinogenic, however it may not always be the case. One of the reasons for sinus headaches worsening in the evening are partially blocked sinuses that fill up during the day. The natural openings of the Maxillary and Sphenoid Sinuses (occipital headache) are located high up and these tend to fill up during the day. The outflow of the Frontal and Ethmoid sinuses is gravity dependent and these sinuses tend to fill up on lying down and cause morning headaches and pressure around the eyes.

7. The CT Reports are fairly accurate. Do not worry about the minor differences. Leave that for the operating surgeon. I follow a 15 point reporting system from the surgeon's perspective and hence there are additional points that will show up.

8. General anesthesia will be possible in your case but the anesthetist has to take extra care since you have many co-existing conditions. That is why I have suggested leaving the septum alone and first trying Balloon Sinuplasty and RF turbinate reduction under local anesthesia.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.

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Brief Answer:
Do not worry, your condition is common. Not invasive FRS.

Detailed Answer:
Hi,

Thank you for writing back.

1. The 15 point CT reporting system includes the following:
a. Septum,
b. Agger nasi cells,
c. Frontal sinus, frontal sinus drainage pathways,
d. Crista galli, Keros Classification, cribriform plate, lamellae
e. Ethmoid sinuses, Concha Bullosa,
f. Maxillary Sinuses, Osteomeateal Complex, Accessory ostia, Haller cells,
g. Uncinate process, attachments,
h. Lamina papyracea,
i. Canals of anterior ethmoid arteries,
j. Skull base slope,
k. Supra orbital cells,
l. Sphenoid sinus, Onodi Cells,
m. Sphenoid Septa, Optic Nerve, ICA
n. Bony margins of all Sinuses,
o. Visualized Orbits, Brain and Nasopharynx.

2. The Lund Mackay scoring system is the most widely used grading system for CRS. This scoring system consists of a scale of 0-2 depending upon the absence, partial or complete opacification of the sinus system and the osteomeatal complex. This scoring system derives a maximum score of 12 per side. Thus the points are given for the maxillary sinuses, anterior ethmoids, posterior ethmoids, sphenoid, and frontal sinuses, as well as the ostiomeatal complex to arrive at the final score.

3. Your condition is common and you do not have an Invasive Fungal Sinusitis.

4. As long as your diabetes is under control, and medication is on, you should be fine. In the meanwhile a diagnostic nasal endoscopy after decongestion of the nose will help check for polyps or fungal mucin (thick mucopus) and planning of the surgical intervention.

5. You must explore and discuss minimally invasive surgical options during this time.

I hope that I have answered your query. If you have any more questions I will be available to answer them.

Regards.

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