Australian Doctor Australia Doctor 18th August 2017 | Page 17

ENT
Dr Peter Ryan
Figure 1.
Figure 2.
ANDREW, 39, has a long history of allergic rhinitis and is referred by his GP for ENT
review of nasal polyps. The ENT surgeon takes the above endoscopic nasal cavity
pictures.
Dr Ryan is an ENT registrar at Royal North Shore Hospital, Sydney, NSW.
THE QUIZ
LFTs had almost normalised, with GGT persist-
ing at 82 and ALT 32, with plans to repeat within
three months to ensure full resolution.
Discussion
In the context of acute EBV infection, pruritus is rare
(fewer than 5% cases) and is a consequence of acute
hepatitis, which is usually self-limiting. This may
manifest in several ways: acute elevation of transami-
nases, abdominal pain, hepatosplenomegaly, clinical
jaundice/hyperbilirubinaemia, cholestasis and bile
acid elevation with pruritus. 1 Accumulation of bile
acid salts in plasma and tissues, along with endo-
genous opioid upregulation are implicated. 2
Treatment is usually supportive. Common medi-
cations used to manage pruritus of cholestasis are
cholestyramine as first-line agent, then rifampicin,
naltrexone/naloxone, SSRIs, ondansetron, phe-
nobarbital, steroids and antihistamines. Special-
ist consultation and inpatient admission may be
required in refractory or protracted cases or where
there is pre-existing chronic liver disease. Such
patients may require treatment with intravenous
opiate antagonists, or rifampicin, which carries its
own risk of hepatotoxicity. 3 ●
References
1. BMJ Case Report 2015; online.
2. Gastroenterology & Hepatology 2011; 7:615-17.
3. Butler DF. Pruritus and Systemic Disease Treatment and
Management. Medscape, June 2017. See: bit.ly/2vcmtz3
[Accessed: 7 August 2017]
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Q. Figure 1 is an
endoscopic view of
the left nasal cavity.
The structure
outlined in the
image on the right
represents:
a. A superior portion of
a leftward deviated
nasal septum
b. The head of the left
middle turbinate
c. A large nasal polyp
arising from the left
lateral wall of the
nasopharynx
d A tumour of the
nasopharyngeal
mucosa
A. The answer is b.
While this view is
difficult to obtain
without endoscopy,
it demonstrates a
normal, healthy middle
turbinate.
Inspection of the
nasal cavity by anterior
rhinoscopy or endoscopy
is always made easier
by topical application
of nasal decongestants
(eg, oxymetazoline or
co-phenylcaine) and
use of an appropriate
thudichum or other nasal
speculum.
Q. With respect to
differentiating
a nasal polyp
from a normal
or hypertrophied
turbinate, which of
the following are
true?
a. Topical nasal
decongestants will
cause both turbinates
and nasal polyps
to shrink, making
inspection of the nose
easier
b. Macroscopically,
nasal polyps appear
paler and glossier
than the turbinates
c. Nasal polyps are
relatively firm and
immobile compared
with the turbinates
d. Both turbinate
hypertrophy and
nasal polyps can
occur as the result
of poorly controlled
allergic or other
inflammatory disease
of the nose.
A. The answers are b
and d.
Topical nasal
decongestants should
be applied to aid
anterior rhinoscopy.
Inspect the nose prior
to their application
to evaluate turbinate
hypertrophy.
Over several minutes,
a significant reduction
in the size of the inferior
turbinates as well as
a mild increase in
mucosal pallor is usually
appreciated whereas
nasal polyps remain
unchanged in size and
appearance.
Nasal polyps (see
figure 2) appear paler
and glossier than the
turbinates and are softer
and more mobile. This
view of the right nasal
cavity demonstrates
extensive nasal
polyposis.
The polyps’ pale,
glossy appearance is
best seen in the large
polyp immediately
inferior to the right
middle turbinate
(outlined region).
Polyps seen here
may be obstructing the
pathway for drainage
of the maxillary sinus,
causing or exacerbating
chronic sinusitis.
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1
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References: 1. Giampietro PG et al. Pediatr Allergy Immnol 2001;12:83–6.
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