Challenging diagnostic nasal imaging

A 5-year-old male child presented with a history of recurrent sore throat, fever, mouth breathing for the past 3 years. The parents also gives history of sleep-disordered breathing including witnessed apneic episodes. History of nocturnal enuresis also present.

On examination

  • Adenoid facies present.
  • Mouth breathing present.
  • Oral cavity: Crowded tooth
  • Oropharynx: Grade III tonsils
  • Anterior rhinoscopy: normal
  • Posterior rhinoscopy: Adenoid hypertrophy present.
  • Ear: Bilateral tympanic membrane appears dull and bulged.
  • Neck: Bilateral jugulodigastric nodes present and tender.

Investigations done

  • Xray nasopharynx: GIII Adenoid hypertrophy.
  • Diagnostic nasal endoscopy: Please see the image above.
  • Routine blood: Hemoglobin, Platelets, aPTT, PTINR were normal
  • Pure tone audiometry: Bilateral mild conductive hearing loss
  • Tympanometry: Bilateral B curve.

Questions

  1. What is your diagnosis?
Submucosal cleft
Inverted papilloma
Antrochoanal polyp
Clival chordoma

Explanation

Diagnosis is chronic adenotonsillar hypertrophy + Bilateral otitis media with effusion + sleep-disordered breathing + occult submucosal cleft palate.

This was a retrograde diagnostic nasal endoscopy done at the time of surgery. Structures marked are

  1. Floor of nasal cavity/palate
  2. Posterior end of left inferior turbinate
  3. Postero-inferior end of septum showing incomplete fusion with the palate – submucosal cleft.
  4. As the septum is not formed completely in the posteroinferior part, posterior end of both inferior turbinates is visible.
  5. Adenoid tissue in nasopharynx.

Adenoidectomy in patients with a submucosal cleft can lead to velopharyngeal insufficiency.

Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

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