AN UNUSUAL CASE OF CHRONIC RHINOSINUSITIS

Abstract

<h3>Introduction</h3> We present a case of long-standing nasal symptoms initially suggestive of chronic rhinosinusitis with nasal polyposis (CRSwNP) but later found to be an atypical etiology. <h3>Case Description</h3> A 30 year-old female with past medical history of tobacco use disorder presented with two years of nasal congestion, rhinorrhea, and lost of taste and smell. She was trialed on diphenhydramine, loratidine, fexofenadine, cetirizine, and intranasal budesonide without significant relief. She had history of ENT provocation testing positive for tree, weeds, grass pollen, mold, dust mite and pet dander and was started on subcutaneous allergy immunotherapy without improvement. Additional history was notable for mild eosinophilia of 300 cells/μL and vomiting and nasal congestion to tramadol and naproxen - though tolerated other NSAIDs. She was evaluated by ENT where she was found to have large nasal polyps via rhinoscopy and diagnosed with CRSwNP. A referral to Allergy was made for consideration of dupilumab therapy. However, CT scan showed large mass eroding into nearby facial sinuses. There was also notable increased bone growth along right middle turbinate initially suggestive of inverted papilloma. Pathology showed invasive poorly differentiated non-keratinizing squamous cell carcinoma positive for HPV. Definitive treatment involved multiple debulking procedures and adjuvant radiation. <h3>Discussion</h3> This case highlights the typical treatment of chronic rhinosinusitis with nasal polyposis as well as the broad differential required of her presenting symptoms. Her symptoms were very suggestive of chronic sinusitis with nasal polyposis, but treatment was resistant. Other etiologies of nasal polyps, including malignancy, should be on differential of recalcitrant nasal symptoms.