Otolaryngology Consultation Letter

Dear Dr.,

Thank you for referring Jacob for otolaryngology consultation. He was seen in our clinic on June 7, 2025.

CHIEF COMPLAINT/REASON FOR CONSULTATION:
Nasal congestion and turbinate hypertrophy.

HISTORY OF PRESENT ILLNESS:
Jacob presents with ongoing nasal congestion, particularly noticeable upon waking in the morning. His parents report administering Omnaris nasal spray nightly. He was previously evaluated for a cough and started on an oral inhaler, with a follow-up planned for the fall. Nasal congestion and turbinate hypertrophy have been persistent despite current management.

PAST MEDICAL HISTORY:
Not available.

PAST SURGICAL HISTORY:
Not available.

MEDICATIONS:
Omnaris nasal spray administered nightly. An oral inhaler prescribed by pediatrics for cough management.

ALLERGIES:
Unknown.

PHYSICAL EXAMINATION:

Nose:
Moderate hypertrophy of both inferior turbinates observed.

The remainder of the ENT examination was normal.

ASSESSMENT:
1. Nasal congestion.
2. Inferior turbinate hypertrophy, likely secondary to allergic rhinitis.

PLAN:
1. Provided a sample of Ryaltris nasal spray with instructions to administer one spray in each nostril every night.
2. Scheduled a follow-up appointment in three months to evaluate the effectiveness of the treatment on turbinate hypertrophy and nasal congestion symptoms.

I appreciate being given the opportunity to participate in the care of your patient and welcome any queries you may have regarding their care.

Sincerely,  
A. Carter, MD  
Regional ENT