Mr. Brown - ENT (COW)
Mr. Brown is 47 years of age, married with children, is employed and is physically very active. He initially presented to a physician more then 10 years ago with the complaint of bilateral nasal obstruction. He has had childhood "hay fever" both in the spring and the fall. This included itchy eyes tearing sneezing and clear nasal discharge. Mr. Brown had allergy tests which identified several allergens and he has been on an avoidance protocol for many years.
He has been treated with antihistamines, Singulair, analgesics and occasional prednisone. He has been unable to smell or taste for some time. Gradually he has had increasing and more constant facial discomfort, nasal obstruction, thick discolored nasal discharge and chronic postnasal discharge with nocturnal cough. A CT scan of the paranasal sinus revealed "pansinusitis" without any erosion of the sinus walls. He has also been diagnosed with nasal polyps and has undergone a number of endoscopic sinus procedures.
In addition, the patient has asthma and sensitivity to nonsteroidal anti-inflammatory agents. for his asthma he administers steroid inhalers , bronchodilators and occasionally systemic steroids (prednisone) and antibiotics.
More recently problems with hearing loss have been a concern and this is making it difficult to perform at work meetings. A diagnosis of serous otitis had been made some time ago but in spite of "tube" insertions he continues to have recurrent ear discharge and is on intermittent antibacterial agents both locally in the ear and systemically. Other investigations have also documented "probable" sarcoidoses with typical chest x-ray changes and a septal perforation (present for > 10 years).
Due to the difficulty controlling his disease investigations have been done to rule out cystic fibrosis and immotile cilia syndrome. Repeated cultures fail to demonstrate fungal growth and biopsy material does not demonstrate hyphae. A constant background of eosinophilia is present. Empirical trials of prolonged systemic steroids and antifungal agents have been somewhat helpful.
PCL Learning Issues for March 29
Dr. Sukerman has suggested some issues below. Each student should pick from the list or choose learning issues of her/his own for Monday.
* Differentiate between URI and acute sinusitis. * What are anatomic and pathologic conditions predisposing to chronic (>12weeks) or recurrent acutre sinusitis (>4 per year) * What is the importance of Samter's Triad? * What is the usefulness of over-the-counter medications as adjuvant Rx in sinusitis. * Institute medical treatment of acute sinusitis * What advice should be given to the patient on possible surgical interventions * What are indications for: a) plain X-rays; b) CT scans * Recognize the influence of sinusitis on "distant sites", e.g. hearing loss, hoarseness, cough, asthma