MEETING WITH A PHYSICIAN

. Posted in DIAGNOSING YOUR SYMPTOMS

As you can see, CAID is complex, and its diagnosis is multifaceted. That is why it is important for anyone who suffers from one or more limbs of CAID to be managed by a team of physicians. I believe that an ENT specialist (otolaryngologist) should be considered the leader of the specialist team. Most internists will admit that they have only the minimum of schooling in sinus issues, but the majority of their patients have these problems. Conversely, ENTs have the most schooling in these issues. It is important for your ENT to keep your primary-care physician updated as to the treatment that is being prescribed.

If you now identify that you are suffering from severe sinus pain, you should seek treatment from an otolaryngologist who can treat your condition with medical and/or surgical remedies. If you have been seen by an ENT before and you have not received satisfactory treatment, you may want to seek out another ENT who specializes in sinus problems. Your primary-care physician, or even a general ENT, can refer you to someone who he or she considers an expert in this field.

Once you make an appointment with an ENT, it will be helpful for you to obtain all applicable information from your current physician(s) describing your past history, any testing, and all treatments provided - both medical (bring in a list of all of the medicines that you have taken)
and surgical (bring in all the operative reports). You should also bring any imaging studies (X-rays, CT scans) that you may have had. It is much more helpful to bring in the original films along with any written reports, as the report will not usually give your ENT as much information as the films themselves. If you have had previous surgery, the surgical reports are also helpful.

Your initial visit to an otolaryngologist should be relatively uniform. In my office, every examination begins with patient questionnaires, a thorough medical history, and a physical examination. While I’m focusing on patients’ ears, noses, throats, and chests, I’m also evaluating their overall appearance. I note if they are well kept, evaluate whether they are overweight, and determine if they breathe with an open or closed mouth. I evaluate their skin color and the general health of their skin. I listen to the quality of their voice, noting if they are hy- ponasal or hoarse. I explore their facial features and check for swelling around the eyes and puffiness around the face, over the forehead, and in the cheeks. I look for black-and-blue marks around the eyes. I perform an evaluation of the eyes and tap or press on the sinus areas for tenderness. I look at the lids for swelling or redness, the whites of the eyes for discoloration or redness, and the corners of the eyes for crusting. I look for tearing, note the position of the eyeballs, and the way that their eyes move. I look at the nose for swelling, creases, crusting, or bleeding and then look into the nose for discolored mucus, blood, crusting, scabbing, and dryness. I note the color of the membranes and the shape of the nasal valve and the septum and see if the turbinates are swollen or obstructive. I also determine if there are any polyps or papilloma.

Next I look at the mouth and throat. I look for a change in the thickness and color of the membranes and look for postnasal drip. I examine the membranes throughout and smell the breath. I look at the teeth and gums to see if there is dryness and/or bleeding or redness. I look at the size of the tonsils and note the way the palate lines up with the back of the throat. I look at the uvula (which hangs down in the back of the throat). I feel the neck for swollen glands, thyroid enlargement, or any enlarged lumps. If patients complain of pain in their teeth, I may tap the teeth to identify an inflamed tooth root.

I examine the ears for wax, note the shape of the ear canal, and look at the quality of the eardrum. Last, I listen to their lungs to detect noisy breathing or wheezing.

Of course, it may be important to evaluate the nose and the sinuses more thoroughly. 1 usually do this after a course of medical therapy has been tried. As well, I try to have a recent CT scan available at the time that I perform an endoscopic exam so that I may compare the films to my findings. However, your ENT may perform the examination and tests in a different manner. For an endoscopic evaluation, I use the most advanced diagnostic tools that are currently available, including an endoscope, which is a special fiber-optic instrument used to examine the interior of the nose and sinuses. 1 find that an endoscopic examination provides the most reliable visualization of many of the accessible areas of the sinus drainage pathways and can quickly allow one to determine if any of these areas are blocked.

To do this procedure, I first numb the nasal cavity with a combination of a decongestant and a topical anesthetic spray. For evaluation of the nose, I prefer to use a rigid nasal endoscope, and I gently place it in each nostril one at a time. During this examination, I can see if there is infection, polyp formation, and/or structural abnormalities that may cause obstruction in both the nose and the sinuses. In patients who have had previous sinus surgery, I can often see directly into the sinuses and evaluate scarring, infection, polyp formation, and closure of the passageways. Evaluation of the nasopharynx and the eustachian tubes gives us additional information. During the endoscopic examination you may feel a firm pressure in the nose, which is slightly uncomfortable, but this is usually not painful.

For patients who complain of hoarseness and/or symptoms consistent with LPRD/GERD, I prefer to use a flexible fiber-optic nasopharyn - golaryngoscope to evaluate the voice box. Although on occasion I have used a rigid laryngoscope.

If I recognize that an infection exists, and the patient has recently finished a course of antibiotics, I may take a culture sample under endoscopic visualization and send it to a laboratory for further investigation. A laboratory may be able to identify a fungus or a resistant organism (a
bacterium that is not sensitive to antibiotic treatment). For the culture, I swab the affected area to obtain a small sample of infected mucus. This sample is then placed in a tube containing culture medium. Many physicians run the swab directly across a glass plate (called “plating a culture”) where the bacteria or fungi will grow. The swab that I send to the lab will be plated there. If bacteria are present, the bacteria will start growing on the plate. Once the organism is identified, the lab can treat the bacteria with various antibiotics to determine which one will yield the best results. If the bacteria continue to grow when placed near a particular antibiotic, then the organism is resistant to that specific antibiotic. Fungal cultures can be performed as well. Tests for major basic protein (MBP) can also be taken by sending your mucus to a lab. MBP is present as a result of fungal sinusitis.

Unfortunately, cultures are not always as accurate as we would like them to be. At times, they yield a false-positive result (cultures that are positive because of contamination although they should really be negative), or a false-negative result (which means that the culture is negative even though bacteria or fungus is really present). For example, a false negative may be found if the patient is on a course of antibiotics.

There are many physicians who feel that cultures are a waste of time. I believe that cultures have their place. For example, if a patient is feeling better but a culture shows a resistant organism, then perhaps a continuation of antibiotic treatment is warranted. In the end, I always put more weight on the clinical picture than on the culture.

If I notice significant nasal obstruction and/or have been told by the patient of repeated infections that have not cleared with medicine or if I suspect a tumor or polyps or cancer, then I will order a CT scan. A CT scan is a very good way to evaluate the sinuses. Patients may obtain a CT scan at a radiology imaging center, a hospital (these scanners are made by various companies including GE, Hitachi, Philips, Siemens, and Toshiba), and in some cases at their physician’s offices using a smaller version called the MiniCAT (made by Xoran Technology). Each type of scanner has benefits and limitations. Today’s CT scan units are not as confining as they used to be and are more comfortable for the patient. The larger scanners operate with the patient lying on a table
and have more capabilities than the smaller versions. Of course CT scan testing, like all testing, is not perfect, although the technology has improved greatly over the years. CT scans show the shadow of the disease but cannot pinpoint the exact nature of the disease. In fact, they occasionally don’t spot the disease altogether, and the scan may appear normal. For this reason, the diagnosis of sinus disease should be based on a comprehensive history and a thorough physical examination including an endoscopic examination, as well as the CT scan.

If during the medical history I am told of a diminished sense of smell or taste, I might want to order a magnetic resonance imaging (MRI) study because this is the best way to evaluate the brain and the olfactory nerve. An MRI scan can be obtained at a radiology facility or at a hospital. These scanners are made by various companies including GE, Hitachi, Philips, Siemens, and Toshiba. If the history suggests an immunological, infectious, or inflammatory cause, various blood tests should be ordered. These blood tests might include the following:

■ Complete blood count (CBC) with a differential, which means we look at the level and activity of the types of white blood cells

■ Erythrocyte sedimentation rate (ESR), which measures an inflammatory response

■ Immunoglobulin G (IgG) and its subclasses and IgE, which are the immunoglobulins affiliated with infection and allergy

■ Immunoglobulins A and M, which are affiliated with fighting infection

■ Antinuclear antibody (ANA) and antineutrophil cytoplasmic antibody (ANCA), both of which measure antibodies in the blood

■ Lyme titer, if there has been exposure to deer ticks

■ Angiotensin-converting enzyme (ACE) level, which is highly suggestive of sarcoid disease

When I get the results from the various tests, I often consult with other specialists to meet each patient’s individual needs. In my practice, I manage the care of my patients, referring them to a variety of medical specialists, including allergist/immunologists, pulmonologists,
infectious disease specialists, endocrinologists, ophthalmologists, and rheumatologists. Should the patient suffer from allergies, I work with an allergist (either medically or otolaryngologically trained) who practices allergy/immunology. Either training for allergy specialization is fine. I recommend to the allergist that he or she do a complete allergy workup and, if needed, recommend that he or she perform immunology testing. If the patient suffers from asthma, I like to work with either a pulmonologist or an allergist/immunologist who specializes in asthma, both types of specialists can perform a pulmonary function test. This test analyzes the patient’s lung capacity.

If I have a suspicion that the infectious agent(s) may be more complex, I might ask for some advice from an infectious disease specialist. If there are underlying eye problems, I will consult an ophthalmologist (eye doctor). If the patient is complaining of different types of headaches

I will send him or her to a neurologist. When there is a question about rheumatological disease involvement as in the case of lupus, sarcoid or wegener’s granulomatosis disease, then I ask a rheumatologist to consult. If there are concerns regarding a patient’s metabolism, I will refer him or her to an endocrinologist.

If a patient is complaining of sinus headaches along with neck and back pain, I will send him or her to a chiropractor or acupuncturist. I will consult with a dentist if there is an infection present in the gums or upper teeth. Last, if diet seems to be an issue, either a traditional or holistic nutritionist will be able to address the problem and offer individual solutions for food plans.

Moreover, I advise patients to make sure either they or the otolaryngologist keeps their primary-care physician - usually an internist, family practitioner, pediatrician, or osteopath - in the loop to manage their total care. The primary-care physician is ultimately the one doctor responsible for your overall health, so he or she needs to be kept abreast of diagnoses and treatments being administered by any specialists.

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