From time to time a patient who is referred to my office presents with a very puzzling complaint. Recently, just such an intriguing case came my way.
Part I of this article is the actual history (with fictitious names of course). Part II, which will appear in the Oct. 23 issue, will present the physical exam findings and discuss the differential diagnoses.
Now, I present a challenge: The history contains all the information necessary to establish the differential diagnosis list -- can you develop differentials that are clearly in line with the historical data?
Let's begin. A patient was referred by an otorhinolaryngologist (ear, nose, throat specialist) for a suspected TM disorder.
The patient, Ms. Arial, was referred to me by Dr. Cristie for an evaluation in regards to persistent jaw complaints apparently associated with ear and nose complaints. The examination of Ms. Arial lasted nearly two hours.
The patient was visibly upset, crying, and in apparent mild, emotional distress. A few minutes spent with the patient and a reassuring conversation calms her.
Ms. Arial described her current complaint as a strictly right-sided problem where she states there is an ever-present focal pain in the temple and a persistent "drip" in the right nostril. The patient reports that the temple pain is a burning pain "like an inflamed nerve." She reports that this pain is momentarily relieved by finger-tip massage and worsens when chewing.
She adds that she has a persistent "clenching habit" which appears to worsen her temple pain. She states that the pain does not radiate or change in character, and adds that it is constant and "never goes away." She further adds that she feels strongly about the correlation of the pain with her postnasal drip. In this regard, she states that a deep massage of the temple pain decreases her nasal complaint and that in those rare instances where the temple pain is gone, the nasal drip (apparently) stops.
In regards to the nasal complaint, the patient reports that her nose is "always dripping," exclusively on the right side. She denies sneezing or nasal itching. She does not report seasonal or diurnal variation, or anything remarkable about her work environment. Ms. Arial denies experiencing headaches, although upon redirected questions, she states that she experiences "normal headaches" which she states are frontal in location. Ms. Arial describes the drip coming from high up in the nose or in the back of the nose. She adds that the rhinorrhea is never cloudy, smelly or thick. She further adds that the "drip" is watery, very slight in amount, and the rate of discharge does not appear to change.
She states that she has sought care with many ENT specialists and medication does not seem to be of any help. The patient states that the only relief she obtains is when the right temple pain is relieved. The patient states that the most recent ENT specialist, Dr. Cristie, apparently told her that the eustachian tube is blocked and this, according to Ms. Arial, accounts for her nose problem.
History of Complaint
Ms. Arial states that her current complaints started about four years ago as a period of persistent "light-headedness" which was followed by a period of right temple burning or stinging pain which, according to the patient, finally produced a scalp lesion in the same area where she now complains of focal temple pain. She reports that this scalp lesion persisted for a short period of time and the lesion healed, but the pain persisted. She also states that soon after the lesion healed, her nasal complaint began which prompted her to see her family physician, whereupon she was referred to an ENT specialist.
The patient states that she has sought care from numerous health care providers in the last four years. She reports seeing general practice physicians, general practice dentists, a chiropractor, an orthodontist, an allergist, and ENT and TMJ specialists. She adds that some diagnoses have been ruled out (e.g., allergies, dental infections, sinusitis, and tumors of the brain). When asked detailed questions about the type or nature of her diagnostic workups or about specific diagnoses that have been considered, the patient responds that she does not know.
Ms. Arial states that within the last six months her facial skin is "breaking out" and this has never happened before. She points to her face to demonstrate the changes; however, this examiner was unable to discern these changes, not having the privilege of seeing this patient before her facial complaints began.
The patient also states that about two years ago she had some of her molars removed because of the suspicion they were the etiology of her chief complaint.
Ms. Arial also states that she has obtained very little therapy directed to the temple area. She reports that she was told to use moist heat as needed and indicates that she does so quite regularly. She reports that her chiropractor applied electrostimulation over the area but this provided only temporary benefit.
The patient concludes the interview presenting a strong conviction that the temple pain is the main factor in her complaints. She further theorizes that the temple pain is causing the clogging of the eustachian tube and this is causing a back-up to her nose, hence the postnasal drip. She further concludes that the blocked eustachian tube is also causing the "toxins" to enter her system, hence the appearance of her most recent facial skin problems. She further adds that she believes that all these complaints will go away once the temple pain is removed -- thus allowing the eustachian tube to function normally.
Past Medical History
Illnesses: Denied except as noted above.
Injuries: Denied
Surgeries: Denied except as noted above
Medications: Occasional Tylenol or antihistamines
Allergies: None reported
Habits: Non-smoker. Non-drinker. Denies other drug use. Reports current history of clenching.
Work History
The patient is employed as a customer representative for Public Services
Social History
Ms. Arial reports that she is happily married (for 19 years) and has a healthy 14-year-old daughter.
PUZZLED?
Do you agree with the patient that the temple pain is the cause of her post-nasal drip?
What are your impressions of the temple pain?
Is there anything in the history that stands out and says, "Look Out!"
Is it safe to assume her vital signs will be normal? Why?
With each article I encourage you to write the questions you may have, commentaries on patient care subsequent to attending the TM seminars, or thoughts to share with your colleagues, to me:
Darryl Curl, D.D.S., D.C.
2330 Golden West Lane
Norco, California 91760
Please enclose your return addressed, stamped envelope.,
Editor's Note:
Drs. Darryl Curl and Paul Hooper will be teaching a new Industrial Consulting seminar for doctors and clinic assistants on September 26-27, 1992, in Long Beach, California. You may register for the seminar by dialing 1-800-359-2289.
