Patient is 8-year-old boy who is brought in by his mother to discuss his chronic mouth breathing state and snoring at night. Mom states that she noticed this first when he was three years old. He complains of nasal stuffiness, mouth breathing, frequent throat clearing, and snoring. He was placed on Singulair at that time and has been on it ever since but has not seemed to help. She states that this occurs almost every day. She does feel that he stops breathing at night when snoring and she is pursuing a sleep study next week. He denies any sinus infections, nasal polyps, frequent headaches, aspirin-induced nasal symptoms, nasal surgery, frequent bad cold, or frequent tonsillitis. This seems to be quite severe. He has tried various nasal sprays, currently Nasonex as well as Claritin and Singular and he has had very little relief. He has never had a CT scan of his sinuses.
He denies frequent ear infection, dizziness, lightheadedness, or hearing impairment.
He denies any eye itching, redness, tearing, dryness, burning, light hurting his eyes, yellow discharge from eyes, eyelid swelling, or eyelid irritation. Mom states that some people have told her that he has those allergic looking eyes with dark circles underneath.
He denies any lung problems or wheezing although has occasional chest tightness and cough during or after exercise. He does use an albuterol inhaler for this. The nurse at schools says that he is never really wheezing but it seems to be more associated with cough. They do say he has frequent coughing spells. They deny recurrent night cough, coughing up mucus, blood in mucus, coughing with wheezing, laughing, or lying down. They do admit to coughing on exertion.
He has not had a chest x-ray within the last five years.
He denies any allergic skin problem. He has not been evaluated for any allergies before.
1. Hypertrophy of tonsils, suspicion of enlarged adenoid causing snoring.
2. Concern for sleep apnea.
3. Allergic rhinitis.
4. Allergic conjunctivitis.
1. At this time, I talked to mom about that this most likely being associated with hypertrophied tissues of adenoid causing his chronic nasal congestion and snoring troubles. She is pursuing a sleep study next week. I also told her that I would refer her to Dr. for otolaryngology to further evaluate this and he may be adequate for tonsillectomy and adenoidectomy.
2. He was mildly allergic to cat and Hormodendrum, although he is not consistently exposed to these things and does not appear to be allergic on physical exam today. I discussed with her to keep him off of Singulair and Zyrtec and see if he does okay without these things. If he has any increase in acute nasal symptoms then she can use nasal sprays however these have not been very effective for him.
3. We also discussed his lactose intolerance troubles and I encouraged her to try Lactaid. I also encouraged her to try ranitidine over the counter for his stomach complaints and see if that helps. If not, then she may want to go see gastroenterologist to further identify what is going on.
4. We will follow up as needed.