Eustachian tube dysfunction

Patient is 47-year-old female who states that she has always had seasonal allergies, but they seem to be getting worse and worse. She is waking up with significant sinus headaches requiring the need to take Advil cold and sinus. This does really help, but she does not like taking this regularly. She does have a lot of ear popping and clear nasal drainage that is constant especially when she is outside. She currently complains of nasal symptoms including sneezing, itching of the nose, nose rubbing, clear nasal discharge, postnasal drip, frequent nose blowing, nasal stuffiness, frequent throat clearing, sore throat, itching inside ears, and heartburn. It seems to be the worse in April, May, and June, and then gets little better through the summer and then start again in the fall. She denies any troubles in the winter. She does have about one sinus infection per year that seems to be this time of the year when her allergies are the worse. She denies nasal polyps, TMJ, frequent headaches, aspirin-induced nasal symptoms, nasal surgeries, frequent bad cold, or frequent tonsillitis. This could be severe. She currently uses Nasacort nasal spray daily. She has also used fluticasone and Nasonex and Rhinocort Aqua and Afrin in the past. She has very little relief with these.

She denies frequent ear infections. She does have some dizziness and lightheadedness. She denies hearing impairment.

She does have some eye itching, redness, and dryness. She denies light hurting her eyes, yellow discharge from eyes, eyelid swelling, or eyelid irritation. This occurs some of the time.

She denies any history of wheezing or lung troubles. No frequent coughing spells or recurrent night cough.

She does not have any allergic skin problems such as eczema or hives. She has never been evaluated for allergies before.

ASSESSMENT:
1. Allergic rhinitis.
2. Allergic conjunctivitis.
3. Eustachian tube dysfunction.

PLAN:
1. At this time, I do think patient would be a good candidate for allergy immunotherapy. She has tried multiple medications and they do not seem to provide her the best relief. Both of her sons come in for immunotherapy and had had good improvement and she would like to begin this treatment as well for long-term management and reduction of medication needs.
2. I did give her a sample of Dymista nasal spray and a prescription with five refills to try one spray each nostril twice daily to see if this one helps any more than any of the other nasal sprays she has tried, and can also utilize this sort of on an as-needed basis and have better luck with it. We will call her for her first shot appointment.

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