Patient is 38-year-old male who comes in to address his problems that have been occurring since last July. He states that he has had increased nasal congestion and has caused his ears to be constantly plugged and popping. He states some of the time, he is whistling and clicking of his ears that seems to occur all the time and is very bothersome. He also has been getting bouts of lightheadedness with this as well as headaches. He has seen an ear, nose and throat doctor for this and undergone balance testing and hearing testing and everything was normal. He has noticed that he has had increased sinus congestion since he has moved here from Pocatello 16 years ago and he does have seasonal allergies that may be contributing. He complains of clear nasal discharge, postnasal drip, colored nasal drainage, frequent nose blowing, nasal stuffiness, mouth breathing, frequent throat clearing, yellow-green discharge, throat hoarseness, decreased smell, itchiness inside ears, heartburn and belching a lot. He denies any problems of sinus infections at least this last year. He does have a history of nasal polyps, but denies any aspirin-induced nasal symptoms. He denies any history of nasal surgeries although he does state he has a deviated nasal septum. He denies frequent bad colds, frequent tonsillitis, or frequent ear infection. He states that his symptoms are severe. He has used over-the-counter antihistamines as well as Afrin just for short amount of time with some help, but very little overall. He has had CT scan of sinuses in April 2014.
He does complain of lightheadedness and hearing impairment associated with his ears popping. He did have a fungal infection in his ears in 2014 for two months that was treated and resolved. He does state that he has eczema and flaking in the ear canal as well.
He does complain of some eye symptoms including redness and tearing. He denies itching, dryness, burning, yellow discharge from eyes, eyelid swelling or eyelid irritation. He does have light hurting his eyes. He does get some eye blurriness as well occasionally.
He denies any history of wheezing or lung problems. He denies any frequent coughing spells or recurrent night cough.
He denies any allergic skin problems in the past. He has never been evaluated for allergies before.
1. Eustachian tube dysfunction.
2. Nasal polyposis.
3. Seborrheic dermatitis.
4. Allergic rhinitis.
5. Allergic conjunctivitis.
8. Fatty liver disease with hypertriglyceridemia.
1. At this time, I would like to try patient on a dose of prednisone 30 mg for four days to see if this can resolve some of his eustachian tube dysfunction as well as severe nasal congestion and reduction in nasal polyp. I also encouraged him to use QNASL nasal spray one spray each nostril twice daily to help reduce the size of the polyp and inflammation in the nasal airway and sinuses.
2. I also prescribed him ketoconazole shampoo for seborrheic dermatitis around his scalp to use three times per week allow to sit on the skin for 5 to 10 minutes before rinsing off for a total of eight weeks or resolution whichever come sooner.
3. I also prescribed him an ointment of hydrocortisone 2.5% to apply to the affected areas on his ears and around his ears to help resolve this dermatitis.
4. I also prescribed him Ciprodex otic suspension to use four drops in each ear twice daily for the next seven days to help resolve the dermatitis in the ear canal itself and potentially resolve some inflammation. We will follow up in two weeks’ time to see how these medication interventions are helping with his symptoms.