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Am Fam Physician. 1999;60(1):298

Causes of Postnasal Drip

(Australia—Australian Family Physician, March 1999, p. 223.) Postnasal drip refers to the accumulation of mucus in the postnasal space, caused by hypersecretion from the paranasal sinuses or a disturbance of normal drainage. In addition to “congestion” and local discomfort, postnasal drip is associated with halitosis, chronic cough and symptoms of inflammation in the sinuses and nasal passages. Postnasal drip may be the result of allergic rhinitis, acute or chronic sinusitis or anatomic obstructions. Allergic rhinitis is common in both adults and children and often has a strong family history. Prolonged or chronic sinusitis is usually associated with obstruction of drainage, but immunodeficiency and mucosal dysfunction should be considered. Nasal polyps are common in adults but extremely rare in children, except for those with cystic fibrosis. In children, enlarged adenoids are a common obstruction to sinus drainage and a reservoir of infection. Other causes of obstruction include septal deflections, congenital abnormalities, foreign bodies and impacted teeth. Exposure to industrial chemicals and cigarette smoke may also contribute to the development of postnasal drip.

Diagnosing Cushing's Syndrome

(Great Britain—The Practitioner, February 1999, p. 118) Advanced Cushing's syndrome usually is easily diagnosed, but mild or early cases can be overlooked. Most cases are iatrogenic, resulting from daily corticosteroid intakes equivalent to or greater than 7.5 mg of prednisone. Noniatrogenic cases are predominantly caused by excess pituitary secretion of corticotropin, with some cases caused by ectopic corticotropin secretion or adrenal hypersecretion of cortisol. Initial symptoms, such as lethargy, depression, weight gain, thirst, polyuria, weakness, hirsutism and easy bruising, may be nonspecific and insidious. Patients develop central obesity, rounded face, facial plethora and fat deposits on the neck and shoulders. Conversely, there is wasting and myopathy of the limbs plus thinning and increased fragility of the skin. Associated conditions include diabetes mellitus, hypertension, dyslipidemia and osteoporosis. In noniatrogenic cases, diagnostic testing is used first to establish the diagnosis by demonstrating cortisol excess and then to identify the most likely source (adrenal, pituitary or other), depending on the specific history and findings in each patient.

Laryngeal Cancer

(Australia—Australian Family Physician, March 1999, p. 209.) The larynx is the second most common site of head and neck cancers, exceeded in frequency only by cancers of the oral cavity. Most laryngeal cancers are squamous cell carcinomas, and the most common site is the glottis. Patients with glottic cancers usually present early because of hoarseness and have an excellent prognosis because of the low rate of lymphatic spread. Patients with other laryngeal cancers have a poorer prognosis because of the rich lymphatic drainage of the subglottic and supraglottic areas. Stridor and hemoptysis are usually late symptoms in all laryngeal cancers. Partial laryngectomy or laser excision may achieve local control of up to 95 percent of early laryngeal cancers while preserving laryngeal function. Radiation may be used as an alternative or adjunctive treatment. The combination of chemotherapy and radiation is being studied, particularly in the treatment of patients with advanced cases of laryngeal cancer in an attempt to maximize preservation of laryngeal function.

Diagnosis and Treatment of Acromegaly

(Great Britain—The Practitioner, February 1999, p. 110) In a population of 1 million, 60 to 70 adults have acromegaly, and about three new cases are detected each year. The diagnosis of this rare disease may be delayed because the symptoms develop slowly over several years, but recognition is important because of the association between acromegaly and diabetes and cardiovascular, cerebrovascular and respiratory complications. The cause is usually a benign pituitary tumor, but any source of excessive growth hormone can lead to acromegaly. The characteristic changes in appearance are related to enlargement of the jaw, hands, feet and facial bones and separation of the teeth. Thickening of the skin and soft tissues also contributes to enlargement of the nose, lips, hands and tongue. Patients have excessive sweating, acne, musculoskeletal pain and weakness, as well as neurologic symptoms related to the growing intracranial tumor. Hypertension and diabetes each occurs in about one third of cases. Treatment options include surgery and radiotherapy to destroy the endocrine-producing tumor or medical therapy based on analogs of somatostatin. Patients with acromegaly require lifelong therapy and monitoring for complications.

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