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Fam Pract Manag. 2005;12(5):86

Horses vs. zebras VII

The complaint from Karen, a 61-year-old longstanding patient with no major medical problems, did not set off bells. “I have some numbness under my right eye,” she began at her annual exam. “It started a year ago and waxes and wanes, but it never goes away. Sometimes my lip tingles and itches.” Karen had a history of chronic sinusitis, and I wondered if her symptoms were related to that. Could she have a maxillary entrapment of the second division of her fifth cranial nerve, or was this a manifestation of a more systemic process? I was clueless.

The area of paresthesia formed an inverted triangle starting under her right eyelid and extending down to her right upper lip. I ran her blood for the usual suspects and included a Lyme titre, a thyroid-stimulating hormone, vitamin B12 and an antinuclear antibody. I also sent her home with a bottle of fluticasone propionate. Two weeks later, she returned for follow up.

“The medicine helped,” Karen said, “but the numbness is still there.” Since all her tests had been negative, the diagnosis of chronic sinusitis was now more likely, so I decided to get a computed tomography scan of the sinuses. The radiologist's report rocked me: “3.5 cm by 4 cm mass centering on the right pterygopalatine fossa eroding adjacent bone, including the posterior wall of the right maxillary sinus, the anterior apex of the right pterygoid bone and the adjacent right skull base. There is extension into the nasal cavity and through the posterior nasal septum to the left side of the nasal cavity. There is also erosion of the right vidian canal and right foramen rotundum. This mass most likely represents a squamous-cell carcinoma.” Wow!

Don, my ENT consultant, wouldn't touch it. “That's tertiary care center stuff,” he said. So I set Karen up at the sinus clinic at Stanford, where she was biopsied and then underwent an embolization of her right internal maxillary artery followed by an eight-hour definitive procedure to resect her tumor. The operative report reminded me how few hours were spent on ENT in medical school: “Right tumor resection using a trans-sphenoethmoid approach to central skull base, internal maxillary artery ligation, mucosal graft, limited nasopharyngectomy, posterior nasal septotomy, partial sphenoidostomy, ethmoidectomy and medial maxillectomy for low-grade chondrosarcoma.” I took out my copy of Gray's to try to follow the anatomy and Dorland's to try to follow the description, but it was hopeless. The good news was that the operation went well and her prognosis was excellent.

Sometimes, I thought, it's enough for us to find this pathology. Thankfully, we don't have to fix it.

Remind me

Yesterday, after lunch, I went into a new bike shop in town and, without saying a word, triggered the owner to consider that, at age 52, he was way overdue for a complete physical. Then, out on the street, I ran into Ed, a patient who told me he was feeling great but experiencing intermittent chest pains that might not be reflux. “I'll call today to make an appointment,” he said. Stopping by the bank on my way back to the office, I saw Carol, a post-stent patient, who said, “I know I'm late for a cholesterol check” – again without me saying a word.

This sort of thing happens to me all the time. It's as though these patients put their medical problems on the back burner until the mere presence of a physician stirs up their guilt or reminds them of their worst fears: “That pain in my left arm might be an impending myocardial infarction” or “That nagging headache could be a brain tumor.”

I don't get it. When they see their dentist in the hardware store, does it suddenly hit them that they're six months past due for an exam and a cleaning? Does a chance run-in with their service-station attendant remind them that their car is 1,000 miles overdue for a lube job? When they bump into the produce man from the supermarket, do they remember that they need to eat more fruits and vegetables?

I suppose I could be less visible in our small community. Some of my colleagues are seldom seen outside of their office, the hospital or their home, but I love to be outside. So I guess I have to accept my role as a reminder card. If it compels people to take better care of themselves, it's worth it.

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