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Abstract: The patient is a middle-aged woman who complained of discomfort in the throat and nasal cavity 3 years ago, and the symptoms have worsened recently, so she came to our hospital.
Basic information】Female, 40 years old
Disease Type】Chronic rhinopharyngitis (hyperplastic chronic rhinopharyngitis)
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Time of consultation】July 2014
Treatment plan】Nebulization treatment (inhalation budesonide suspension) + topical medication (compound peppermint oil antibacterial solution)
[Treatment period] 1 day of outpatient treatment, 7 weeks of discharge medication, 3 months of outpatient follow-up
Treatment effect] Disappearance of nasopharyngeal discomfort, stable condition
I. Initial consultation
The patient is female, 40 years old. She reported that 3 years ago, she had a foreign body sensation in the throat with no obvious cause, sometimes with discomfort in the throat and nasal cavity and dryness, but her body temperature was normal, and she had no fever, cough and sputum. At that time, he was treated at a local clinic and took 18 oral herbal medicines (details unknown), but the results were not good. One month ago, the symptoms worsened, and he took cephalosporin (exact name of the drug is not known) on his own, but it did not improve.
II. Treatment history
The patient cooperated with the perfect nasopharyngeal CT for differential diagnosis with nasopharyngeal cancer, and the examination results suggested that the thickened mucosa was growing toward the mucosal surface and in the lumen without obvious external infiltration, and the pharyngeal suture was normal, which could confirm the diagnosis of chronic nasopharyngitis. After communicating the patient’s condition with the patient and his family, it was decided to take drug treatment. The patient was given a nebulized inhalation of budesonide suspension for inhalation to provide anti-inflammatory and anti-allergic relief of respiratory tract inflammation; and topical nasal drops, namely compound peppermint oil antibacterial solution, were used to lubricate the nasal mucosa and improve nasal discomfort. Patients were also instructed to improve their living habits during the treatment period and avoid places with high concentrations of pollen and dust to avoid aggravating the inflammation of the nasopharynx and affecting the treatment effect.
III. Treatment effect
After 7 weeks of continuous drug treatment, the patient reported that the nasal discomfort and dryness gradually decreased during the drug treatment period, and the discomfort symptoms before the treatment had completely disappeared so far. Physical examination showed that the patient’s pharyngeal mucosa was not congested; indirect laryngoscopy showed that the patient’s laryngeal mucosa was diffusely congested and swollen, and bilateral vocal fold congestion disappeared and could be closed normally.
IV. Precautions
After 7 weeks of treatment, the patient’s condition was normal on the recheck, and I am happy for the patient. At the same time, I reminded the patient that his condition has improved, but he still needs to strengthen his life management. Pay attention to more rest, ensure enough sleep, and avoid staying up late and overworking. Avoid spicy and irritating foods such as chili, garlic and ginger. In daily life, indoor ventilation should be diligent to keep the air circulating, and masks can be worn in and out of the outdoor environment to keep away from second-hand smoke, car exhaust and other negative stimuli. In addition, patients should be instructed to come to the clinic for follow-up every 3 months, and if the results are normal after the second follow-up, they should be instructed to follow-up every 6 months afterwards.
V. Personal insight
The patient with chronic rhinopharyngitis in this article received targeted treatment only 3 years after the onset of the disease, so the treatment period was longer and more difficult to treat, but the prognosis was good with no serious consequences. At the same time, if this disease is not treated in time, otitis media, sinusitis and other types of respiratory inflammation may occur, so patients should pay close attention to their own changes, such as nasal congestion, nasal pain, dry throat and other symptoms, timely consultation to inhibit the development of the disease.