DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: This is a (XX)-year-old male seen in followup for possible worsening of obstructive sleep apnea. The patient initially presented prior with a chief complaint of chronic rhinosinusitis and nasal congestion along with worsening obstructive sleep apnea. The patient has had a known diagnosis of obstructive sleep apnea since about 16 years ago. He has been on CPAP since that time.
However, over the past year or so, he has noted that the CPAP machine has become less effective for him. He also notes chronic nasal congestion with a sensation of continued nasal drainage. He denies frank facial pain or headaches. Because of his symptoms, he subsequently was sent for a CT scan of the sinuses as well as repeating of the sleep study, since he has not had one for the last 16 years or so. He returns in followup following the CT scan.
In the interim, the patient continues to note continued nasal congestion and drainage. He is on a nasal steroid spray along with Allegra that he takes daily. He has been taking these medications for the last year or so with minimal benefit in nasal symptoms. He also notes continued daytime somnolence and feels that he is requiring a lot more hours of sleep in order to feel rested the following morning.
The CT scan that was obtained demonstrated pansinusitis with an obstructing mucous retention cyst in the left maxillary sinus that is obstructing the ostiomeatal complex on the left side. However, on our review of the CT scan, there seems to be a mild mucosal thickening of the maxillary sinuses bilaterally, left greater than right, with some mucosal thickening of the left ethmoid sinus. We do note the mucous retention cyst that is in the left maxillary sinus that is indeed obstructing the ostiomeatal complex.
Of note, the CT scan also notes a possible pituitary mass that is eroding the sella turcica as well as the bone of the sphenoid sinus. The patient has no previous studies that we can see; however, upon questioning the patient, he states that he has a known diagnosis of a prolactinoma and is followed by an endocrinologist. He states that the last CT scan he has had was about one or two years prior and, according to the patient, showed that the mass was smaller than on previous exam.
OBJECTIVE: On physical examination, the patient is well developed, well nourished, in no acute distress. Extraocular movements are intact. Visual field exam shows no evidence of hemianopsia. He has full visual field acuity bilaterally. Nasal exam demonstrates pink mucosa without any evidence of nasal drainage. The turbinates are moderately sized. On oral exam, the patient with a long uvula and redundant soft tissue. Tonsils are 1+. The neck is soft and supple. There is no palpable lymphadenopathy. The patient has full range of motion of the neck.
ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman who was referred to us with chronic rhinosinusitis as well as worsening of his obstructive sleep apnea. He was also noted to have a pituitary mass on CT scan that is eroding the bone of the sella turcica.
In regards to the rhinosinusitis, we recommend continuing the nasal steroid sprays and the Allegra. We will readdress this rhinosinusitis once the patient comes back for further evaluation. The plan is to make sure that the patient undergoes the repeat sleep study and to return to our clinic after the sleep study is performed.
In regards to the pituitary mass that the patient states is a known prolactinoma, we recommend that the patient get a copy of his CT scan obtained here and bring it to his own endocrinologist to ensure that the mass has not changed in size or depth of invasion. The patient fully understands the importance of doing this and agrees to that plan.
