By Ronald Pies, MD, professor of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University, Syracuse, New York; clinical professor of psychiatry, Tufts University School of Medicine, Boston; editor-in-chief emeritus of Psychiatric Times. Dr. Pies is also the author, most recently of, The Three-Petaled Rose, an exploration of the synthesis of Judaism, Buddhism, and Stoicism (iUniverse).
Doyle Alphabet by fdecomite, via Flickr
It all started suddenly: weird, creeping sensations in my forehead and between my eyes, especially when I lay on my back or bent my head forward. The expression “my skin is crawling” quickly came to mind. Over the next few days, I began to experience intense pressure in my forehead and a weird sensation on the bridge of my nose—as if a large clothespin had been clipped onto it. Within a few days, it felt like someone had poured a sack of concrete into my head.
My self-diagnosis was sinusitis—a term that covers many etiologies. But most cases of sinusitis begin with head or facial pain and nasal discharge—not the strange sensations my wife and I soon started calling “the aliens.”
Nevertheless, I began an aggressive self-treatment program: decongestants, aspirin, and something called a Neti pot—an ancient form of nasal irrigation using a vessel resembling a small, plastic teapot.
After a couple of days, my symptoms were considerably milder—but by no means gone. I saw my primary care doctor a few days later, and—despite the “alien” sensations—he concurred with my diagnosis. Antibiotics are notoriously overprescribed for sinusitis, and my very conservative PCP was not about to do so. Steroid nasal sprays are also used, and I asked Dr. G. if he’d consider a trial.
“Nope!” he replied, “I’d like you to see an ENT. If you have a nasal polyp, I don’t want to shrink it with steroids and miss the diagnosis.”
I nodded in agreement, but I was disappointed. My doctor was talking the language of science—“Don’t introduce extraneous variables into your investigations”—and I was wagging the tongue of misery.
“OK,” I said glumly, “but my head feels like somebody inflated an inner tube inside it. What should I do in the meantime?”
“Decongestants, pain relievers, liquids, and the Neti pot!” he replied firmly.
Fortunately, I managed to get an appointment with an ENT the following week. But after presenting my history, I could see that he looked subdued and a little pale. What he said next left me with a sinking feeling in the pit of my stomach.
“Your history is very atypical for sinusitis,” he said quietly. “Sounds more like something neurological—maybe some kind of atypical migraine.”
I was stunned. In my entire life, I’d never had a single migraine. Why, at the ripe old age of 59, would migraines start now?
Physicians and nurses are taught that “when you hear hoof beats, don’t think zebras.” Your diagnosis should reflect the most probable causes, not exotic possibilities. But we are also trained to consider worst case scenarios—and so I began to run through some of the “zebra” diagnoses.
One possible if rare cause of abnormal facial sensations is a brain tumor. I knew the likelihood was very small, but I couldn’t dislodge the thought from my mind: maybe the “aliens” were due to a truly alien mass in my head. In the meantime, the ENT didn’t want to prescribe anything, pending a neurologic consultation and maybe some brain imaging. It was back to the Neti pot—and more misery.
The neurologist listened carefully to my history and did a thorough examination, finding nothing out of the ordinary. Nonetheless—“out of an abundance of caution”—he advised an MRI of my head. Naturally, I was relieved by the normal exam. But as a psychiatrist, I knew of many cases in which the neurologic exam was normal, only to have the brain CT or MRI show something really nasty.
Finally the day of the MRI arrived. Some patients describe the MRI’s tubular enclosure as a bit like being inside a coffin. But I relaxed and nearly drifted off to sleep, despite the rhythmic, knocking sounds inside the giant apparatus. The neurologist was extraordinarily kind and told me to call him within 24 hours for the results. The next day, I got the good news: “Your MRI was totally normal,” he said calmly. “Nothing much in the sinuses, either.”
Great news—except that the aliens were still hammering me. Now it was time to “noodge” the ENT. I immediately called his office and informed him of the negative MRI. The next day, he phoned in a prescription for nasal steroids. After I’d used them for less than a week, my symptoms had abated markedly. I still didn’t understand the genesis of my condition, but I was beginning to feel fully human again.
It had taken my doctors nearly two months to start routing the aliens. As a physician, I can’t fault them for their cautious “let’s find out what we’re dealing with” approach. And yet, I sometimes wonder how much discomfort I might have been spared had I received those nasal steroids early on.
Science is wonderful—suffering, not so much. And as for medical self-diagnosis, I am reminded of the lawyer’s adage: someone who represents himself in court has a fool for a client.
Thanks, I appreciate the chance to convey a message to all in the caring and health professions: do a careful work-up and diagnostic process, but keep in mind that the patient may be very uncomfortable during the “long wait”! –Best regards, Ron Pies
Editor’s note: this comment was slightly edited to preserve all parties’ privacy:
Someone I know has has a chronic cough for more than six months. The cough is intermittent. She saw her primary physician who said ”pollen allergy” , gave palliative care,— no relief. Saw an ENT specialist who gave steroids and said ”sinusitis”—- no change. I asked her to consider a pulmonologist but she continues to cough and to resist further investigation.
As a retired Registered Respiratory Therapist I have seen many folk who self diagnosed and turned blind eyes toward the obvious, and eventually paid the PRICE! Sad.
So glad the MRI supported the exam findings!! Thanks for sharing this story.