Aw, crud!

As usual, we'll take this one step at a time.

Q: I am [age deleted - he's under 50] have been coughing phlegm up for the last three years, I am also SOB alot, I also have hard brown crud in my nose sometimes blood encrusted, this is going on three years also. As a kid I had asthma, as a teenager hayfever and rhinitis, as an adult I binge smoked socially at the weekend. I never smoked more than 40 a week and have not smoked in three years.

SOB = short of breath, for you non-medical types.

We all produce about four cups of mucus a day. If it's thin enough, we don't notice this stuff, but if it's thick, we have to cough it up. That's a problem.

The history of smoking and asthma may be relevant. Excessive phlegm can be a sign of rhinitis (nasal inflammation) or sinusitis, but it can also be a sign of lung disease. He's a little young for it, but it's still a possibility. A chest X-ray would be prudent (but he's had better . . . see below).

Nasal crusting can indicate a number of things, from chronic low-level nose bleeds, chronic sinusitis, atrophic rhinitis, or even a bacterial infection (nasal impetigo, an infection with Staphylococcus).

Do you see how impossible it is to narrow this down without examining the patient? There's no substitute for looking up someone's nose and listening to their lungs. Back to our emailer:

At the start of this trouble I had tinnitus, eye pain, dizziness and earache for many months, this also went undiagnosed despite repeated visits to the local Eye and Ear hospital. I ended up with suspected blocked eustacian tube, anyway this eye, ear and sinus trouble cleared up two years ago and hasn't returned.

Tinnitus can be a symptom of Eustachian tube dysfunction, but can indicate many other conditions, too; similarly, eye pain, dizziness, and earache could all be related to his nasal/sinus condition. Impossible to say now, since the symptoms have passed, but a workup at the time might have bolstered this hypothesis, or pointed the doctor elsewhere.

He goes on to say that he's had a number of normal tests, including a high resolution chest CT scan and normal pulmonary function tests. To the best of my knowledge of pulmonary medicine, this should exclude most primary lung conditions. He mentions that he has sinus polyps (yes, this might be relevant) and then proceeds to his question:

I have self-diagnosed myself as having some sort of chronic bronchitis.

My question to you is what is the connection between crud in the nasal cavity and chronic bronchitis. Are they related, ie one airway, similar symptoms. I had a bronchoscopy and biopsy and they maintained that the mucosal layer was normal. ~ No Bronchitis.

The normal bronchoscopy sounds convincing to me, but he'd have to ask his pulmonologist. In any case, one need not invoke chronic bronchitis to explain the phlegm production or the nasal crusting. The nose and sinuses are quite capable of producing this problem all by themselves. Given the normal pulmonary workup, the nose/sinuses sure sound like the leading suspect.

Is it worthwhile looking into PCD / ICS as a cause for these symptoms, I feel my doctors have either given up or want to concentrate on people with life threatening conditions rather than uncomfortable ones!

It is worthwhile for me getting an alternative opinion from across the pond.

I sure wish I knew what PCD and ICS were. Amazing how we all speak English, yet we use different acronyms!

Anyway, I think this fellow should go back to his ear, nose, and throat doctor and ask for a few things. I suspect he's had a sinus CT scan (since he mentions sinus polyps), but if not, this would be helpful. If he hasn't had an endoscopic exam of the nose, this might prove helpful, too. There are many, many things we can do to help nasal crusting and excessive phlegm. True, it might not be life threatening, but it is quality-of-life threatening.

I can't make treatment recommendations when I'm so much in the dark as regards this patient's disease process. First thing I would do would be to satisfy myself that the problem resides in the nose or sinuses, and I'd try to figure out if it came from either (or both). My next step would be to figure out if infection was present or absent, and if allergy was present or absent. That would help me determine which medications to use. I would also be thinking about adjunctive measures, such as having the patient improve his hydration, and possibly begin a plan of nasal irrigations.

And you all thought snot was easy.

D.