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Looking for the signs

01 September 2010

Mr X was a 25-year-old man with depression. He was seeing his GP Dr K regularly with this and was prescribed some antidepressant medication, which was helping. His consultations would often be long, as he discussed his feelings at length and how this was affecting his life. He was currently out of work due to depression and was living with his parents.

Mr X developed left-sided earache and mentioned this to Dr K during one of his consultations. Dr K examined his ear but said it looked healthy and gave reassuring advice.

Over the next few weeks Mr X was bothered by unilateral earache. Rather than improving, it seemed to be getting worse and was waking him up at night. He explained this to Dr K on a subsequent visit. Dr K put his sleep disturbance down to low mood and again reassured him about his earache.

Mr X saw several different GPs about his earache over the next few weeks because it had become a constant, nagging pain rather like toothache. Minimal examination notes suggested otitis externa, for which he was given a steroid spray, and otitis media, for which he received three different types of antibiotic. Mr X was rather distressed about his earache and felt tired. The GPs thought this was a reflection of his depression and discussed increasing his antidepressant medication.

Shortly after, Mr X developed left-sided nasal congestion and an aching sensation in his neck on the same side. He was seen by Dr K again, who thought he was run-down and that focusing on his health in a negative way could be part of his depression.

The most frightening thing for Mr X was that he became aware of swallowing difficulties. Although he could swallow liquids with no problems, he was beginning to find it difficult to swallow foods like bread and meat. He had to chew very carefully or food would feel like it was sticking. He had had one choking episode so had changed his diet to eat softer foods. He noticed that he was losing weight and feeling tired all the time.

He again made an appointment with Dr K to discuss this. Dr K made a record that no abnormalities had been found on examination, but this did not include any record of a cranial nerve examination. Dr K attributed his symptoms of tiredness, generalised weakness and weight loss to his low mood. In fact, on three occasions, there were records in his notes indicating that these symptoms were an illustration of his mental state.

After eight months of GP appointments, Mr X attended his local emergency department because he was feeling so unwell. He had a CT followed by an MRI and was quickly diagnosed with a large destructive mass centred on the left naso-pharynx and skull base, eroding bone and spreading into the anterior pituitary fossa. The tumour was found to be a low-grade adenocarcinoma. Mr P was given palliative radiotherapy, which relieved some of the pain for a time, but the prognosis was terminal.

Mr X was very upset and angry and made a claim against his GPs. The delay had caused little change to the prognosis, but the case was settled for a moderate sum.

Learning points

  • Symptoms should only be put down to anxiety or depression after organic causes have been excluded. The risk of missing organic pathology in patients with mental health problems is always real. 
  • Taking a good history and performing a thorough examination is essential. 
  • Regular attendees sometimes need special consideration to make sure nothing has been missed. This could involve taking some time to read through the whole story of consultations, particularly if the patient has seen several different GPs, and gathering together exactly what examinations and tests have been done to ensure things have not been missed. Putting a summary in the notes would demonstrate this review had taken place and would be good practice. 
  • It is good practice to challenge previous diagnoses, both of our own and our colleagues, when diagnostic doubt remains. 
  • With rare conditions, doctors need to be aware of the “red flags” – in this case the unilateral ear pain and the unilateral nasal congestion if it’s persistent. 
  • Symptoms that don’t go away but progress should be investigated, even without any abnormal signs.