Mr. M, a healthy-looking Middle Eastern man age 30 years, was first seen at the primary-care clinic with a complaint of throat pain with no voice change or difficulty swallowing.

He lived on the Mediterranean coast in a crowded city with smog and noise pollution far above the international standards (>75 db). Mr. M owned a store in the center of the city and lived above his shop. Every morning, he produced black matter from his nose and throat. Medical history included tonsillectomy and adenoidectomy at age 10 years, fever blisters, and recurrent sinus congestions and headaches. No allergies to food or drugs were reported. There was something in Mr. M’s body language and facial expressions that led me to believe he was not telling me everything.

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1. Physical examination

Objective data and vital signs included: temperature 98.9°F; pulse 72 beats per minute; BP 125/75 mm Hg; and respiration rate 16 breaths per minute. Examination revealed redness to the external ears (more extensive on the right ear) when the penna was touched or manipulated. Mr. M described discomfort with hyperesthesia at the mastoid process. The slightest touch would radiate pain to the anterior neck region. The throat was red and inflamed. Uvula and its surrounding seemed inflamed without exudates or punctation.

Palpation of the neck provoked discomfort at the thyroid region. There was pain with touching and manipulating the cricoid cartilage and the areas near the supraclavicular fossa (the right was more sensitive than the left). No lump, mass, or palpable nodule was detected in the neck area, and the range of motion in the neck and shoulders was not limited. Mr. M described the pain as “being punched in the neck” and “feeling like a rope was tied around my neck.” Sneezing or coughing aggravated the pain.

Routine blood tests, urinalysis, rapid strep, mono spot, and ultrasound of the thyroid gland were within normal limits. The differential diagnosis included mastoiditis, otitis externa, pharyngitis, and herpes zoster in the head and neck region.

2. Diagnosis

As I was considering prescribing an antibiotic and nonsteroidal anti-inflammatory drug for pain and inflammation, Mr. M told me he had trouble sleeping and had to rest his head on the left side since touching the pillow on the right side was too uncomfortable. Then he said, “If I tell you something, will you promise not to write it in my record?” I assured Mr. M of his privacy as long as what he told me did not harm anyone. He told me, “I have had epilepsy for 20 years, and I do not want anyone to know. In my culture, such a diagnosis can prevent you from getting married because families check the health history of the suitor.”

He explained that he believed his living conditions were exacerbating his ailment. Mr. M described how he coped with the noise by putting plugs in his ears and letting the television and kitchen fan run all night. His earplugs were made of waxed cotton balls that he would form to fit tightly in his ear canal. Mr. M’s ear canals were clean but red and irritated (especially the right). His attempts to block out noise contributed to topical irritation of the external ear. It was possible that warmth and moisture helped organisms to grow. I found nothing in his ears to sample for culture.  

3. Literature review  

Finding no history of motor vehicle accident or neck injury, thyroid cartilage fracture was ruled out.1 The absence of redness, heat, or superficial swelling to the neck excluded the possibility of cervical necrotizing fasciitis.2 Literature on throat pain and seizure activities was mostly limited to procedures.3 Several articles on the effects of noise on epileptic patients did not address environmental noise exposure.4,5 I found no published studies on the effects of environmental noise on epileptic patients.

4. Management

Without health insurance, Mr. M could afford a prescription for amoxicillin 500 mg/day for 10 days and ibuprofen (Motrin) 800 mg t.i.d. for three days and then as needed. I advised warm compress to the ears and neck for comfort. He was asked to avoid ear plugs and seriously consider moving to a different location for health reasons. He was instructed to return in two weeks for a follow-up appointment. One week later, I received a note from Mr. M explaining that he was doing much better and moving to Dubai.

5. Lessons learned

Mr. M’s case reinforced my belief in trusting my instincts, showing an unbiased attitude toward other cultural beliefs, considering environmental elements as a potential source of health problems, and asking about the home environment and coping methods.

Dr. Fooladi is a professor at the Florida State University College of Nursing in Tallahassee and a senior consultant at the American University of Beirut in Lebanon.


1. Lin HL, Kuo LC, Chen CW, et al. Neck hyperflexion causing isolated  thyroid cartilage fracture—a case report. Am J Emerg Med. 2008;26:1064.

2. Islam A, Oko M. Cervical necrotising fasciitis and descending mediastinitis secondary to unilateral tonsillitis: a case report. J Med Case Reports. 2008;2:368.

3. Ramani R. Vagus nerve stimulation therapy for seizures. J Neurosurg Anesthesiol. 2008;20:29-35.   

4. Hermes D, Miller KJ, Noordmans HJ, et al. Automated electrocorticographic electrode localization on individually rendered brain surfaces. J Neurosci Methods. 2010;185:293-298.

5. Parrino L, Halasz P, Tassinari CA, Terzano MG. CAP, epilepsy and motor events  during sleep: the unifying role of arousal. Sleep Med Rev. 2006;10:267-285.

All electronic documents accessed October 15, 2010.