What happened to this father's face?” the medical assistant asks as she hands me the chart for my next patient, a 4-year-old girl who stuck a rubber eraser up her nose.
Momentarily, I'm taken aback. I glance at the name on the medical record. Do I know this father? Have I seen him before? Somehow, I just can't remember.
When I step into the exam room, the girl's mother greets me with a smile. My eyes shift to the child sitting on the examination table: a petite girl with dark hair, dark eyes, and milk white complexion. A man—her father—stands next to her. Our eyes meet; I extend my hand in greeting and force a smile. Truthfully, it's all I can do to keep from looking away.
The man holds his head slightly forward, cocked to one side. What at one time had been a nostril and cheek has been replaced with a mass of deformed flesh. The extensive skin graft gives no definition to the natural contours of the left side of his face. The rebuilt visage is grotesque, repulsive, unsettling to the eye.
Immediately, I delve into the reason for today's visit. “I understand that your little girl may have put something up her nose. When did this happen?”
“Just this morning,” the mother says. “Her father found her sitting on the living room floor with her finger up her nose. He thought he saw something in one nostril. He went looking for tweezers, but when he came back, it wasn't there.”
“I found these on the floor beside her,” the man says, showing me a small plastic bag with two small rubber cubes inside. His voice is surprisingly soft, almost soothing to the ear, I think. “One of them seemed to have mucus on it. I thought maybe she sneezed it out, but I wasn't sure.”
“We thought it best to have her checked,” the mother continues.
“Let's have a look,” I say, grasping the handheld otoscope and a plastic speculum. The little girl recoils as I approach her with the instrument in hand. “Don't worry,” I say, “it's just a flashlight. See?” I let her inspect the unit, show her how my finger lights up, and explain that it's not hot, that it won't hurt. From her body posture, I can tell she's not convinced.
“He won't hurt you, honey.” The man speaks in low tones, again that soothing voice. “He just wants to see. Let him look, just like you let Daddy look before, okay?” He puts his hand on her shoulder as he speaks. I can see her relax.
“Tilt your head back just a bit,” I say, as I lift the tip of her nose with my thumb. A quick inspection reveals no foreign object in either side. Gently, I hold the otoscope in front of each naris and ask the little girl to blow her nose. The lens fogs with each exhalation.
As I step back to replace the otoscope in its cradle, the little girl reaches out for the man. He lifts her off the table, and she throws her arms around his neck. “See,” he whispers, “I told you it wouldn't hurt. He's a nice man.”
“There doesn't seem to be anything lodged inside her nose at this point. I think you're right,” I continue, looking into the father's eyes. “Most likely, she blew the piece out of her nose when you went to look for the tweezers.”
“So she's all right?” the mother asks.
“Yes. I would just watch for any sign of nasal discharge over the next couple of days. If you start to see a thick foulsmelling discharge from one side of the nose, give me a call. That may indicate a foreign body further up inside. But I doubt that will happen. I think she blew it out.”
“Well, I feel a lot better now,” the mother says. “Always better to be safe than sorry.”
“Can we go home?” the little girl asks her father, holding his deformed face in her tiny hands.
He kisses her on the cheek. “Yes, darlin'; we can go home now.” Gently, he puts her down and holds out a hand. She slips her tiny fingers into his palm.
“There you go,” I say, as the family filters out into the hallway.
The father pauses to shake my hand. “Thanks for looking at her,” he says with a distorted smile.
“You're welcome,” I say, grinning for both of us.
Back in my office, I reflect that beneath the grotesque deformity of his face, this man is no different than any other father. We all wear masks of some sort. Some masks look better than others. Most of us never take them off in public; some of us don't even take them off when we look in the mirror. Sometimes it takes a child's love to see through the mask to the true person whose soul bears little resemblance to the outward appearance. JAAPA
Brian T. Maurer, PA-C, practices pediatrics at Enfield Pediatric Associates, Enfield, Connecticut. He is the author of Patients Are a Virtue and a member of the JAAPA editorial board. Visit the author at http://briantmaurer.wordpress.com.