Question of the Week - April 2023

 

April 12, 2023

A 52-year-old man presents to the clinic with a lump in his neck. He first noticed the lump 3 months ago when he was taking off a necktie after work. He is otherwise well and denies dysphagia or loss of appetite. He states the lump has not changed in size since he first noticed it. He reports a 15 pack year smoking history, and he drinks 2 beers every night. A hard, fixed lump is palpable in the anterior triangle of the neck. Which of the following is the next best step in evaluation? 


A) FDG PET-CT whole body
B) Radioactive iodine uptake test
C) CT thorax
D) Ultrasound of the neck
E) X-ray neck

  • Correct Answer: D (ultrasound of the neck)

    Explanation:
    The imaging modality of choice for a neck lump is ultrasound though CT scan with contrast of the neck (not the thorax) is strongly recommended per clinical practice guidelines. During examination, if the lump looks suspicious, an ultrasound guided biopsy (fine needle aspiration preferred over core biopsy) may be performed to obtain a tissue sample for analysis. Most neck masses in adults are neoplastic or malignant. Neck masses that are noninfectious, have been present for ≥2 weeks and are fixed, firm, >1.5 cm in size, and with ulceration of overlying skin are at increased risk of being malignant. Risk factors for head and neck malignancy include age, smoking and alcohol history, and male gender, in addition to poor oral and dental hygiene, environmental and occupational factors, exposure to EBV & HPV, and previous history of head and neck cancer. MRI or PET-CT scanning may be indicated during follow-up evaluation, not initial presentation.

    References:
    Pynnonen MA, Gillespie MB, Roman B, et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. Otolaryngol Head Neck Surg. 2017;157(2_suppl):S1-S30. doi:10.1177/0194599817722550

April 26, 2023

A 49-year-old female patient presents at the clinic seeking further management of symptoms related to Ménière's disease in her left ear. Two years ago, she was diagnosed with the disease after experiencing weekly vertigo attacks that lasted 2-3 hours, accompanied by aural fullness. At the time, her audiogram showed mild low-frequency sensorineural hearing loss in the left ear but no deficits in the right ear. She was advised on dietary (sodium restriction and caffeine and alcohol reduction/elimination) and lifestyle changes (stress reduction) and given 0.5 mg lorazepam for acute attacks. The frequency of her attacks has since been reduced to once every two months, but she desires to know if more can be done to prevent attacks. Her recent audiogram shows a moderate low-frequency sensorineural hearing loss in the left ear with no deficits in the right ear. What is the next appropriate treatment option for this patient?

A.  Surgical labyrinthectomy

B.  Diuretic

C.  Intratympanic gentamicin

D.  Endolymphatic sac surgery

E.  Cochlear Implant

  • Correct Answer: B (Diuretic)

    Explanation: Ménière's disease is a chronic condition that currently has no cure, and its treatment aims to reduce the severity and frequency of vertigo attacks and improve the patient's quality of life. The approach to treatment involves a step-by-step escalation of therapies until the patient achieves sufficient symptom management. The initial therapy involves dietary and lifestyle modifications such as sodium restriction, caffeine and alcohol reduction, and stress reduction. Oral pharmacological therapy should include diuretics, typically thiazides, with or without potassium-sparing diuretics. These medications work by altering the electrolyte balance in the endolymph and reducing its volume, thereby decreasing the severity and frequency of vertigo attacks. Betahistine is another pharmacological option, commonly used as maintenance therapy in Europe. However, its use is limited in the United States due to limited evidence supporting its effectiveness. If lifestyle and oral pharmacological therapies are insufficient, intratympanic medications such as corticosteroids and/or gentamicin can be offered. It is important to note that gentamicin carries the risk of hearing loss when injected. If the above treatment options are not effective, surgical interventions such as endolymphatic sac decompression or shunt surgery, vestibular neurectomy, or surgical labyrinthectomy may be considered. This patient does not meet the criteria for a cochlear implant and instead could be offered a hearing aid to improve their hearing.

    References:

    Basura, G. J., Adams, M. E., Monfared, A., Schwartz, S. R., Antonelli, P. J., Burkard, R., ... & Buchanan, E. M. (2020). Clinical practice guideline: Ménière’s disease. Otolaryngology–Head and Neck Surgery, 162, S1-S55.

    Hoskin, J. L. (2022). Ménière's disease: new guidelines, subtypes, imaging, and more. Current Opinion in Neurology, 35(1), 90-97.