Question of the Week - February 2o23

February 8th, 2023

A 19-year-old female presents to your office for evaluation of a ‘growing mass’ on her left ear. She says she first started to notice it after she had her ears pierced last year. It has been increasing in size and causing worsening discomfort. She denies any otorrhea, hearing loss, or recent ear infections.

Which of the following chemical mediators is most likely responsible for this patient’s condition?

A.IFN-α

B. IL-8

C. IFN-γ

D. TGF-β

  • Correct answer: D (TGF-β)

    Explanation:
    This patient presents with a keloid, a pathologic form of scarring that develops beyond the initial borders of a wound (unlike hypertrophic scarring). Overexpression of TGF-β results in overactivation of keloid fibroblasts, resulting in increased synthesis of extracellular matrix collagen. Other inflammatory markers are also thought to play a role in collagen overproduction, including IL-6, VEGF, and PDGF. Interleukin-8 [B] has not been shown to play a role in keloid formation.

    Treatment of keloids is often performed for cosmetic improvement due to their appearance. Though evidence is limited, interferons [A, C] are being evaluated as potential therapies for keloids.

    References:
    Betarbet U, Blalock TW. Keloids: A Review of Etiology, Prevention, and Treatment. J Clin Aesthet Dermatol. 2020;13(2):33-43.

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7158916/

    Image Reference: https://www.ncbi.nlm.nih.gov/books/NBK586098/figure/ch28.Fig3/

February 22nd, 2023

A 4-year-old girl is brought to the pediatric ED by her mother for persistent nose-bleeds. Her mother states she sees her daughter picking her nose nearly every day and while she has gotten nose-bleeds in the past, they typically resolve on their own after pinching her nose. Her mother reports she’s tried pinching the nasal alae for an hour while the girl leans forward, but blood continues to trickle from the left nostril, which is seen on physical exam in the ED. She denies family history of bleeding disorders. If performed, silver nitrate cautery should be directed toward which of the following locations in the nasal cavity?

A.  Middle meatus
B.  Nasal septum
C.  Posterolateral wall
D.  Posterior choanae

  • Correct answer: B (nasal septum)

    Explanation:
    Recurrent epistaxis is a common condition in children, and the majority of cases are self-limiting with simple first aid measures. Management is directed at stopping the bleeding, which may require cautery of the area surrounding the bleeding when persistent. In the vast majority of cases of epistaxis, bleeding originates from Little’s area, i.e. the anterior nasal septum, where a number of arteries anastomose forming Kiesselbach’s plexus under the thin overlying nasal mucosa. The middle meatus (A) is a pathway that drains the frontal, maxillary, and anterior ethmoidal sinuses. The posterolateral wall and posterior choanae (C&D) are supplied by branches of the sphenopalatine artery, a more likely source of posterior nosebleeds, which are more severe and less amenable to cautery control.

    References:
    Siddiq S, Grainger J. Fifteen-minute consultation: investigation and management of childhood epistaxis. Arch Dis Child Educ Pract Ed. 2015 Feb;100(1):2-5. doi: 10.1136/archdischild-2013-304931. Epub 2014 Jul 17. PMID: 25035314.