Question of the Week - January 2023

 

January 18th, 2023

A 58 year old male presented to the ED with a fever, facial swelling, and nasal congestion over the past two weeks. He woke up three days ago with sudden facial pain near his right eye. He reports recently being diagnosed with a condition, however he was lost to follow-up. Notable labs include an absolute neutrophil count (ANC) of 473/µL. Histopathology and CT show the following:

Which of the following is not one of the mainstays of treatment for this patient’s condition?

A. Antibacterial therapy
B. Correction of the underlying disease
C. Antifungal therapy
D. Surgical debridement
E. None of the above

  • Quiz answer: A (antibacterial therapy)

    Explanation: This patient presents with acute invasive fungal rhinosinusitis (AIFR), a rare but serious disease involving fungal hyphae (as seen on histopathology of necrotic tissue) infiltrating sinus mucosa, submucosa, vasculature, and/or bone of the nasal cavity/paranasal sinuses.

    Patients present with sinusitis symptoms for 4 weeks or less. CT imaging may show significant thickening of nasal and sinus mucosa, intracavity air-fluid levels, sinus opacification, middle turbinate infiltration, bony erosion, and involvement of the brain, orbit, cavernous sinus, and the pterygopalatine fossa.

    Diabetes mellitus and hematologic malignancies are the most common comorbidities. The mainstays of treatment include the following: correction of the underlying disease, antifungal therapy (ie. amphotericin B, voriconazole), and surgical debridement. In this patient with neutropenia with a presumed hematologic malignancy, correction of neutropenia may require successful bone marrow transplant and the use of G-CSF (granulocyte colony stimulating factor).

    References: Luo YT,https://pubmed.ncbi.nlm.nih.gov/35589479/ Zhu CR, He B, Yan AH, Wei HQ. Diagnostic and therapeutic strategies of acute invasive fungal rhinosinusitis. Asian J Surg. 2023;46(1):58-65. doi:10.1016/j.asjsur.2022.05.006

    https://pubmed.ncbi.nlm.nih.gov/35589479/

 

January 25th, 2023

A 43-year-old woman is seen in the clinic for 3 days of left-sided hearing loss. She had a productive cough and stuffy nose one week ago while on vacation in Hawaii. She states she had stabbing pain in her left ear during plane descent on her return flight and that the flight attendant’s pre-landing announcements sounded muffled. She also noticed blood on the tissue she used to rub her ear canal during landing. All symptoms have resolved except her unilateral hearing loss. What is the next step in management?

A. Tympanoplasty

B. Irrigation of the external auditory canal

C. Oral antibiotics + steroids

D. Topical antibiotics

E. Reassurance

  • Correct answer: E (Reassurance)

    Explanation: This patient most likely suffered barotraumatic tympanic membrane rupture, which typically heals spontaneously within a few weeks. Her recent rhinogenic infection predisposes her to this condition as any condition that restricts eustachian tube function may prevent equalization of the pressure between the middle ear and the external environment, increasing risk of ear barotrauma during rapid shifts in barometric pressure. This is a clinical diagnosis and any hearing loss that accompanies tympanic membrane perforation is usually transient, although patients should seek reevaluation if ear symptoms persist or worsen. Workup should include an otoscopic exam looking for hemotympanum and/or ruptured tympanic membrane, hearing tests, and tympanometry. Management is conservative with active follow-up. Surgery (A), such as tympanoplasty or myringotomy, is indicated when conservative management is unsuccessful or when rupture of tympanic membrane is large or complicated by perilymphatic fistula formation. Irrigation of the external auditory canal (B) may be used to treat cerumen impaction, but would not be indicated in this scenario. Antibiotics (C&D) are indicated only when there is a rupture of the tympanic membrane and contamination of the middle ear.

    References:
    Basu A. Middle ear pain and trauma during air travel. BMJ Clin Evid. 2007 Sep 1;2007:0501. PMID: 19450303; PMCID: PMC2943805. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943805/

    Mirza S, Richardson H. Otic barotrauma from air travel. J Laryngol Otol. 2005 May;119(5):366-70. doi: 10.1258/0022215053945723. PMID: 15949100. https://pubmed.ncbi.nlm.nih.gov/15949100/