Question of the Week - June 2022

 

June 24th, 2022

A 49-year-old patient presents to clinic for progressive neck swelling over the last 1 year. Palpation of the neck reveals a painless left-sided pulsatile mass that can be moved transversely, but not vertically. She has no known medical conditions, and she denies any pain.

Which of the following additional symptoms or findings did this patient most likely present with?


A. Tongue deviation to the right
B. Dysphagia
C. Bilateral hearing loss
D. Intermittent left-sided vision loss

  • B (Dysphagia)

    Explanation: This patient most likely has a carotid body tumor (CBT), the most common type of paraganglioma found in the head and neck region. On clinical examination, CBTs are more mobile transversely compared to vertically (Fontaine’s sign). While most cases are asymptomatic, vagal dysfunction causing dysphagia or dysphonia is the most common cranial nerve dysfunction observed (B).

    Other cranial nerve palsies (CN VII, IX, XI, XII) are comparatively less common. Involvement of CN XII would cause tongue deviation to the side of the tumor rather than away (A). Hearing loss is extremely rare in CBTs and would not present bilaterally with a unilateral CBT (C). CBTs are not associated with vision loss (D)–ipsilateral vision loss may instead be seen in carotid artery stenosis or temporal arteritis, neither of which present as seen in this patient.

    Reference: Cleere EF, Martin-Grace J, Gendre A, Sherlock M, O'Neill JP. Contemporary management of paragangliomas of the head and neck. Laryngoscope Investig Otolaryngol. 2021;7(1):93-107. Published 2021 Nov 26.

    Image: Hoang VT, Trinh CT, Lai TAK, Doan DT, Tran TTT. Carotid body tumor: a case report and literature review. J Radiol Case Rep. 2019;13(8):19-30. Published 2019 Aug 31.

    https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC6738487/

June 10th, 2022

A 45 year old man is referred to you for dyspnea. He has a history of recurrent sinusitis, otitis media, cough, and occasional hemoptysis. Laryngoscopy reveals significant nasal crusting and a septal perforation with subglottic stenosis. Review of an old chest X-ray reveals pulmonary nodules. Peripheral blood eosinophils are within the normal range. Which of the following lab findings, if abnormal, would most support the most likely diagnosis?

A. c-ANCA
B. p-ANCA
C. CD4/CD8 ratio
D. ANA

  • A (c-ANCA)

    Explanation: The most likely diagnosis is granulomatosis with polyangiitis (GPA). c-ANCA is highly sensitive (95%) for systemic GPA, as seen in this patient. p-ANCA titers should be obtained in this patient as well to evaluate for eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Lack of peripheral blood eosinophilia makes this diagnosis less likely. An elevated CD4/CD8 ratio is associated with sarcoidosis. Supraglottic swelling is more indicative of laryngeal sarcoidosis. ANA is useful in evaluation for SLE, systemic sclerosis, and Sjögren's syndrome.

    Reference: Garlapati P, Qurie A. Granulomatosis with Polyangiitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; December 7, 2021.

 

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