Question of the Week - March 2023

 

March 8th, 2023

A 40-year-old woman presents to the office due to nasal congestion and runny nose. She states she had similar symptoms 2 months ago, but at that time, she had a cough, fatigue, and fever. Since then, she has been using over-the-counter acetaminophen and another medication whose name she can’t recall. She reports her fever subsided and symptoms improved, but her nasal congestion has gotten worse despite continued medication use. Nasal examination reveals swollen, red nasal mucous membranes; otolaryngologic exam is otherwise unremarkable. What is the most likely medication she has been using?

A. Oral antihistamine
B. Nasal decongestant spray
C. Nasal steroid spray
D. Topical bronchodilators
E. This is allergic rhinitis and unrelated to medication use

  • Correct Answer: B (nasal decongestant spray)

    Explanation:
    History of nasal congestion following prolonged use of medication combined with erythematous nasal mucosa is suggestive of rhinitis medicamentosa, a condition of rebound nasal congestion following extended use of nasal decongestant sprays (oxymetazoline, phenylephrine, e.g.). These over-the-counter decongestant sprays lead to rapid relief of nasal congestion by causing vasoconstriction. Many days of regular use leads to rebound nasal congestion as the medication wears off, prompting patients to administer the medicine more frequently to obtain relief. This can lead to a vicious cycle, both caused and relieved by the medication, with escalating use. While antihistamines (A) cause drying of the mucosa, they do not cause rebound congestion. Nasal steroids (C) and bronchodilators (D) also do not cause rebound congestion. There is evidence steroids make rebound congestion less likely to occur when coadministered with the nasal decongestant. Allergic rhinitis (E) is more likely associated with sneezing and itching symptoms, and physical exam would show edematous, pale nasal mucosa, rather than the ‘beefy red’ mucosa classically associated with rhinitis medicamentosa.

    References:
    Vaidyanathan S, Williamson P, Clearie K, Khan F, Lipworth B. Fluticasone reverses oxymetazoline-induced tachyphylaxis of response and rebound congestion. Am J Respir Crit Care Med. 2010 Jul 1;182(1):19-24. doi: 10.1164/rccm.200911-1701OC. Epub 2010 Mar 4. PMID: 20203244.

    https://pubmed.ncbi.nlm.nih.gov/20203244/

March 22nd, 2023

A 6-year-old is brought to clinic for repeat evaluation of hearing loss. Which of the following characteristics would be most suggestive of congenital stapes fixation?
 
A.  The patient has a recent history of multiple ear infections
B.  There is conductive hearing loss that has worsened since the prior visit
C.  Otoscopy reveals a perforated tympanic membrane
D.  All of the above
E.  None of the above

  • Answer: E (none of the above)

    Explanation: Congenital stapes fixation is the most common congenital ossicular anomaly, and it can be described by fixation between the peripheral lamina of the stapes and the annular ligament. This causes nonprogressive conductive hearing loss that is usually bilateral in the setting of a normal tympanic membrane. While congenital ossicular anomalies are rare, they are a clinically relevant cause of hearing loss in the absence of trauma or infections. In pediatrics, congenital stapes fixation can be differentiated from juvenile otosclerosis, which instead presents with progressive conductive hearing loss.

    Reference:

    Park HY, Han DH, Lee JB, Han NS, Choung YH, Park K. Congenital stapes anomalies with normal eardrum. Clin Exp Otorhinolaryngol. 2009;2(1):33-38. doi:10.3342/ceo.2009.2.1.33 Article Link