Question of the Week - October 2022

 

October 12th, 2022

A three-year-old is brought into the clinic for evaluation. The following is seen on her otoscopy exam. She has no history of otitis media or previous otologic procedures.

Which of the following is most likely to be true in this patient’s case?

A. Surgical intervention is not indicated because the cause of this patient’s presentation is not infectious and can be treated medically.

B. The likely etiology of this patient’s presentation involves perforation of the eardrum.

C. This finding likely arose from trapped squamous epithelium during embryogenesis.

D. If left untreated, this patient is most likely to develop sensorineural, rather than conductive, hearing loss.

  • Quiz Answer: C

    Explanation: This patient presents with a congenital cholesteatoma, which appears as a white mass that forms prior to birth behind an intact eardrum and with no history of otitis media, previous otologic procedures, or perforation of the eardrum. They are thought to develop during embryogenesis. This is in comparison to an acquired cholesteatoma, which develops either as a retraction pocket in which desquamated keratin epithelium accumulates behind an apparently intact eardrum, or secondary to epithelial migration into the middle ear through a perforated eardrum [B], which is in turn caused by infection, trauma, or iatrogenesis.

October 25th, 2022

A 32-year-old female presents to your office complaining of trouble sleeping and unintentional weight loss. She also reports feeling “anxious all the time” and having palpitations over the past few weeks. On your physical exam, you note mild tremor, moist skin, lagophthalmos, and scleral show. Which of the following medication combinations would be best to initiate for this patient?


A.Metoprolol and levothyroxine
B.Phentolamine and liothyronine
C.Phenoxybenzamine and propylthiouracil
D.Propanolol and methimazole
E.Prednisone and Lugol's solution  

  • Quiz Answer: D

    This patient is presenting with clinical findings most consistent with hyperthyroidism or Grave’s disease. Her weight loss, anxiety, and palpitations are likely due to adrenergic stimulation. Propranolol is the most effective beta-blocker for controlling these symptoms. In order to control her overactive thyroid, antithyroid medications, like methimazole or propylthiouracil, act by inhibiting TPO and thereby blocking the production of thyroid hormone in the thyroid gland.

    A, B. Levothyroxine and liothyronine (shorter half-life) are thyroid replacement medications that would be most appropriate for patients who are hypothyroid.

    C. Phenoxybenzamine is an alpha blocker commonly used to treat episodes of high blood pressure and sweating related to pheochromocytoma.

    E. Glucocorticoids (e.g. prednisone) are useful for decreasing peripheral conversion of T4 to T3. While lugol’s solution (i.e. super-saturated potassium iodide) can block thyroidal iodide uptake and prevent the release of thyroid hormone, it should not be used without first initiating an antithyroid medication (e.g. methimazole).

    Reference: Shindo M. Surgery for hyperthyroidism. ORL J Otorhinolaryngol Relat Spec. 2008;70(5):298-304.