RESUMEN
Chronic nasal crusting is a commonly encountered entity in an otolaryngology office. Progressive, extensive nasal crusting with erosion is relatively unusual, however. We present the case a 58-year-old renal transplant patient with a history of vasculitis and immunosuppression who presents with subjective headache and facial pain, nasal crusting, and isolated left ethmoid sinusitis. She developed extensive intranasal necrosis and underwent multiple endoscopic sinus surgeries with intraoperative biopsies, which played a critical role in her workup and eventual diagnosis of Acanthamoeba rhinosinusitis. Although she endured a difficult course, proper diagnosis and treatment allowed for her recovery over time. The differential diagnosis for intranasal necrosis is often broad. This case highlights the wide range of etiologies to be considered in a patient with extensive nasal crusting and erosion/necrosis, and the importance of thorough diagnostic evaluation in these patients, especially those in an immunocompromised state.
Asunto(s)
Acanthamoeba , Rinitis , Sinusitis , Enfermedad Crónica , Endoscopía/efectos adversos , Femenino , Humanos , Persona de Mediana Edad , Necrosis , Rinitis/complicaciones , Sinusitis/terapiaRESUMEN
Importance: Telemedicine is rapidly gaining traction as a way to reduce costs and connect patients with medical experts outside their local communities. Peritonsillar abscess (PTA) is a logical pathologic condition to evaluate for effectiveness of remote diagnosis given its prevalence and the paucity of on-site otolaryngologists at many institutions. Objective: To explore the potential of otolaryngology telemedical consultation in triaging and diagnosing patients with suspected PTA. Design, Setting, and Participants: A comparative effectiveness research study was conducted from January 1 to June 30, 2018, at 3 tertiary care hospitals among 31 consecutive patients aged 18 to 85 years for whom the otolaryngology department was consulted to assess for PTA. Statistical analysis was conducted from July 1 to September 30, 2018. Interventions: Telemedical evaluation of suspected PTA by 5 attending otolaryngologists blinded to patients' history aside from the chief report of odynophagia. Otolaryngologists rated each patient video on whether they believed the patient had a PTA and whether the case warranted prompt evaluation by an otolaryngologist. Predictions were compared with the criterion standard of drainage or negative needle aspiration. Otolaryngologists additionally assessed video quality. Main Outcomes and Measures: Rates of accurate diagnosis and triage of PTA based on otolaryngologists' review of oropharyngeal examinations recorded using standard smartphone cameras, as well as percentage of videos of oropharyngeal examinations using standard smartphone cameras deemed of sufficiently high quality for clinical decision-making. Results: A total of 31 patients (16 women [51.6%]; mean age, 31.9 years [range, 18-62 years]) were recruited, and 16 patients (51.6%) had a PTA. Comparing otolaryngologists' predictions with PTA status by the criterion standard, the prediction was consistent with that of the criterion standard 81% of the time averaged across otolaryngologists (mean diagnostic accuracy, 0.81). Similarly, the mean diagnostic accuracy was 0.83 when comparing the otolaryngologist's suggestion for a prompt in-person evaluation with actual PTA status by the criterion standard. Comparing patients who were deemed to require prompt otolaryngology evaluation and those with PTA by the criterion standard, mean sensitivity was 90%. Videos were rated as of sufficiently high quality to make a diagnosis in 154 of 155 videos (99.4%). Conclusions and Relevance: This study suggests that telemedical consultation is a viable, cost-conscious, efficient, and safe approach to PTA management. Despite having some difficulty diagnosing PTAs based on "history concerning for PTA" and oropharyngeal video alone, otolaryngologists are able to determine, with high sensitivity, which patients require prompt otolaryngology evaluation. The recording of consistently high-quality video using a standard smartphone camera is achievable without formal training.
Asunto(s)
Otolaringología , Absceso Peritonsilar/diagnóstico , Consulta Remota , Teléfono Inteligente , Triaje , Adolescente , Adulto , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sensibilidad y Especificidad , Adulto JovenRESUMEN
Objective To evaluate (1) whether changes in serum prestin aid in early detection of cisplatin ototoxicity, (2) the role of diltiazem as an otoprotectant, and (3) whether prestin levels are sensitive to effects of diltiazem. Study Design Experimental animal study. Setting Translational research laboratory. Subjects Twenty female guinea pigs. Methods Two groups of 10 guinea pigs were used. The relationship between serum prestin levels and auditory brainstem response (ABR) thresholds was compared between the groups. All animals had baseline blood draws and ABR thresholds recorded prior to cisplatin administration. Intraperitoneal cisplatin bolus (8 mg/kg) was administered followed by 5 consecutive days of intratympanic (IT) diltiazem (2 mg/kg) or sham IT-saline injection. Serum prestin levels and ABR thresholds were measured at days 1, 2, 3, 7, and 14 postcisplatin. Results In sham, IT-saline-treated animals, mean prestin levels were elevated above baseline on days 1 to 7. The prestin levels were significantly elevated from baseline on day 1 ( P < .001), while significant ABR threshold elevations did not occur until day 2 ( P = .028) for click-evoked ABRs and day 3 ( P = .041) for tones. In diltiazem-treated animals, prestin levels were not elevated above baseline but ABR thresholds were elevated on days 1 to 3. However, the thresholds returned toward baseline on days 7 and 14. Conclusion Changes in serum prestin levels were detectable prior to shifts in ABR thresholds in a guinea pig cisplatin ototoxicity model. These changes did not occur in diltiazem-treated animals. Prestin may serve as a biomarker of cochlear injury that is sensitive to therapeutic interventions in cisplatin ototoxicity.