Case-based MCQ

Correct Answer Is D Clear, unilateral rhinorrhea that increases at times of relatively increased intracranial pressure (eg, bending over, bowel movements) is suspicious for cerebrospinal fluid (CSF) rhinorrhea.  Patients also often report a salty or metallic taste.  Most cases occur after head trauma, especially with fracture of the skull base (eg, cribriform plate, temporal bone).  CSF rhinorrhea can be evident immediately after the trauma or may have a delayed presentation (days to months) in which rhinorrhea is noted after acute edema resolves. Testing the nasal discharge for CSF-specific proteins (eg, beta-2 transferrin, beta-trace protein) is diagnostic.  Imaging or endoscopic nasal examination can be used to localize the precise site of the defect.  Patients typically require inpatient management for bed rest, head-of-bed elevation, and frequent neurologic evaluation because they are at risk for meningitis due to nasal flora contamination of the CSF.  If the CSF rhinorrhea does not resolve with these measures, further interventions (eg, lumbar drain, operative repair) are necessary. A personal or family history of atopy may suggest allergic rhinitis, which would present with bilateral (rather than unilateral) rhinorrhea and pale or bluish, boggy, edematous turbinates.  Accompanying symptoms of sneezing, itching, and watery eyes are also typically present. Intranasal cocaine and nasal decongestants cause vasoconstriction.  Overuse can result in bilateral (rather than unilateral) rhinorrhea and severe “rebound” nasal congestion (eg, rhinitis medicamentosa).  Examination often shows swollen, erythematous turbinates.  Tissue destruction from vasoconstriction caused by intranasal cocaine typically occurs at the septum (resulting in septal perforations) rather than at the skull base. Clear, unilateral rhinorrhea that increases at times of relatively increased intracranial pressure (eg, bending over, bowel movements) is suspicious for cerebrospinal fluid rhinorrhea, which is most often caused by head trauma and can result in meningitis

A 35-year-old woman comes to the office due to persistent rhinorrhea.  The patient has clear drainage from the right side of her nose that increases when she has a bowel movement or bends over to pick something off the floor.  On examination, the external nose appears normal, the turbinates are pink, and the septum is straight.  There is a small amount of clear fluid from her right nostril.  The remainder of the examination is normal.  Which of the following additional history is most important for establishing a diagnosis in this patient? A. Family history B. Illicit drug use C. Prior seasonal allergies D. Recent head trauma E. Use of decongestant sprays

Correct Answer Is C Epiglottitis is a rare, potentially fatal infection that presents with acute onset of fever, sore throat, and signs of upper airway obstruction (eg, stridor, drooling).  Symptoms often develop over hours without a notable prodrome, as seen in this patient.  Impending signs of respiratory failure include anxiety, worsening stridor, and a muffled/hoarse, “hot potato” voice.  Patients may display tripod positioning (leaning forward, neck hyperextension) to maximize airway diameter.  The anterior neck near the hyoid bone may be tender, and oropharyngeal examination is typically normal other than pooled oral secretions. X-ray is not required for diagnosis if clinical suspicion is high, but lateral view shows an enlarged epiglottis, suggestive of edema.  Diagnosis is confirmed via direct visualization of an edematous epiglottis.  However, detailed oropharyngeal examination is often deferred in children due to risk of laryngospasm from provoked aggravation.  Direct laryngoscopy during intubation (a controlled setting to secure the airway) is often preferred for diagnosis and management. Bacterial tracheitis presents with fever, stridor, and respiratory distress.  Croup presents with a “barky” cough, hoarseness, stridor, and fever.  In both conditions, onset is gradual (over days), and neck x-ray (posterioanterior view) reveals subglottic narrowing (eg, steeple sign) and a normal epiglottis.  This patient has a thickened epiglottis on x-ray, a finding consistent only with epiglottitis. Foreign body aspiration most commonly presents with acute onset of wheezing, stridor, and/or respiratory distress without fever.  X-ray may reveal a foreign body if the object is radiopaque (eg, coin).  Examination typically shows unilateral wheezing or asymmetric breath sounds, neither of which are found in this case. Peritonsillar abscess is most common in older children and adolescents; it presents with gradual onset of fever, muffled voice, and unilateral tonsillar swelling with uvular deviation.  This patient’s age, normal oropharyngeal examination, and acute symptom onset make this diagnosis unlikely. Epiglottitis is a rare but potentially fatal infection that presents with acute onset of fever, sore throat, and signs of upper airway obstruction (eg, stridor, drooling).  Plain x-rays may help confirm the diagnosis by revealing an enlarged epiglottis (thumb sign).

A 3-year-old boy is brought to the emergency department due to a sore throat.  The boy woke up with the sore throat this morning and has refused to eat.  His mother gave him acetaminophen, but it did not relieve his pain.  Temperature is 38.7 C and respirations are 28/min.  The patient is sitting still on his mother’s lap and appears scared.  He has a hoarse voice, rhinorrhea, and mild stridor.  Tympanic membranes are clear bilaterally.  Examination of the posterior pharynx shows no erythema or tonsillar exudate.  The anterior neck is tender to palpation.  Lung examination reveals transmitted upper airway sounds that are equal bilaterally without crackles or wheezes.  Lateral neck x-ray is shown below. Which of the following is the most likely diagnosis in this patient? A. Bacterial tracheitis B. Croup C. Epiglottitis D. Foreign body aspiration E. Peritonsillar abscess

Correct Answer Is A This clinical finding is known as external auditory exostosis (EAE) or ‘Surfer’s ear’ and is a common condition among both professional and recreational surfers. The exact cause of the condition is unknown, but it is thought that exposure to cold water and wind may stimulate osteoblasts in the temporal bone to produce bony growths that project into the ear canal. Surfer’s ear is a benign but irreversible condition and is often asymptomatic in the early stages. Patients are recommended to avoid cold and windy conditions, and the use of ear plugs and a protective hood may also be helpful as a preventative measure. Ear plugs, however, will not resolve exostoses that are already present. Surgical treatment is reserved for patients with severe and symptomatic external auditory exostosis. Referral is indicated for large lesions, progressive hearing loss, and recurrent ear infections

A 25 year old male patient who attends with right-sided ear discomfort. He tells you that he has had discomfort for a few months and has a feeling like his ear is ‘blocked’. He is a keen early morning surfer and thinks that the blocked feeling might just be some trapped water in his ears. He has not noticed any ear discharge. He has no fevers and feels systemically well. However, the aching sensation is getting progressively worse in his right ear and he is keen to know if there is any problem. You perform an otoscopic examination of his ears and note the following finding on both left and right sides: What is the most appropriate advice to provide to him today about his ear complaint? A. Advise him that he has an increased risk of developing otitis externa and conductive hearing loss B. Advise him that he will require oral flucloxacillin 500mg 6 hourly for five days C. Advise him that the condition is aggravated by sand in the auditory canals D. Advise him that wearing ear plugs while surfing will assist with resolution of the condition. E. Advise him that he will require an urgent review with an Ear Nose Throat (ENT) surgeon due to the malignant potential of this condition

Correct Answer Is A Of the options, labyrinthitis, Meniere’s disease and lateral medullary syndrome can cause acute onset vertigo, tinnitus and hearing loss. Ataxia can be a presentation in patients with cerebellar or vestibular disease. Of these three and given the inconclusive neurological examination, labyrinthitis is the most likely diagnosis. Another hint that pointed towards labyrinthitis is that the vertigo provoked with changes in head position as stated in the context. Acute labyrinthitis presents with acute vertigo often followed by nausea and vomiting, tinnitus and  hearing loss. A history of preceding viral upper respiratory tract infection is present in up to 50% of patients. Change in head position provokes vertigo. Each episode of vertigo lasts from few seconds to minutes. Meniere’s disease also presents with episodes of acute onset vertigo, tinnitus and hearing loss. However, patients with Meniere’s disease often complain of ear fullness because the pathophysiology is excess endolymph in the labyrinth. Patients are usually middle-aged women with a positive family history for the condition. Finally, Meniere’s disease is much less common compared to labyrinthitis. Given these, Meniere’s disease in this patient is a less likely diagnosis compared to labyrinthitis. Vestibular neuronitis is the inflammation of the vestibular nerve often by a viral infection. Patients usually have a preceding viral upper respiratory infection or herpes zoster. Vertigo and imbalance are the prominent features of vestibular neuronitis and there is no hearing loss or tinnitus. Loss of balance is more prominent in vestibular neuronitis compared to other causes of vertigo and patient commonly present with vertigo and falls. Symptoms in vestibular neuronitis are aggravated by change in the position of the head. Neurological examination in patients with vestibular neuronitis is otherwise normal. Acoustic neuromas are intracranial tumors that arise from the Schwann cell sheath of either the vestibular or cochlear nerve. As acoustic neuromas increase in size, they eventually occupy a large portion of the cerebellopontine angle. Although 5-15% of patients with acoustic neuroma present with acute onset of unilateral hearing loss, deafness has an insidious onset in this condition, making it a less likely diagnosis. Gradual hearing loss is overwhelmingly the most common presenting symptom of patients with acoustic neuroma . Imbalance and vertigo is not a prominent feature because as the tumor growth disrupts the vestibular nerve function slowly, there is enough time for compensation. Other features that may be present in patients with acoustic neuroma are headache and facial sensory impairment. Lateral medullary syndrome, also known as Wallenberg syndrome or posterior inferior cerebellar artery (PICA) syndrome has other clinical features in addition to vertigo, hearing loss,and tinnitus. Such features include cross-body sensory impairment (sensory impairment of the face on the affected side and that of the body on the other side), Horner’ssyndrome, and signs and symptoms indicative of the involvement of cranial nerves or their nucleus. Such signs and symptoms may include dysphagia(due to involvement of nucleus ambiguus that supplies the vagus and glossopharyngeal nerves),dysarthria, dysphonia, disrupted temperature and pain sensation, palatal clonus and heart rate and blood pressure dysregulation (due to involvement of the vagus nerve)

A 54-year-old woman presents to the emergency department with complaints of sudden onset vertigo, nausea, vomiting and hearing loss in her left  ear. Vertigo provoked with changes in head position. On examination, her vitals are within the normal  range. Hearing is decreased on the left side on whisper test. Rinne and Weber tests establish sensori neural deafness of the left ear. She has also nystagmus with the rapid eye to the left side. The rest of the examination is inconclusive.Which one of the following could be the most likely diagnosis? A. Labyrinthitis B. Vestibular neuronitis C. Acoustic neuroma D. Meniere's disease E. Lateral medullary syndrome

Correct Answer Is E The inner ear contains the endolymphatic fluid-filled semicircular canals (which convey movement and position of the head) and the cochlea (which is the sensory organ of hearing).  Conditions that cause disruption of endolymph flow can present with vertigo (semicircular canals) and/or sensorineural hearing loss (cochlea). Perilymphatic fistulas are a rare, but debilitating, complication of head injury or barotrauma.  They cause leakage of endolymph from the semicircular canals and cochlea into surrounding tissues, resulting in characteristic clinical features: Progressive sensorineural hearing loss caused by damage to cochlear hair cells from loss of endolymph. Episodic vertigo with nystagmus triggered by pressure changes in the inner ear (eg, Valsalva maneuver, elevation changes [eg, riding in elevator]) due to acutely increased endolymph leakage.  This can be demonstrated clinically by performing a loud clap (ie, pressure change due to sound conduction through the ossicles) near the patient’s ear and observing for nystagmus (Tullio phenomenon). Patients are advised to limit activities that increase inner ear pressure; they also require ENT referral for further management. Benign paroxysmal positional vertigo is caused by debris (otoliths) that temporarily alters endolymph flow through the semicircular canals.  Therefore, patients typically have sudden, brief (<1-min) episodes of vertigo triggered by head movement. Eustachian tube dysfunction can result in fluid in the middle ear space (not the inner ear vestibular system) and can cause ear popping, cracking, and hearing loss in response to changes in pressure.  However, it also causes a sense of ear fullness or pain, not episodic vertigo with nystagmus. Ménière disease is caused by increased endolymphatic fluid volume or pressure in the vestibular system.  It also causes episodic vertigo with hearing loss, but episodes are accompanied by aural fullness or tinnitus, last 20 minutes to 24 hours, and often lack specific, identifiable triggers. Orthostatic hypotension causes lightheadedness, presyncope, or syncope when the patient assumes a standing position due to cerebral hypoperfusion.  It does not involve the vestibular system and therefore does not cause true vertigo or nystagmus. A perilymphatic fistula can occur after head trauma and result in episodic vertigo triggered by sudden pressure changes (eg, Valsalva maneuvers) or loud noises (Tullio phenomenon).

A 34-year-old man comes to the office due to intermittent dizziness over the past 3 months.  The patient has had episodes of a sudden spinning sensation, accompanied by nausea, that resolve spontaneously after approximately a minute.  Symptoms occur when he is lifting heavy weights, riding on an elevator, or after sneezing.  He has had no headache or ear pain but has trouble hearing out of the right ear.  The patient had a concussion after a bicycle collision 4 months ago but has no other medical conditions and has had no recent upper respiratory illness.  Vital signs are within normal limits.  Physical examination shows normal ears, including tympanic membranes.  There is no extremity weakness or sensory loss.  No nystagmus is present at rest but performing a Valsalva maneuver provokes nystagmus and the other reported symptoms.  Which of the following is the most likely diagnosis? A. Benign paroxysmal positional vertigo B. Eustachian tube dysfunction C. Ménière disease D. Orthostatic hypotension E. Perilymphatic fistula

Correct Answer Is B There is an increased risk of floppy iris syndrome with the use of selective-alpha blockers (especially tamsulosin) and interrupting treatment does not reduce this risk. The ophthalmologist may need to use a different operative technique and therefore it is important that the ophthalmologist is aware of past and / or current selective-alpha blocker use prior to surgery. While prazosin is a cheaper option, it has more side effects and requires multiple doses each day. Therefore, it is not recommended in international BPH guidelines. Tamsulosin is likely to reduce blood pressure and is not likely to worsen his hypertension. The 5-alpha reductase inhibitors (rather than the alpha-adrenoreceptor antagonists) can take several months to reach maximal effect in terms of symptoms. While sildenafil may improve voiding symptoms, it is not traditionally prescribed as a first-line option for BPH

A 67 year old male presents to see you for review after being started on tamsulosin two months ago by a colleague for symptomatic management of benign prostatic hyperplasia. He wishes to discuss the new medication with you today and is keen to know more about alternative options as his friends with similar problems are taking different medications to him. He has a past history of hypertension and is having cataract surgery in two weeks. Which piece of advice below is most appropriate for him? A. You advise him that prazosin may be a cheaper option compared with tamsulosin with less adverse effects B. You advise him that the tamsulosin may affect his cataract surgery and the ophthalmologist will need to be notified prior to surgery C. You advise him the tamsulosin is likely to worsen his hypertension and should be ceased D. You advise him that the tamsulosin can take several months to provide maximal improvement in symptoms and he should continue taking it for now E. You advise him that sildanafeil is a more effective first-line treatment for benign prostatic hyperplasia compared with tamsulosin

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