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Chapter 15. Otolaryngology: Head & Neck Surgery

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You are asked to evaluate a 6-year-old child with nasal pain. She is on the pediatric hematology-oncology service, and is undergoing chemotherapy for acute lymphoblastic leukemia. She has no other pertinent medical history. The pain has been present for 12 hours. On examination, you note no abnormalities in the oral cavity, oropharynx, or external head and neck examination. Her pulse is regular and her respirations are nonlabored. On nasal examination you note a slight duskiness to the anterior face of the left middle turbinate. An appropriate response would be

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A. Reassure the child and her parents that she is most likely fine, and schedule a follow-up visit for the following day

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B. Take her to the operating room immediately for an emergent biopsy

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C. Order a contrasted MRI of the nose/face/orbits and a complete blood count (CBC) with differential

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D. Start her on nasal decongestant spray (oxymetazoline) twice daily, nasal saline irrigations, and an oral antihistamine once daily

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B. Take her to the operating room immediately for an emergent biopsy. Invasive fungal sinusitis is usually seen in immunocompromised patients, such as the patient described here. It is caused by uncontrolled infiltrative growth of usually nonpathogenic fungal organisms such as Rhizopus or Aspergillus species. Even with prompt diagnosis, aggressive surgical therapy, and modern antifungal agents, the disease still carries a significant mortality rate (up to 30%). The index of suspicion for invasive fungal sinusitis must be high for any immunocompromised patient, as the symptoms can be subtle and the disease rapidly progressive. If invasive fungal sinusitis is suspected, biopsies should be taken of the suspicious areas and sent for immediate pathologic examination. Note that this can often involve calling a pathologist in from home in the middle of the night or on a weekend, if they are not in-house. In the case presented here, the likelihood of the child cooperating with an examination and biopsy is low, thus an emergent posting to the operating room is the most prudent action.

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You are asked to evaluate a patient in the emergency room with rapid onset of lip and tongue swelling. He develops shortness of breath and stridor during your examination. Following an emergent tracheotomy to establish his airway you do a thorough review of his medication history. Which of the following drug class(es) is/are known to be associated with acute angioedema?

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A. Angiotensin converting enzyme inhibitors (ACE inhibitors, such as lisinopril)

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B. Angiotensin II receptor blockers (ARBs, such as losartan)

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C. Recombinant tissue plasminogen activators (r-tPAs, such as alteplase)

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