Clinical Problem Solving

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Clinical Problem Solving

• Tuesday November 14, 2006
• Stan Massie
• Lisa Willett

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Case 1

• 26 YOBM with facial swelling
• Duration 7 days
• Unilateral, right side
• Progressively worsening
• Painful
• Hurts to chew

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Case 1

• No prior history of facial swelling
• No tooth pain, no fever, no drooling
• No abdominal pain
• No change in urine output
• No shortness of breath
• No history of trauma

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Case 1

• PMH discoid lupus
• Medications Tylenol prn
• SH no tobacco, alcohol, drugs
• New cat
• FH noncontributory

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Physical Exam

• AF VSS
• Right facial swelling over cheek
• Extends supraorbital area to maxilla
• Increased lacrimation
• No lip swelling

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exam, continued

• Palpation
• pain on palpation at TMJ
• Warm
• Preauricular lymphandenopathy
• OP
• good dentition
• no tongue swelling
• No exudate or erythema

• EOMI, no proptosis
• TMs clear, canal red, swollen
• Rest unremarkable

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Evaluation

• WBCs 6,000, normal differential
• Creatinine 0.8
• Further studies?

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Imaging

• CT scan Right parotid inflammation
• Soft tissue edema
• Cervical lymphadenopathy
• No abscess
• No parotid stone visualized
• Diagnosis Acute suppurative parotitis

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Acute Suppurative Parotitis

• Historically, complication of abdominal surgery
  prior to perioperative antibiotics
• Incidence now 0.01 to 0.02
• President James A. Garfield, GSW to abdomen
  during assassination attempt (1881)
• died of suppurative parotitis

J Oral Maxillofac Surg 2002 60446-48
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Acute Suppurative Parotitis

• Infection usually confined to capsule, but spread
  can occur along fascial planes
• Necrotizing mediastinitis reported
• Ascending bacterial sialoadenitis via retrograde
  transductal flow of bacteria from Stensons duct
  into the gland parenchyma

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Predisposing Factors

• Immunosuppression DM, alcoholism
• Sjogrens, sarcoidosis
• Poor oral hygiene
• Decrease in salivary flow from medications
• antidepressants, anticholinergics, diuretics
• Post-surgical dehydration
• Sialolithiasis, tumor or foreign body

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Etiology

• Staphylococcus aureus 80
• Anaerobes increasing (40), mixed
• Gram negatives more likely if hospitalized
• Viral (mumps, influenza, coxsackie, HIV)
• TB and fungal rare

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Clinical Manifestations

• Swelling of cheek
• Indurated, red, warm
• Fever, pain
• Intraorally, Stensons duct orifice red with pus
  expression from gland palpation
• Facial nerve dysfunction rare

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Evaluation and Treatment

• CT scan with contrast
• Sialography contraindicated in acute infection
• Antibiotics 10-14 days, rehydration critical
• Surgical indications
• No improvement after 3-5 days of antibiotics
• Facial nerve or vital structures involvement
• Abscess
• Follow up CT to r/o cancer

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1893 Shutouts Auburn 7 Alabama 14 Longest
winning streak Auburn 5 games Alabama 9 games 38
27 - 1
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Case 2

• 56 YOWM with food stuck
• Progressive over 3 months
• First solids, now liquids too
• catching at base of throat
• No aspiration, no emesis
• No weight loss
• Good appetitie

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Case 2

• PMH
• GERD
• HTN
• DM2
• Hyperlipidemia
• Sleep apnea
• OA

• Meds
• Beta-blocker
• ACE-inhibitor
• Statin
• Sulfonylurea
• H2 blocker BID
• Aspirin

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Case 2

• SH
• Former heavy alcohol
• Now social drinker
• Quit tobacco 10 years ago, 40 pack-year
• FH NC
• ROS NC

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Case 2

• PE AF VSS
• HEENT no lymphadenopathy, no masses
• Thyroid normal
• Neck exam normal
• stiff in axial joints
• Otherwise unremarkable

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Evaluation

• Modified barium swallow

Normal
Abnormal
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Results

• DISH with osteophytes impinging on esophagus

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Dysphagia

• Tumors - larynx, esophagus, lung, mediastinum
• Esophageal motility disorders
• Esophagitis
• Strictures
• Zenker diverticulum
• Plummer-Vinson syndrome
• GERD

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DISH

• Diffuse Idiopathic Skeletal Hyperostosis
• Forestier disease
• Senile ankylosing hyperostosis
• Noninflammatory, unknown etiology
• Common in elderly, up to 10 gt65 yrs
• Usually asymptomatic
• Axial skeletal, thoracic (back stiffness)

Castellano, Laryngoscope 2006
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DISH

• Flowing calcification and ossification within the
  anterior longitudinal ligament (gt4 contiguous
  vertebral bodies)
• Preserved disc space

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Associated conditions

• Hyperinsulinemia, with/out DM
• Obesity
• Gout
• Dyslipidemia
• Prolonged use of isortynol (increased Vitamin A
  levels)

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DISH-phagia

• Cervical spine (up to 75)
• Osteophytes? dysphagia (C4-C7), 25
• Direct mechanical compression
• Inflammation of soft tissues
• Pain and spasm
• Hoarseness, stridor (C2-C3)
• Myelopathy, thoracic outlet syndrome
• OSA

Curtis, J Rheum 2004 Mader, Semin Arthr and Rheum
2002
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Treatment

• Dietary modification, swallowing therapy
• NSAIDS
• Muscle relaxants
• Surgery if severe or fail conservative therapy

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Case 3

• 49 YOF c/o worsening LBP for 1 month
• History of chronic LBP
• MRI 6 months ago with DJD
• No recent trauma, exacerbating etiology
• Right sided, sharp, intermittent
• No radiation, not positional
• Feels different

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Case 3

• PMH chronic LBP, HTN, nephrolitiasis, obesity,
  COPD
• Lortab, HCTZ, Combivent, NSAIDs
• SH tobacco, married, no drugs
• ROS No fever, weight loss, neuro sx
• Dysuria, no hematuria, other GU sx

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PE

• T 99 VSS 220 lbs, 52 (BMI 40)
• No CVAT
• No vertebral point tenderness
• Bilateral SLR (chronic)
• Paraspinal muscle spasm RgtL
• Pelvic normal
• Neuro NF

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Labs

• Creatinine 1.3, baseline 1.1
• UA 1 protein, 1 blood, 10-12 RBCs, no WBCs
• WBC 9,000 with normal differential
• Hct 49
• Further studies?

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CT without contrast

• Right renal mass, 3.2 cm upper pole
• Repeated with contrast increased vascularity
• Consistent with renal cell carcinoma

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Renal Cell Carcinoma

• 3 of adult malignancies
• 6th leading cause of cancer death
• Incidence increasing
• Median survival for metastatic disease 13mos
• Challenging
• 30-50 asymptomatic, incidental finding
• 30 metastatic, symptoms
• Refractory to standard chemotherapy
• Prognosis poor

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Symptoms

• Triad flank pain, hematuria, palpable abdominal
  mass 10
• Fever 20
• Hematuria (clots, colicky pain) 8
• Scrotal varicoceles 10
• Paraneoplastic polycythemia, hypercalcemia
• Anemia, cachexia, dermatomyositis, HTN
• Lung, lymph node, bone, liver, brain mets

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Risk factors for adult RCC

• Hereditary Von Hippel-Lindau
• Sporadic systematic review, 236 articles (59 met
  selection criteria)
• Tobacco, obesity, kidney diseases, HTN, drugs,
  occupational, hormonal status, socioeconomic
  status, alcohol, and coffee
• Tobacco use (men) and severe obesity (both)

R. Dhote,Urologic Clinics of North America May
2004
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Treatment Surgical

• Localized disease resection for cure
• Laproscopic for small-volume tumors
• 20-30 metastatic disease later
• Metastatic disease palliation
• Pain, hemorrhage, hypercalcemia
• Improved survival if isolated met resected
• Metastatic disease regression

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Treatment Biological therapies

• Interferon alpha
• IL-2 T-cell growth factor and activator of T
  cells and NK cells
• VEGF (vascular endothelial growth factor)
  inhibitors Sunitinib malate, sorafenib tosylate
• TNF-alpha inhibitors (via epidermal growth factor
  receptor)
• Vaccines

NEJM 2005353
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Summary

• Facial swelling
• Acute suppurative parotitis
• Dysphagia
• Diffuse Idiopathic Skeletal Hyperostosis
• Change in chronic back pain
• Renal Cell Carcinoma
• Watch football this weekend

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Happy Birthday Dr. H!!