DQ Reply 2 634

DQ-1

Cholesteatoma is a keratinized white mass within the tympanic membrane, typically involved in the middle ear cavity and mastoid cavities. It may be congenital or acquired, and may erode invading the ossicles, antrum, mastoid process, nerve canal, tegmen tympani, and the posterior semicircular canal wall (Medany, Sabra, Hakim, Sadawy, & Elshafei, 2018). Typically, 98% of cholesteatoma is acquired and can be developed as a result of acute or chronic otitis media (Young, 2015). Affecting the ear, cholesteatomas may cause some pressure and discomfort within the ear or behind the ear, lead to hearing loss, and in severe cases, it may lead to central nervous system complications, such as meningitis and unilateral facial palsy. In a patient presents with any of those symptoms, a thorough ear exam should be done.

Cholesteatomas may cause conductive hearing loss; therefore, a Rinne and Weber test should be done. Patients with conductive hearing loss are no longer able to hear the air sound waves resulting in a negative Rinne test while in a Weber test, sound lateralizes to the affected side (Bickley & Szilagyi, 2017). Under otoscopic examination, cholesteatomas appear as a white, pearly mass medial to the tympanic membrane, in which it should be further evaluated with imaging. A CT scan and/or MRI can identify the expansion of the lesion, but the soft-tissue attenuation can make it difficult to differentiate between cholesteatomas from middle ear inflammation or infection; however, diffusion-weighted MRI (DWMRI) may be beneficial. (Young, 2015). A temporal bone computed tomography (TBCT) can locate and measure the size of the cholesteatoma in order to determine the type and stage of cholesteatoma to determine the appropriate treatment (Song et al., 2019). Cholesteatomas do require surgical resection to preserve anatomical and functionality of the ear, but depending on the size, there is a high chance of residual or recurrent cholesteatoma. Therefore, DWMRI is essential for identifying residual or recurrent disease and avoid unnecessary surgical reexploration (Medany et al., 2018).

 

References

Bickley, L., & Szilagyi, P. G. (2017). The head and neck. In R. M. Hoffman (Ed.), Bates’ guide to physical examination and history taking (12th ed., pp. 215-299). Philadelphia, PA: Wolters Kluwer.

Medany, M. M., Sabra, R. M., Hakim, E. K., Sadawy, A. M. I., & Elshafei, A. M. M. (2018). Reliability of diffusion weighted MRI for the diagnosis of residual and recurrent cholesteatoma. The Egyptian Journal of Hospital Medicine, 72(10), 5403-5408. Retrieved from https://eds-b-ebscohost-com.lopes.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=0&sid=9b08b180-e035-4836-bbbb-e9be18bb7294%40pdc-v-sessmgr01

Song, I. S., Han, W. G., Lim, K. H., Nam, K. J., Yoo, M. H. Rah, Y. C., & Choi, J. (2019). Clinical characteristics and treatment outcomes of congenital cholesteatoma. The Journal of International Advanced Otology, 15(3), 386-390. doi:10.5152/iao.2019.6279

Young, C. (2015). Temporal bone CT: Anatomy, technique, and associated pathophysiology. Radiologic Technology, 86(5), 535-555. Retrieved from https://eds-b-ebscohost-com.lopes.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=0&sid=e0cfc7df-76e5-422f-ad10-1f20b181b8e4%40sessionmgr103

DQ-2

Retinal detachment is a serious eye emergency and requires immediate treatment to prevent blindness (Akhlaghi, Zarei, Ziaei, & Pourazizi, 2020). Initial signs and symptoms of retinal detachment is an increase in floaters in the eye, floaters with flashes, shadows in peripheral vision, a grey curtain over part of the vision, or a sudden decrease in vision (Akhlaghi et al., 2020).

There are issues with retinal detachment diagnostic testing. Initial testing includes the use of ophthalmoscope and biomicroscopic examination of the fundus with a slit lamp, however, if the patient has dense media opacities the diagnosis may not be accurate in these patients (Akhlaghi et al., 2020). In this case, an ocular ultrasound is required as a diagnostic imaging tool but also has its limitations (Akhlaghi et al., 2020). Grey-scale ultrasound cannot differentiate layers of the retina so it is difficult to differentiate retinoschisis from retinal detachment (Akhlaghi et al., 2020). So the addition of a color doppler ultrasound can show blood flow through the retina, even with dense opacities, and shows a direct view of the posterior segment of the retina (Akhlaghi et al., 2020). All of these tests need to be completed in a short period of time to confirm retinal detachment (Akhlaghi et al., 2020).

The major issue is that if there is suspicion of retinal detachment, the decision to perform surgery also incurs a heavy cost on the patient and healthcare system, but the decision to wait for diagnostic tests to be performed could lead to the patient's blindness (Hoogewoud et al., 2016).  These issues call for early recognition and identification coupled with the patient's history of the present illness, and stat imaging performed in a timely manner (Hoogewoud et al., 2016). 

Knowing this, meeting the patient for the first time, and listening to their history of present illness, I would begin with a focused assessment on their eyes. Comparing the right and left eyes with an ophthalmoscope. If I noticed thick, dense, media, and opacities in one eye when compared to the other and compared it to the patient's complaint of rapid loss of vision, I would immediately call for stat ultrasound of the eye and color doppler. Once out of the room I would also involve the on-call ophthalmologist and letting them know what tests I had ordered so that when the ophthalmologist arrives all the information would be available. Since the treatment is corrective surgery performed by an ophthalmologist, I think it would be appropriate to get one involved at this point in early recognition and intervention. 

References:

Akhlaghi, M., Zarei, M., Ziaei, M., & Pourazizi, M. (2020). Sensitivity, Specificity, and Accuracy of Color Doppler Ultrasonography for Diagnosis of Retinal Detachment. Journal of Ophthalmic & Vision Research, 15(2), 166–171. https://doi-org.lopes.idm.oclc.org/10.18502/jovr.v15i2.6733

Hoogewoud, F., Chronopoulos, A., Varga, Z., Souteyrand, G., Thumann, G., & Schutz, J. S. (2016). Traumatic retinal detachment—the difficulty and importance of correct diagnosis. Survey of Ophthalmology, 61(2), 156–163. https://doi-org.lopes.idm.oclc.org/10.1016/j.survophthal.2015.07.003

DQ-3

Infectious Mononucleosis is described as a viral illness most likely caused by Epstein- Barr virus that affects frequently young adults in their early 20’s and thirty times more common in white compared to black (Riviere, 2020). Epstein Barr Virus is also called a human herpes 4 virus that can only be found in humans (CDC, 2018). The signs and symptoms of infectious mononucleosis are: fatigue, fever, chills, pharyngitis, lymphadenopathy, splenomegaly, headache, tonsillitis, mild hepatomegaly, abdominal pain, nausea, sensitivity to light, erythema- multiforme rash, palatal petechiae or gray-white necrosis of tonsillar tissue in adolescents (Riviere, 2018, p. 180-181). Complete Blood Count, Monospot rapid tests, rapid strep test, throat culture, liver enzymes and ultrasound are some of the diagnostic test used to assess a patient with possible infectious mononucleosis. Complete blood count is used to assess for elevation of lymphocytes, presence of atypical lymphocytes in approximately 20% of the time (Riviera, 2018, p. 181). The enlargement of the spleen that is commonly seen in almost 50% of the patients can be checked by ultrasound (Riviera, 2018, p. 181).

Monospot is a rapid test used to screen patients for presence of heterophil antibodies that appear to be positive during the second or third week of illness. The sensitivity of monospot is 96-99% if the antibodies are increased and almost 90% of the adolescents on the third week of illness showed a positive monospot test. The provider can repeat a monotest after one week from the time that the patient tested negative if the provider still suspect that a patient is at risk for developing infectious mononucleosis. The provider may also order an EBV titer blood test in patients who have unusual signs and symptoms of infectious mononucleosis. According to CDC (2018), monospot is not generally recommended due to some studies showing that monospot can produce a false positive and false negative results (CDC, 2018). It can only show that the patient has a positive cause of infectious mononucleosis but cannot validate the presence of EBV. Viral Capsid Antigen, Early Antigen and EBV Nuclear Antigen (EBNA) are some of recommended antibody testing used to see if the patient has an EBV-associated antigens (CDC, 2018).

Anti-viral Capsid Antigen (VCA) Ig M can be seen in patients who have a new onset EBV infection and usually disappears after four to six weeks (CDC, 2018). Anti-VCA IgG can also be seen in patients with a new onset of EBV infection and peaks within two to four weeks and decreases a little bit and can always be seen for a lifetime. The normal IgG and IgM is less than 1:10 to be negative (Ferri, 2019, p. 172). A patient who has more than 1:10 IgG and IgM anti- VCA is considered positive. A positive IgG can indicate a current or previous infection while a positive IgM is considered a current or recent infection (Ferri, 2019, p. 172). Additionally, an EBV nuclear antigen is described as a standard immunofluorescent test that cannot be seen during the acute phase (CDC, 2018). The normal anti-EBNA is less than 1.5 (Ferri, 2019, p. 172). A result of 1.5 or more can indicate that the patient has a previous EBV infection It can only show two to four months after the signs and symptoms of EBV appears and can last for the rest of the patient’s life. In my experience, I have encountered patients with EBV but not fully aware of the titers and their functionality. Knowing what I know now, I am excited to see and appreciate how doctors and nurse practitioners diagnose and treat patients with EBV.

 

 

References:

Centers for Disease Control and Prevention (2018). Epstein Barr| Mononucleosis| Laboratory Testing| Mono| CDC. Retrieved from https://www.cdc.gov/epstein-barr/laboratory-testing.html

Ferri, F. (2019). Ferri’s Best Test: A practical guide to clinical laboratory medicine and diagnostic imaging. Elsevier, Inc. Philadelphia,PA

Riviere, S.L. (2018). Infectious Mononucleosis. Holier, A(Eds). Clinical Guidelines in Primary Care (3rd edition pp. 180-181). Advanced Practice Education Associates, Inc. Lafayette, L.A.