Unnecessary Delay In Diagnosis Research Articles

Clinical Practice Guideline: Bell's Palsy Executive Summary

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Bell's Palsy. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 11 recommendations developed encourage accurate and efficient diagnosis and treatment and, when applicable, facilitate patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. There are myriad treatment options for Bell's palsy; some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, there are numerous diagnostic tests available that are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have an unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.

Clinical Practice Guideline: Bell's Palsy

Bell's palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mono-neuropathy, or disorder affecting a single nerve, and is the most common diagnosis associated with facial nerve weakness/paralysis. Bell's palsy is a rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause. The condition leads to the partial or complete inability to voluntarily move facial muscles on the affected side of the face. Although typically self-limited, the facial paresis/paralysis that occurs in Bell's palsy may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential eye injury. Additional long-term poor outcomes do occur and can be devastating to the patient. Treatments are generally designed to improve facial function and facilitate recovery. There are myriad treatment options for Bell's palsy, and some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, numerous diagnostic tests available are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy. The primary purpose of this guideline is to improve the accuracy of diagnosis for Bell's palsy, to improve the quality of care and outcomes for patients with Bell's palsy, and to decrease harmful variations in the evaluation and management of Bell's palsy. This guideline addresses these needs by encouraging accurate and efficient diagnosis and treatment and, when applicable, facilitating patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell's palsy. The target population is inclusive of both adults and children presenting with Bell's palsy. ACTION STATEMENTS: The development group made a strong recommendation that (a) clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute-onset unilateral facial paresis or paralysis, (b) clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell's palsy patients 16 years and older, (c) clinicians should not prescribe oral antiviral therapy alone for patients with new-onset Bell's palsy, and (d) clinicians should implement eye protection for Bell's palsy patients with impaired eye closure. The panel made recommendations that (a) clinicians should not obtain routine laboratory testing in patients with new-onset Bell's palsy, (b) clinicians should not routinely perform diagnostic imaging for patients with new-onset Bell's palsy, (c) clinicians should not perform electrodiagnostic testing in Bell's palsy patients with incomplete facial paralysis, and (d) clinicians should reassess or refer to a facial nerve specialist those Bell's palsy patients with (1) new or worsening neurologic findings at any point, (2) ocular symptoms developing at any point, or (3) incomplete facial recovery 3 months after initial symptom onset. The development group provided the following options: (a) clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell's palsy, and (b) clinicians may offer electrodiagnostic testing to Bell's palsy patients with complete facial paralysis. The development group offered the following no recommendations: (a) no recommendation can be made regarding surgical decompression for patients with Bell's palsy, (b) no recommendation can be made regarding the effect of acupuncture in patients with Bell's palsy, and (c) no recommendation can be made regarding the effect of physical therapy in patients with Bell's palsy.

Gastrointestinal Tuberculosis (TB): A Great Mimicker!

Purpose: INTRODUCTION: Gastrointestinal TB is known as the great mimicker because of its diverse presentations. It is the sixth most common extra-pulmonary site of involvement. Its incidence is predicted to rise with increasing cases of HIV infection. CASE: 66 y/o from Gambia with history of diabetes, hypertension and dyslipidemia presented with generalized malaise, epigastric pain and significant unintentional weight loss for 4 weeks. Travel history included frequent visits to Africa. Initial labs showed Hct=27.2 %, WBC=16 k/μl, albumin=2.9 g/dl, total bilirubin=1.3 mg/dl and ESR=78 mm/hr. CA 19.9 U/ml, AFP and CEA levels were normal. Serology for hepatitis B, hepatitis C and blood cultures were negative. Blood smear for parasites was negative. Transthoracic echocardiogram and CXR were unremarkable. She continued to have intermittent fever spikes of 102-103F despite broad spectrum empirical antibiotic therapy. She was diagnosed with AIDS (CD4=10). Abdominal CT revealed enlarged retroperitoneal lymph nodes with a 3.2cm hypodense lesion in the caudate lobe and in the head of pancreas. MRI revealed 3.5 cm enhancing lesion with irregular rim (T1 hypointense and T2 hyperintense) superior to the head of pancreas at the porta hepatis with restricted diffusion; suggestive of an abscess versus exophytic lesion in the caudate lobe. Bile duct appeared normal. Few tiny non-specific splenic lesions were noted. Gallium scan showed a focus of activity inferior and medial to the liver. Patient continued to have fever with worsening leukocytosis, direct hyperbilirubinemia, coagulopathy. Later, she developed oliguric acute renal failure. CT guided drainage of perihepatic abscess was performed. 90 ml purulent aspirate was obtained. Specimen histology showed reactive mesothelial cells. Culture tested positive for Mycobacterium tuberculosis by DNA prob. No fungus, malignant cell or parasite was detected. Subsequent respiratory cultures grew Mycobacterium tuberculosis as well. Anti-tuberculosis therapy was soon interrupted due to marked elevation in transaminases (AST=4122 U/L, ALT=331 U/L). Patient subsequently developed septic shock and finally died on day 20 of hospitalization. DISCUSSION: TB should be considered in the differential diagnosis of intra-abdominal or hepatic lesions, especially in immunocompromised patients. Liver tuberculosis abscess may mimic common hepatic diseases including primary or metastatic liver cancer, amebic or pyogenic liver abscess. A greater awareness, coupled with high index of suspicion is required to avoid unnecessary delay in diagnosis and treatment of this rare clinical entity; particularly in patients with recent travel history or native to TB endemic areas.

Human papillomavirus-associated oropharyngeal cancer: a new clinical entity

The incidence of oropharyngeal cancers is rising worldwide in both nonsmokers and nondrinkers. Epidemiology studies suggest a strong association between human papillomavirus (HPV) 16 infection, changing sexual behavior and cancer development. Despite initial presentation with locally advanced disease and poorly differentiated histology, HPV-associated oropharyngeal carcinoma is associated with a good prognosis because its response to chemotherapy and radiation. Clinicians should be aware of the risk of oropharyngeal cancer in young people to avoid unnecessary delay in diagnosis and treatment. A history of oral sex should be elicited in young patients with enlarged neck nodes and/or tonsillar masses.

Staphylococcus warneri ventriculoperitoneal shunt infection: failure of diagnosis by ventricular CSF sampling

The definite diagnosis of hydrocephalus valve infection is generally made by cerebrospinal fluid (CSF) sampling via the valve reservoir, which is considered to be more dependable than that of the CSF obtained by lumbar puncture. We treated a 17-year-old boy with an intra-abdominal pseudocyst due to ventriculoperitoneal shunt infection caused by Staphylococcus warneri whose ventricular CSF, obtained via the valve reservoir, was repeatedly sterile thus causing a considerable delay in the management of the complication. S. warneri constitutes an emergent contaminant of catheters and prostheses. We found only a detailed report of S. warneri infection of a ventriculoatrial shunt. If manifestations of peritoneal involvement in shunted patients would occur, the attention should be shifted to the distal component of the shunt hardware, even in the presence of a normal ventricular CSF as happened in our case to avoid unnecessary delay in diagnosis and management.

Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis

Clearing the cervical spine in polytrauma patients still presents a challenge to the trauma team. The risk of an overlooked cervical spine injury is substantial since these patients show painful and life-threatening injuries to one or more organ systems so that clinical examination is usually not reliable. A generally approved guideline to assess the cervical spine in polytrauma patients might significantly reduce delays in diagnosis, but a consistent protocol for evaluating the cervical spine has not been uniformly accepted or followed by clinicians. One purpose of this study was to analyse the common methods for cervical spine evaluation in critically injured patients and its safety and efficacy at this trauma centre. The second purpose was to present a comprehensive diagnostic C-spine protocol, based on the authors' experiences with documented cases. From a prospectively gathered polytrauma database, we retrospectively analysed the clinical records of all polytrauma patients, with skeletal and/or non-skeletal cervical spine injuries, who were admitted to this level I trauma centre between 1980 and 2004. All patients were assessed following the trauma algorithm of our unit (modified by Nast-Kolb). Standard radiological evaluation of the cervical spine consisted of either a single lateral view or a three-view cervical spine series (anteroposterior, lateral, odontoid). Further radiological examinations (functional flexion/extension views, oblique views, CT scan, MRI) were carried out for clinical suspicion of an injury or when indicated by the standard radiographs. Sixteen patients (14%) had a single cross-table lateral view for radiological assessment of the cervical spine during initial trauma evaluation, Twenty-nine patients had a three-view cervical spine series (anteroposterior, lateral, odontoid) and 81 patients underwent extended radiological examinations by cervical CT scan (n=52), functional flexion/extension views (n=26) or MRI (n=3). Correct diagnosis was made in 107 patients (91%) during primary trauma evaluation, whereas in 11 patients (9%) our approach to clear the cervical spine failed to detect significant cervical spine injuries. In six patients skeletal injuries were missed by a single lateral view and in two patients by a three-view standard series because inadequate radiographs with poor technical quality or incomplete visualization of the cervical spine did not show the extent of the injury. In three cases ligamentous injuries were missed despite complete sets of standard radiographs and cervical CT scan, but without functional radiography. Common methods for cervical spine evaluation in critically injured patients were plain radiographs, cervical CT scan and functional flexion/extension views. Cervical CT scan was the most efficient imaging tool in detecting skeletal injuries, showing a sensitivity of 100%. A single cross-table lateral view appeared to be insufficient, as we found a sensitivity of only 63%. Functional radiography or MRI was also necessary, as plain radiographs and CT scan failed to detect significant ligamentous injuries in 6% of the patients. For more comprehensive assessment of the C-spine, we presented a new C-spine protocol based on the authors' experiences, with the aim to avoid unnecessary delays in diagnosis.

Early recognition and treatment of staphylococcal and streptococcal toxic shock

A diverse array of human infection is caused by Staphylococcus aureus and Streptococcus pyogenes, from minor skin and soft tissue infections to disseminated, invasive disease associated with significant morbidity and mortality. The term toxic shock syndrome is used to describe serious, life-threatening illness associated with particular strains of Staphylococcus aureus and Streptococcus pyogenes that demonstrate the ability to excrete a variety of toxins capable of inducing rash, shock, focal pyogenic, and/or necrotizing infection and multi-organ system failure. It has been my experience that in many cases of toxic shock syndrome, early clinical clues are missed, leading to unnecessary delays in diagnosis and initiation of specific anti-staphylococcal and streptococcal antimicrobial therapy. The key to effective management of toxic shock syndrome lies in the early recognition of telltale symptoms and physical findings so that treatment interventions can be initiated early enough to have a significant impact on the considerable morbidity and mortality associated with this disease.

Vasculopathy in von recklinghausen's neurofibromatosis–a diagnostic quandary

Vasculopathy is a not well–described presentation of neurofibromatosis type 1 in the dermatologic literature. We report a fatal case of neurofibromatosis vasculopathy in a 28-year-old woman who presented with skin ulcers and livedo racemosa; extensive gastrointestinal ulcers; and infarction of the bowel, liver, and spleen. Being alert to this manifestation may avoid unnecessary delay in diagnosis and enable, whenever possible, appropriate therapy.

Overnight dexamethasone suppression test: normal responses and the diagnosis of cushing's syndrome

Serum cortisol levels were measured the morning after the administration of 1 mg of dexamethasone. Only 5 of 190 subjects had serum cortisol levels greater than 2 μg/dL. Thus, the normal value after dexamethasone suppression is less than 2 μg/dL rather than less than 5 μg/dL as has generally been accepted. The distinction is important because some individuals with Cushing's syndrome partially suppress their cortisol levels to less than 5 but more than 2 μg/dL during the test procedure. Thus, the use of 5 μg/dL as the normal value may lead to an unnecessary delay in diagnosis.

Juvenile Pemphigus Vulgaris

Pemphigus vulgaris (PV), usually considered to be a disease of middle age, is becoming increasingly recognized in children. Twenty-two cases of PV in patients younger than 20 years of age have been reported since 1955. However, PV is not always considered early in the differential diagnosis of vesiculobullous disorders in younger patients and this may result in an unnecessary delay in diagnosis. We report herein a case of PV in a 15-year-old boy that satisfies currently acceptable clinical, histopathologic, and immunologic criteria for the diagnosis of this disease. Our purpose is to emphasize that this disease may occur in juvenile patients and should be considered in the differential diagnosis of erosive lesions of the oral mucosa in such patients. In addition, the success of therapy with prednisone and azathioprine recorded in our patient is of interest, since therapy can be difficult in this group of patients. Report of a

Blunt abdominal trauma: Exploratory laparotomy or peritoneal lavage?

In contrast to other series purporting advantages of routine lavage [20], our data support the position that, in patients with blunt abdominal trauma, certain criteria eliminate the need for peritoneal lavage and make this procedure an unwise investment of valuable time on a routine basis. Criteria such as evidence of hollow organ rupture on radiologic studies, gross abdominal wall defects (excluding simple lacerations), rapidly increasing abdominal distention, uncorrectable hypotension and isolated rigidity on abdominal examination in an otherwise intact and cooperative patient, should be considered indications for laparotomy. In a stable patient with associated injuries or altered central nervous system status, abdominal examination should be viewed as suspect and peritoneal lavage considered mandatory. However, in over one fourth of cases, positive lavage may fail to correlate with intraabdominal injury of a degree that necessitates operative repair. In patients admitted for observation of abdominal injuries with concurrent alterations in central nervous system status or associated injuries that hinder accurate abdominal examination when no urgency exists, we support the opinion that selective use of peritoneal lavage will save unnecessary delay in diagnosis and operative treatment. The highly lethal nature of multiple injuries and central nervous system damage is confirmed by our data, verifying reports by Davis et al [6] of a 70 percent or greater mortality rate among comatose patients hospitalized with multiple trauma.

The prevalence and clinical presentation of psychiatric illness in a rural setting in Kenya.

One hundred and forty patients seen in a suburban walk-in walk-out clinic over a period of 30 days were studied. Twenty-eight (20 per cent) of them were found to be primarily psychiatrically disabled, 83 (59.3 per cent) primarily physically disabled and the diagnosis of the rest (20.7 per cent) was uncertain. The psychiatric patients were found to be suffering from anxiety and depressive states. Their sex, age, education, economic status, symptomatology and duration of the illness were analysed. The findings suggest among other things that the prevalence of psychiatric disorders in the rural setting in Kenya is high and therefore calls for a proportionate provision of mental health care facilities. They also suggest that anxiety and depression in African patients are masked by somatic symptoms, often leading to unnecessary delays in diagnosis and management.

Cholecystitis in Childhood and Adolescence

Thirty-four patients less than 20 years old with acute or chronic cholecystitis were treated in a 12-year period. Recent pregnancy and prior or concurrent urinary tract infections were present in a substantial number of patients, but hematologic disease and anomalies of the biliary tract were relatively infrequent. Ten patients had jaundice at some time during their illness, but none of these was found to have common duct stones. Symptoms and signs of the disease are remarkably similar to those in adults, but unnecessary delay in diagnosis occurred because of failure to suspect the disease in this age group. Cholecystectomy was carried out in each of the 34 patients without mortality or significant morbidity.

Localized Unilateral Pulmonary Edema: An Unusual Presentation of Left Heart Failure

A patient with mitral insufficiency caused by infarction of the anterior papillary muscle, presenting with localized unilateral pulmonary edema, is reported. On the basis of previous reports it appears that unilateral presentation of acute pulmonary edema, although unusual, is not so rare as is generally believed. The exact underlying mechanism is not clear but various hypotheses put forward to explain the unilateral distribution include the effect of gravity and posture, variations in the pulmonary venous pressure and some disturbance of the neurogenic control of capillary size and permeability. We believe that a wider recognition of the unilateral presentation of acute pulmonary edema is important to avoid unnecessary delay in diagnosis and proper management.