A 72 year old female with no significant medical history presented with a rapidly enlarging, left-sided, non-tender neck mass for the previous four days. On further history, she noted left-sided ear pain with hearing loss for the previous four months, for which she had been treated with four courses of antibiotics without improvement. A CT scan showed a soft tissue mass extending from the left nasopharynx and along the left parapharyngeal space. She was also found to have a right parapharyngeal soft tissue mass. Biopsy showed diffuse large B cell lymphoma. Imaging for staging purposes revealed extensive diffuse lymphadenopathy as well as a 5.6cm mass in the pericardial space, partially encasing the ascending aorta. The patient was started on chemotherapy for lymphoma during her hospitalization.
In this case, there are important learning points in the diagnostic approach. The patient was initially treated for acute bacterial rhinosinusitis with multiple antibiotics without improvement. Antimicrobials have a specific role in the treatment of sinusitis, indicated in patients with persistent or worsening symptoms despite conservative management. If there is persistent treatment failure after first and second-line antibiotics are tried, then imaging is indicated. Imaging is especially important in this patient, given her initial chief complaint of otalgia, which may not only be caused by sinusitis, but can also be due to referred pain from a pharyngeal tumor or other head and neck tumors. In this patient, appropriate imaging was delayed by several months, leading to a delay in diagnosis, patient distress, and antibiotic over-utilization. Several cognitive errors likely played a role in the management of this patient. Premature closure, which leads to false assurance of the diagnosis before the entire differential is considered, likely led to the diagnosis of sinusitis in this patient with ongoing otalgia. Diagnosis momentum, which prevents necessary re-evaluation of those not responding appropriately to management, possibly led to repeated courses of antibiotics and delay in imaging.
In the care of all patients, active strategies are needed to prevent cognitive errors. Consequences can range from inappropriate use of therapies to iatrogenic mortality. Examples include premature closure, diagnostic momentum, and anchoring. As the pace of medicine increases, with increasing volume and complexity of patients, it remains important for clinicians to be aware of potential cognitive errors. While pattern recognition is an important part of developing clinical skills, this should not come at the expense of cognitive pitfalls or the use of the availability heuristic as a means to bypass careful consideration.
To cite this abstract:Parris RS, Carbo AR. Anchors Away: A Case of Apparent Sinusitis. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 728. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/anchors-away-a-case-of-apparent-sinusitis/. Accessed April 3, 2020.