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Clinical Challenge
October 13, 2016

A Toddler With Nasal Congestion and a Limp

Author Affiliations
  • 1Head and Neck Surgery Branch, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland
  • 2Section on Skeletal Disorders and Mineral Homeostasis, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
  • 3Division of Endocrinology and Diabetes, Children's National Health System, Washington, DC
  • 4Bone Health Program, Division of Orthopedics and Sports Medicine, Children's National Health System, Washington, DC
  • 5Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

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JAMA Otolaryngol Head Neck Surg. Published online October 13, 2016. doi:10.1001/jamaoto.2016.2392

A toddler presented with recent onset of nasal congestion, constant rhinorrhea, and difficulty hearing. Previous treatment with montelukast provided symptomatic relief; however, this was discontinued owing to behavioral changes. His medical history was significant for an unusual gait with anterior displacement of the pelvis and hips since he began walking at 10 months of age. Since then he had experienced intermittent episodes of limping accompanied by pain in both femurs. Radiographs revealed no active fractures but did show extensive bony changes in the long bones and the skull. On examination, mild asymmetry of the head was noted on palpation with prominence of the right temporal and parietal area. On limited endoscopic examination, mucosal edema and mucopurulent discharge were observed in the left more than the right naris. An endoscope could not be advanced posteriorly owing to patient discomfort and right-sided sinonasal obstruction. Multiple macules with irregular borders were observed on the lower back, upper buttock, upper chest, upper neck, and right postauricular area. There was also a varus deformity of the lower extremities with mild discrepancy in leg length. An audiogram showed bilateral conductive hearing loss with a flat tympanogram. A computed tomographic (CT) scan of the head and neck revealed heterogenous opacification of the right ethmoid and maxillary sinuses with fluid accumulation within the bilateral mastoid bones and middle ears. His thyroid-stimulating hormone level was 0.19 mIU/mL (reference range, 0.5-2.4 mIU/mL), free thyroxine level was 1.3 ng/dL (0.9-1.6 ng/dL), and free triiodothyronine levelwas 4.6 pg/mL (3.4-5.1 pg/mL) (Figure).

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