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- In select chronic or refractory cases, ENT specialists may use prescription, culture-directed topical antibiotic irrigations delivered by high-volume rinse methods (this is not the same as a standard OTC spray bottle)

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22,23 In patients with a normal or low-normal serum vitamin B 12 level, complete blood count results demonstrating macrocytosis, or suspected clinical manifestations, a serum methylmalonic acid level is an appropriate next step 1,2,6,18 and is a more direct measure of vitamin B 12 's physiologic activity