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Senior - ENT > 4 - Nose > Flashcards

4 - Nose Flashcards

1
Q

Nose hole anatomy

A

Slide 5, 6, 7, 8

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2
Q

Ostiomeatal complex (OMC)

A

Channel that links the frontal sinus, anterior ethmoid air cells and maxillary sinus to the middle meatus, allowing air flow and mucocilary drainage

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3
Q

Essentials of diagnosis for acute viral rhinitis?

A

Clear rhinorrhea
Hyposmia
Nasal congestion

Malaise
HA
Cough

Erythematous engorged nasal mucosa
W/o intranasal purulence

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4
Q

How long does the common cold last?

A

Generally 3-10 days but symptoms should be better in
- 10 days to 4 weeks

Self limited

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5
Q

Fever with viral rhinitis?

A

Not common

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6
Q

Complications for viral rhinitis?

A

Usually
- Benign and self limited

ETD
Otitis media w effusion
Acute bacterial sinusitis

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7
Q

Tx for acute viral rhinitis?

A

Z pack

Jk dont do that

Symptomatic or zinc (75mg) (controversial)

  • nasal irrigation
  • decongestants
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8
Q

Acute bacterial rhinosinuitis (ABRS) essentials?

A

Purulent yellow/green discharge/expectorant

Facial pain/pressure

Nasal obstruction

Acute onset

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9
Q

What causers ABRS?

A

Impaired mucociliary clearance and obstruction of the ostiomeatal complex

Oatmeal complex is clogged

This gets infected in the sinuses

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10
Q

Predisposing symptoms for ABRS?

A

URI
Allergies
Mechanical obstruction (deviated septum)

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11
Q

MC community and hospital acquired bacteria for ABRS?

A

Community:

  • S pneumonia
  • H influenzae

Hospital:

  • pseudomonas
  • S. Aureus
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12
Q

Presentation of ABRS?

A 
Facial pain/pressure
Fever
Cough
Hyposmia/anosmia
Purulent nasal discharge
Nasal congestion
Maxillary tooth discomfort
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13
Q

ABRS vs AVRS?

A

AVRS - complete resolution in 7-10 days

ABRS - no good criterai but may see

  • 10+ days
  • > 102*F
  • purulent discharge/pain x 3-4 days
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14
Q

Classification of ABRS?

A

Acute <4 weeks
Subacute: 4-12 wks
Chronic: >12 wks
Recurrent: >/= 4 per yr

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15
Q

MC paranasal sinusitis?

A

Acute maxillary sinusitis

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16
Q

Acute maxillary sinusitis specific sx?

A
  • Unilateral facial fullness

- tenderness over cheeks

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17
Q

Can mimic Acute maxillary sinusitis pain?

A

Tooth infection can refer to the maxillary sinus via CN V

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18
Q

Acute ethmoid sinusitis sx?

A

Localized pain/pressure over high lateral wall of nose between eyes
- may radiate to orbit

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19
Q

Acute sphenoid sinusitis?

A

HA “in the middle of the head”

- pt often points to vertex

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20
Q

Acute frontal sinusitis

A

Tenderness of the forehead

- easily elicited by palpation

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21
Q

Hospital associated sinusitis

A

May be the cause of fever in critical pts

Associated w prolonged NG tube

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22
Q

PE for acute rhinosinusitis?

A

Pain in sinuses when bending forward

Direct percussion/palpation

Rhinoscopy

  • diffuse mucosal edema
  • narrowing/hypertrophy of middle meatus
  • septal deviation or polyps
  • purulent rhinorrhea
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23
Q

Imaging for acute rhinosinusitis?

A

Not really indicated but:

  • CT test of choice
  • NOT Xray
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24
Q

Tx of ABRS

A

Basically same as AVRS

Analgesics
Saline irrigation
Decongestants
Topical decongestants
Intranasal corticosteroids

Abx - (controversial in uncomplicated cases)

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25
Q

Abx for ABRS?

A

Amoxicillin-clavulante (first line)
PCN allergy (pick 1)
- doxy
- clinda

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26
Q

For ABRS never use?

A

Macrolides (azithromycin) or TMP/SMX due to high rates of resistance and poor sinus penetration

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27
Q

Which pts get abx for ABRS?

A

> 10 days
Severe symptoms
Symptoms worsen after period of improvement

If <7 days; symptomatic tx only

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28
Q

Complications of ABRS?

A

Orbital cellulitis
Osteomyelitis
- “pott puffy tumor”
Intracranial extension (rare)

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29
Q

If you suspect orbital cellulitis you should?

A

Get a CT
IV abx
Surgery
Stat opthalmology consult

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30
Q

Intracranial extension pts need?

A

MRI of the Danger triangle

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31
Q

What is intracranial extension?

A 
Hematogenous spread as in cavernous sinusthrombosis and meningitis 
Sx
- opthalmoplegia
- chemosis
- visual loss
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32
Q

Intracranial extension can have direct extension. What does this mean?

A

Can become epidural and intraparenchymal brain abscess

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33
Q

When to refer ABRS?

A 
Failure to respond to abx
Suspected extension outside sinus
Facial cellulitis 
Proptosis
Immunocompromised pts
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34
Q

What is nasal vestibulitis/S. Aureus nasal colonization

A

Infection caused by colonization of S. Aureus (MC)

Beware the danger triangle

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35
Q

Tx for nasal colonization?

A

Dicloxacillin 250mg qid 7-10 days

Mupirocin nasally

Chlorhexidine facial wash bid

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36
Q

Invasive fungal sinusitis is aka?

A

Rhinocerebral mucormycosis

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37
Q

What is invasive fungal sinusitis?

A

Aspergillus or similar in the vascular space causing tissue necrosis

Found it your immunocompromised pts

  • DM
  • long term corticosteroids
  • mustache wearing
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38
Q

Sx of invasive fungal sinusitis?

A

Similar to abrs though pain is more severe

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39
Q

Rhinocerebral mucormycosis can lead to?

A

Brain infection

  • cavernous sinus thrombosis
  • seizures
  • thrombotic stroke
40
Q

Tx for invasive fungal sinusitis?

A

Amphotericin B

Surgery

41
Q

Mortality rate for invasive fungal sinusitis?

A

DM - 20%
Kidney disease - >50%
Aids - 100%

42
Q

Allergic rhinitis

A

You should know

But presence of allergen-specific IgE

43
Q

MC cause of allergic rhinitis?

A

Pollens and spores

  • flowering
  • grass
  • ragweed
  • dust
  • pollution

Often (though not always) seasonal

44
Q

Allergic rhinitis PE?

A 
General
- allergic shiners 
Nose
- pale/violaceous turbinates
- nasal polyps
- rhinorrhea
- allergic salute
Oropharynx
- cobblestoning

Pics on 40-42

45
Q

When treating allergies remind pts that tx may?

A

Take 2+ weeks to work

46
Q

Common nasal allergy meds (corticosteroids)?

A 
Beclomethasone
Flunisolide
Mometasone furoate
Budesonide
Fluticasone propionate
47
Q

Oral allergy meds? (H1 blockers)

A

Non sedating

  • loratadine
  • desloratadine
  • fexofenadine

Minimally sedating
- cetrizine

Sedating

  • brompheniramine
  • chlorpheniramine

Nasal spray
- azelastine

48
Q

Adjunctive measures for allergy tx?

A

Antileukotriene: montelukast

Mast cell stabilizer: cromolyn sodium and sodium nedocromil

49
Q

For extremely bothersom allergy symptoms what test can be done?

A

Radioallergosorbent test (RAST)

By an allergy doc

50
Q

Nonallergic rhinitis?

A

Nasal symptoms caused by non allergic things

  • Gustatory rhinitis
  • Rhinitis medicamentosa
  • Vasomotor rhinitis
  • Occupational rhinitis
51
Q

rhinitis medicamentosa?

A

Chronic inflammatory condition caused by too much topical decongestants
- afrin

Leads to rebound nasal congestion

52
Q

Tx for rhinitis medicamentosa?

A

Cessation of med

Withdrawl meds

  • flunisolide
  • ipratropium
  • PO prednisone
  • NSAID
53
Q

Essentials of diagnosis for olfactory dysfunction?

A
  • Subjective diminished smell/taste
  • lack of objective nasal obstruction
  • objective decrease in olfaction demonstrated by testing
54
Q

MCC of olfactory dysfunction?

A

Anatomic blockage

55
Q

PE for olfactory dysfunction?

A

Nose
Nervous system CN1
UPSIT - university of pennsylvania smell ID test

56
Q

Tx for olfactory dysfunction

A

Depends:

  • Obstruction - surgery
  • Primary disruption of olfaction - no tx
57
Q

Greatest predictor fo recovery of olfactory dysfunction?

A

Degree of hyposmia is the greatest predictor of recovery

58
Q

If your pt has permanent hypsoma you need to?

A

Counsel them about

  • over seasoning
  • abuse of table salt
  • safety (smoke etc)
59
Q

Epistaxis?

A

Nose bleed

Bleeding from unilateral anterior nasal cavity

60
Q

Most epistaxis can be treated with?

A

Direct pressure x 15 min

Can go to

  • Sympathomimetics
  • Nasal tamponade methods
61
Q

Posterior, bilateral or large volume epistaxis needs?

A

Triage immediately to specialist in critical care setting

62
Q

Causes of epistaxis?

A 
Trauma
Rhinitis
Dry mucosa (low humidity, o2 therapy)
Deviated septum
HTN, 
atherosclerosis 
hereditary diseases 
Nasal drugs
Anticoagulation meds
63
Q

Why are posterior bleeds more severe?

A

The arterial supply is bigger - woodruffs plexus

- usually associated w HTN, atherosclerosis

64
Q

Tx for anterior nosebleed

A
  1. Direct pressure x 15 min
  2. Inspect then try nasal decongestant (spray)
  3. Reapply decongestant or cocaine
    - also can cauterize w silver nitrate or electrocautery
  4. Nasal packing
65
Q

Instructions for packing the nose?

A

Slide 59, there are pics

66
Q

Tx of posterior nose bleed?

A

Pneumatic tamponade
Nasal packing
Double balloon pack
Surgical ligation

Admission and monitoring

67
Q

If packing nose you need?

A

Antistaphy abx to prevent toxic shock syndrome

68
Q

What do the nose and bladder have in common?

A

Both can use the foley catheter

- different uses though

69
Q

What is the dual balloon tamponading system?

A

Sweet nose tube with 2 ballons
- can pack posterior and anterior chamber

Pic on 63

70
Q

If bleeding goes beyond 15 min?

A

Take to local ED

71
Q

Complications of epistaxis?

A 
Complications:
§ Severe bleeding, syncope
§ Hypoxia, hypercarbia
§ Sinusitis, otitis	media
§ Tissue necrosis
§ Toxic Shock Syndrome (TSS):	If	sudden	nausea,	vomiting, fever,	erythrodermic rash
72
Q

MC fractured bone in body?

A

Nasal fracture

73
Q

With nasal fx you need to ensure?

A

No palpable step-off of the infraorbital rim (zygomatic compelx fx)

No infraorbital numbness

74
Q

What is a septal hematoma

A

Blood clot between perichondrium and cartilage

75
Q

Risk with septal hematoma?

A

Septal necrosis leading to perforation

Untreated leads to loss of cartilage and saddle nose deformatiy

76
Q

Septal hematoma must be?

A

Incised and drained on both sides

77
Q

Tx for nasal trauma?

A

Goal - ensure patent airway

There are more thoughts and ideas about tx varying by condition on slide 68 (sorry john, i know you hate these)

78
Q

What is Le Fort?

A

A system for describing complex mid face fx

Le Fort 1
Le Fort 2
Le fort 3

79
Q

Problem with le forte classification?

A

Many complex fx do not conform to such classifications and have comminution, additional levels or lines of fx

80
Q

Le fort levels?

A

Le fort I - horizontal maxillary fx

Le fort II - pyramidal maxillary fx

Leforte III - craniofacial dysjunction

Pic on 72

81
Q

Tumors and granulomatous disease includes?

A

Benign nasal tumors

  • nasal polyps
  • inverted papilloma

Malignant nasopharyngeal and paranasal sinus tumors

Sinonasal inflammatory disease
- granulomatosis w polyangiitis and sarcoidosis

82
Q

What are nasal polyps?

A

Pale, yellow, endematous, mucosally covered masses commonly associated w allergic rhinitis

  • chronic nasal obstruction and hyposmia
83
Q

Traid asthma or samter triad?

A

Nasal polyps
Asthama
Aspirin sensitivity
- may precipate severe episode of bronchospasm

84
Q

If nasal polyps are found in a child?

A

R/o cystic fibrosis

85
Q

Tx for benign nasal polyps?

A

1-3 mo nasal steroids
Prednisone 6 day taper
Surgery

86
Q

Inverted or schneiderian papillomas are caused by?

A

Human papillomavirus (HPV)

87
Q

Inverted or schneiderian papillomas are?

A

Cauliflower-like growths in or around the middle meatus that cause:
- Unilateral nasal obstruction and occasional hemorrhage

88
Q

Tx for Inverted or schneiderian papillomas?

A

Excision - Medial maxillectomy

F/u - 20% recurrence

89
Q

Benign nasal polyps are associated w?

A

10% are squamous cell carcinoma

90
Q

Symptoms of malignant nasopharyngeal and paranasal sinus tumors?

A

Often asymptomatic until late

Early - non-specific (rhinitis/sinusitis)
Late - after invasion of adjacent areas
- proptosis, pain/expansion of cheek or ill-fitting maxillary dentures

91
Q

Dx for malignant nasopharyngeal and paranasal sinus tumors?

A

Biopsy

MRI to plan surgery

92
Q

Granulomatosis w polyangiitis (wegeners) is?

A

rare blood vessel disease
- 90% involve nose and paranasal sinus

PE: Bloodstained crusts and friable mucosa.

Biopsy: Necrotizing granulomas and vasculitis

93
Q

Sarcoidosis is?

A

Multisystem granulomatous disorder that can involve nose and paranasal sinus

PE: turbinates engorged w small white granulomas

Biopsy: noncaseating granulomas

94
Q

What is polymorphic reticulosis?

A

Lethal midline granuloma
- not well understood (lymphoma maybe)

PE: may include extensive bone destruction

Biopsy: nasal T-cell or NK-cell lymphoma

95
Q

Slide 81

A

The red is pance stuff

The rest is important stuff i guess

96
Q

What do you call someone with no body and no nose?

A

Nobody knows

Senior - ENT (8 decks)

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