4 - Nose Flashcards
Nose hole anatomy
Slide 5, 6, 7, 8
Ostiomeatal complex (OMC)
Channel that links the frontal sinus, anterior ethmoid air cells and maxillary sinus to the middle meatus, allowing air flow and mucocilary drainage
Essentials of diagnosis for acute viral rhinitis?
Clear rhinorrhea
Hyposmia
Nasal congestion
Malaise
HA
Cough
Erythematous engorged nasal mucosa
W/o intranasal purulence
How long does the common cold last?
Generally 3-10 days but symptoms should be better in
- 10 days to 4 weeks
Self limited
Fever with viral rhinitis?
Not common
Complications for viral rhinitis?
Usually
- Benign and self limited
ETD
Otitis media w effusion
Acute bacterial sinusitis
Tx for acute viral rhinitis?
Z pack
Jk dont do that
Symptomatic or zinc (75mg) (controversial)
- nasal irrigation
- decongestants
Acute bacterial rhinosinuitis (ABRS) essentials?
Purulent yellow/green discharge/expectorant
Facial pain/pressure
Nasal obstruction
Acute onset
What causers ABRS?
Impaired mucociliary clearance and obstruction of the ostiomeatal complex
Oatmeal complex is clogged
This gets infected in the sinuses
Predisposing symptoms for ABRS?
URI
Allergies
Mechanical obstruction (deviated septum)
MC community and hospital acquired bacteria for ABRS?
Community:
- S pneumonia
- H influenzae
Hospital:
- pseudomonas
- S. Aureus
Presentation of ABRS?
Facial pain/pressure Fever Cough Hyposmia/anosmia Purulent nasal discharge Nasal congestion Maxillary tooth discomfort
ABRS vs AVRS?
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
Classification of ABRS?
Acute <4 weeks
Subacute: 4-12 wks
Chronic: >12 wks
Recurrent: >/= 4 per yr
MC paranasal sinusitis?
Acute maxillary sinusitis
Acute maxillary sinusitis specific sx?
- Unilateral facial fullness
- tenderness over cheeks
Can mimic Acute maxillary sinusitis pain?
Tooth infection can refer to the maxillary sinus via CN V
Acute ethmoid sinusitis sx?
Localized pain/pressure over high lateral wall of nose between eyes
- may radiate to orbit
Acute sphenoid sinusitis?
HA “in the middle of the head”
- pt often points to vertex
Acute frontal sinusitis
Tenderness of the forehead
- easily elicited by palpation
Hospital associated sinusitis
May be the cause of fever in critical pts
Associated w prolonged NG tube
PE for acute rhinosinusitis?
Pain in sinuses when bending forward
Direct percussion/palpation
Rhinoscopy
- diffuse mucosal edema
- narrowing/hypertrophy of middle meatus
- septal deviation or polyps
- purulent rhinorrhea
Imaging for acute rhinosinusitis?
Not really indicated but:
- CT test of choice
- NOT Xray
Tx of ABRS
Basically same as AVRS
Analgesics Saline irrigation Decongestants Topical decongestants Intranasal corticosteroids
Abx - (controversial in uncomplicated cases)
Abx for ABRS?
Amoxicillin-clavulante (first line)
PCN allergy (pick 1)
- doxy
- clinda
For ABRS never use?
Macrolides (azithromycin) or TMP/SMX due to high rates of resistance and poor sinus penetration
Which pts get abx for ABRS?
> 10 days
Severe symptoms
Symptoms worsen after period of improvement
If <7 days; symptomatic tx only
Complications of ABRS?
Orbital cellulitis
Osteomyelitis
- “pott puffy tumor”
Intracranial extension (rare)
If you suspect orbital cellulitis you should?
Get a CT
IV abx
Surgery
Stat opthalmology consult
Intracranial extension pts need?
MRI of the Danger triangle
What is intracranial extension?
Hematogenous spread as in cavernous sinusthrombosis and meningitis Sx - opthalmoplegia - chemosis - visual loss
Intracranial extension can have direct extension. What does this mean?
Can become epidural and intraparenchymal brain abscess
When to refer ABRS?
Failure to respond to abx Suspected extension outside sinus Facial cellulitis Proptosis Immunocompromised pts
What is nasal vestibulitis/S. Aureus nasal colonization
Infection caused by colonization of S. Aureus (MC)
Beware the danger triangle
Tx for nasal colonization?
Dicloxacillin 250mg qid 7-10 days
Mupirocin nasally
Chlorhexidine facial wash bid
Invasive fungal sinusitis is aka?
Rhinocerebral mucormycosis
What is invasive fungal sinusitis?
Aspergillus or similar in the vascular space causing tissue necrosis
Found it your immunocompromised pts
- DM
- long term corticosteroids
- mustache wearing
Sx of invasive fungal sinusitis?
Similar to abrs though pain is more severe
Rhinocerebral mucormycosis can lead to?
Brain infection
- cavernous sinus thrombosis
- seizures
- thrombotic stroke
Tx for invasive fungal sinusitis?
Amphotericin B
Surgery
Mortality rate for invasive fungal sinusitis?
DM - 20%
Kidney disease - >50%
Aids - 100%
Allergic rhinitis
You should know
But presence of allergen-specific IgE
MC cause of allergic rhinitis?
Pollens and spores
- flowering
- grass
- ragweed
- dust
- pollution
Often (though not always) seasonal
Allergic rhinitis PE?
General - allergic shiners Nose - pale/violaceous turbinates - nasal polyps - rhinorrhea - allergic salute Oropharynx - cobblestoning
Pics on 40-42
When treating allergies remind pts that tx may?
Take 2+ weeks to work
Common nasal allergy meds (corticosteroids)?
Beclomethasone Flunisolide Mometasone furoate Budesonide Fluticasone propionate
Oral allergy meds? (H1 blockers)
Non sedating
- loratadine
- desloratadine
- fexofenadine
Minimally sedating
- cetrizine
Sedating
- brompheniramine
- chlorpheniramine
Nasal spray
- azelastine
Adjunctive measures for allergy tx?
Antileukotriene: montelukast
Mast cell stabilizer: cromolyn sodium and sodium nedocromil
For extremely bothersom allergy symptoms what test can be done?
Radioallergosorbent test (RAST)
By an allergy doc
Nonallergic rhinitis?
Nasal symptoms caused by non allergic things
- Gustatory rhinitis
- Rhinitis medicamentosa
- Vasomotor rhinitis
- Occupational rhinitis
rhinitis medicamentosa?
Chronic inflammatory condition caused by too much topical decongestants
- afrin
Leads to rebound nasal congestion
Tx for rhinitis medicamentosa?
Cessation of med
Withdrawl meds
- flunisolide
- ipratropium
- PO prednisone
- NSAID
Essentials of diagnosis for olfactory dysfunction?
- Subjective diminished smell/taste
- lack of objective nasal obstruction
- objective decrease in olfaction demonstrated by testing
MCC of olfactory dysfunction?
Anatomic blockage
PE for olfactory dysfunction?
Nose
Nervous system CN1
UPSIT - university of pennsylvania smell ID test
Tx for olfactory dysfunction
Depends:
- Obstruction - surgery
- Primary disruption of olfaction - no tx
Greatest predictor fo recovery of olfactory dysfunction?
Degree of hyposmia is the greatest predictor of recovery
If your pt has permanent hypsoma you need to?
Counsel them about
- over seasoning
- abuse of table salt
- safety (smoke etc)
Epistaxis?
Nose bleed
Bleeding from unilateral anterior nasal cavity
Most epistaxis can be treated with?
Direct pressure x 15 min
Can go to
- Sympathomimetics
- Nasal tamponade methods
Posterior, bilateral or large volume epistaxis needs?
Triage immediately to specialist in critical care setting
Causes of epistaxis?
Trauma Rhinitis Dry mucosa (low humidity, o2 therapy) Deviated septum HTN, atherosclerosis hereditary diseases Nasal drugs Anticoagulation meds
Why are posterior bleeds more severe?
The arterial supply is bigger - woodruffs plexus
- usually associated w HTN, atherosclerosis
Tx for anterior nosebleed
- Direct pressure x 15 min
- Inspect then try nasal decongestant (spray)
- Reapply decongestant or cocaine
- also can cauterize w silver nitrate or electrocautery - Nasal packing
Instructions for packing the nose?
Slide 59, there are pics
Tx of posterior nose bleed?
Pneumatic tamponade
Nasal packing
Double balloon pack
Surgical ligation
Admission and monitoring
If packing nose you need?
Antistaphy abx to prevent toxic shock syndrome
What do the nose and bladder have in common?
Both can use the foley catheter
- different uses though
What is the dual balloon tamponading system?
Sweet nose tube with 2 ballons
- can pack posterior and anterior chamber
Pic on 63
If bleeding goes beyond 15 min?
Take to local ED
Complications of epistaxis?
Complications: § Severe bleeding, syncope § Hypoxia, hypercarbia § Sinusitis, otitis media § Tissue necrosis § Toxic Shock Syndrome (TSS): If sudden nausea, vomiting, fever, erythrodermic rash
MC fractured bone in body?
Nasal fracture
With nasal fx you need to ensure?
No palpable step-off of the infraorbital rim (zygomatic compelx fx)
No infraorbital numbness
What is a septal hematoma
Blood clot between perichondrium and cartilage
Risk with septal hematoma?
Septal necrosis leading to perforation
Untreated leads to loss of cartilage and saddle nose deformatiy
Septal hematoma must be?
Incised and drained on both sides
Tx for nasal trauma?
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)
What is Le Fort?
A system for describing complex mid face fx
Le Fort 1
Le Fort 2
Le fort 3
Problem with le forte classification?
Many complex fx do not conform to such classifications and have comminution, additional levels or lines of fx
Le fort levels?
Le fort I - horizontal maxillary fx
Le fort II - pyramidal maxillary fx
Leforte III - craniofacial dysjunction
Pic on 72
Tumors and granulomatous disease includes?
Benign nasal tumors
- nasal polyps
- inverted papilloma
Malignant nasopharyngeal and paranasal sinus tumors
Sinonasal inflammatory disease
- granulomatosis w polyangiitis and sarcoidosis
What are nasal polyps?
Pale, yellow, endematous, mucosally covered masses commonly associated w allergic rhinitis
- chronic nasal obstruction and hyposmia
Traid asthma or samter triad?
Nasal polyps
Asthama
Aspirin sensitivity
- may precipate severe episode of bronchospasm
If nasal polyps are found in a child?
R/o cystic fibrosis
Tx for benign nasal polyps?
1-3 mo nasal steroids
Prednisone 6 day taper
Surgery
Inverted or schneiderian papillomas are caused by?
Human papillomavirus (HPV)
Inverted or schneiderian papillomas are?
Cauliflower-like growths in or around the middle meatus that cause:
- Unilateral nasal obstruction and occasional hemorrhage
Tx for Inverted or schneiderian papillomas?
Excision - Medial maxillectomy
F/u - 20% recurrence
Benign nasal polyps are associated w?
10% are squamous cell carcinoma
Symptoms of malignant nasopharyngeal and paranasal sinus tumors?
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
Dx for malignant nasopharyngeal and paranasal sinus tumors?
Biopsy
MRI to plan surgery
Granulomatosis w polyangiitis (wegeners) is?
rare blood vessel disease
- 90% involve nose and paranasal sinus
PE: Bloodstained crusts and friable mucosa.
Biopsy: Necrotizing granulomas and vasculitis
Sarcoidosis is?
Multisystem granulomatous disorder that can involve nose and paranasal sinus
PE: turbinates engorged w small white granulomas
Biopsy: noncaseating granulomas
What is polymorphic reticulosis?
Lethal midline granuloma
- not well understood (lymphoma maybe)
PE: may include extensive bone destruction
Biopsy: nasal T-cell or NK-cell lymphoma
Slide 81
The red is pance stuff
The rest is important stuff i guess
What do you call someone with no body and no nose?
Nobody knows
