Acute Rhinosinusitis and Common Cold

Question 1

Symptoms of acute bacterial rhinosinusitus

Answer 1

fever, nasal congestion/obstruction, purulent nasal discharge, maxillary tooth discomfort, facial pain/pressure that worsens with bending foward

Question 2

Diagnosis of acute bacterial rhinosinusitis

Answer 2

persistent sx >10 days without improvement

severe sx: high fever >102.2,

purulent nasal discharge,

facial pain >3 days,

worsening sx >5 days after initially improving viral upper resp infection

Question 3

treatment for acute bacterial rhinosinusitis

Answer 3

1st line therapy amoxicillin clavulanate alternate: doxycycline or fluoroquinolones supportive care : analgesic,s decongestants, saline irrigation topical steroids

Question 4

Which abx to avoid prescribing for acute bacterial rhinosinusitis?

Answer 4

amoxicillin, macrolides, Bactrim or 2nd or 3rd gen cephalosporins

Question 5

most common cause of acute sinusitis?

Answer 5

common cold

Question 6

does acute viral rhinosinusitis need abx?

Answer 6

no. improve after 7 days or by 10 days with supportive care.

Question 7

what is supportive care for rhinosinusitis?

Answer 7

analgesics, saline irrigation, topical decongestants, topical steroids.

Question 8

time frame to treat someone with flu with oseltamivir?

Answer 8

only within 48 hrs of symptom onset.

Question 9

major causes of rhinitis

Answer 9

Question 10

what is rhinitis

Answer 10

inflammation of mucous membranes of the nose

Question 11

what is vasomotor rhinitis and what causes it?

Answer 11

from swelling of the blood vessels in nose causing congestion and runny nose. Not sure why this happens

Onset is 20-45 yrs and perennial symptoms, lack itchy eyes, nose. no atopic symptoms

Question 12

Allergic rhinitis is

Answer 12

perennial and associated with seasons.

seen with eye and nasal itching.

Has onset before age 20 yrs.

1st line treatment of glucocorticoid nasal sprays.

Question 13

how to relieve vasomotor rhinitis?

Answer 13

nasal corticosteroids - provides most consistent relief compared to an antihistamine.

More severe cases: nasal corticosteroids and nasal antihistamine. Nasal saline irrigation is recommended prior to use of nasal preparations to cleanse the mucous so that steroids are better absorbed.

Question 14

caution with using oral and nasal decongestants with individuals who have

Answer 14

HTN

Question 15

what is rhinitis medicamentosa? and how to avoid it?

Answer 15

this is rebound symptoms of rhinitis with prolonged use of nasal decongestants.

Nasal decongestants should only be used for 3 days before stopping.

Question 16

major causes of rhinitis (inflammation of mucous membranes)

Answer 16

non allergic (vasomotor)

allergic

occupational

rhinitis medicamentosa

pregnancy

systemic dx

systemic medication.

Question 17

when to consider if a patient has bacterial sinusitis?

Answer 17

symptoms have been >10 days and severe symptoms with fever >102,

purulent nasal discharge or facial pain >3 days

worsening symptoms >5 days after initailly improving viral upper respiratory system

Question 18

how to treat bacterial sinusitis?

if allergic to penillicin?

Answer 18

5-7 days of amoxcillin clavulanate for acute bacterial sinusitis in non pencillin allergic pts

Doxycycline and respiratory quinolones (levofloxacin and moxifloxacin) are alternatives for penicillin allergic pts.

Amoxicillin is not first choice due to resistance with Strep and H influenzae. Macrolides (azithromycin, clarithomycin, bactrim and 2nd and 3rd generation are not recommended as 1st line due to increasing resistance.

Question 19

If pt fails abx treatment for bacterial sinusitis what to give next?

Answer 19

high dose amoxicillin clavulanate 2000mg/125 mg or fluoroquinolones instead.

Question 20

most acute sinusitis or rhinosinusitis is from

Answer 20

viral infections and associated with common cold. Don’t treat with antibiotics.

Can have a secondary bacterial sinusitis after and this is seen with:

symptoms >10 days,

severe fever >102,

purulent nasal discharge or facial pain >3 days

worsening symptoms >5 days after an initially imporving viral upper respiratory infection.

Question 21

what causes rhinitis medicamentosa

Answer 21

overuse from OTC nasal decongestants sprays.

• Spray’s vasoconstrictive effect requires increasing amounts drug for symptomatic relief due to tachyphylaxis and leads to rebound vasodilation and swelling with rhinorrhea.

PTs use more nasal decongestant spray to relieve their symptoms and begins a cycle of congestion with temporary relief.

Pts can also get a emotional lift and become dependent on spray

Question 22

Diagnosis of rhinitis medicamentosa

Answer 22

history and physical exam with seeing swollen red nasal mucosa.

Treatment involves: medication cessation which can be difficult since pts experience worsening rebound symptoms. Some data shows that intranasal fluticasone for a few days may help alleviate the withdrawal nasal congestion. Some require steroids for severe withdrawal.

Can be prevented via using nasal decongestants for <5 days.

Question 23

chronic rhinisitis is defined as

how to treat this?

Answer 23

sinus congestion refractory to medical therapy for >12 weeks

tx with regular nasaline nasal lavage.

Question 24

allergic and non allergic rhinitis treatment

Answer 24

ipatropium nasal spray can help treat rhinorrhea related to this. WIll see sneezing and itchy eyes.

Question 25

Allergic rhinitis is

Answer 25

allergy related inflammation of the nasal mucosa

• affects large percentage of normal population.
• 1st line treatment is glucocorticoid nasal spray
• avoid antihistamines due to anticholinergic effect in older pts.
• 2nd line tx: second gen antihistamines if additional relief is needed.

symptoms are disturbing and can lower quality of life and impair sleep.

Question 26

allergic rhinitis diagnosis is

Answer 26

clinical and don’t need special testing but can get skin testing to detect allergens.

Question 27

best treatment of allergic rhinitis:

Answer 27

nasal corticosteroids. - fluticasone

The following are NOT first line:

nasal decongestants - Aftrin, Vicks (oxymetazoline, phenylephrine, pseudophedrine) - should be avoided due to de-sensitization and rebound symtpoms - can cause overuse and rhinitis medicamentosa

oral decongestants - Aftrin, Vicks (oxymetazoline, phenylephrine, pseudophedrine) effective but short periods and only decrease rhinorrhea and not nasal congestion (no impact on sneezing or itchy eyes and increase BP)

sedating and non sedating antihistamines - benadryl, zertec ( relieve symptoms but only for paroxysmal mild symptoms ) inferior to nasal steroids for moderate to severe symptoms in pts

Question 28

why are nasal decongestants not 1st line treatment for allergic rhinitis?

Answer 28

nasal decongestants - should be avoided due to de-sensitization and rebound symptoms - can cause overuse and rhinitis medicamentosa

pseudoephedrine

Question 29

why are oral decongestants not 1st line for treatment of allergic rhinitis?

Answer 29

oral decongestants - effective but short periods and only decrease rhinorrhea and not nasal congestion (no impact on sneezing or itchy eyes) AND they increase BP

Question 30

what medication is appropriate to use for mild or paroxysmal allergic rhinitis?

Answer 30

sedating and non sedating antihistamines- relieve symptoms but only for paroxysmal mild symptoms

nasal steroids for moderate to severe symptoms allergic rhinitis

Question 31

Corynebacterium diptheria infection presents as

Answer 31

sore throat with gray white tonsillar exudates (pseudomembrane)

See cervical LAD, fever, cutaneous ulcers

Infection can lead to neck and respiratory tract to cause respiratory distress and septic emboli are not seen.

Question 32

what is cervicofacial actinomycosis?

Answer 32

actinomyces is an anaerobic gram positive and filamentous branching bacteria that colonizes the oral cavity

seen with pts who have poor oral hygiene and it develops as a slowly growing non tender indurated mass that can form abscesses, fistulas, draining sinus tracts and has characteristic sulfur granules in infected tissues and extends through local tissues instead of lymphangitic or hematological spread

Question 33

actinomycosis can mimic other conditions

Answer 33

malignancy and TB infection or sarcoid

diagnosis is by tissue culture and actinomyces grows slowly (fastidious bug)

Question 34

treatment of actinomyces is

Answer 34

IV penicillin for 4-6 weeks initially

then 6 to 12 months of oral penicillin

if allergic to penicillin give clindamycin

surgical resection is needed in severe cases.

Question 35

allergic fungal sinusitis is

Answer 35

immune mediated dx that typically affects young immunocompetent adults with increased prevalence of allergic fungal sinusitis in Mississippi basin and South western US

see asthma, atopy, serum eosinophilia >1000,

See on CT scan: unilateral or asymmetric involvement of the sinuses and involvement of ethmoid sinus.

Management: is surgical debridement and immunotherapy with fungal and non fungal antigens

oral corticosteroids for up to 4-6 weeks and self cleansing or nasal irrigation by pt.

goal of therapy is remove eosinophilic mucin and elminate antigenic inciting factors.

Question 36

if needed for complicated or recurrent or refractory sinusitis, what imaging study is preferred?

Answer 36

Coronal CT study of sinuses

Question 37

Atrophic rhinitis presentation

Answer 37

Atrophic rhinitis: pt smells foul smelling odor that stems from loss of normal function of nose.

-seen in young /middle aged pts with girls at onset of puberty. -See nasal crusting, nasal congestion, and nasal pain with inspiration and smelling foul smell (fetor). High risk for atropic rhiniits if they’ve had multiple sinus surgeries and chronic nasal irrigations and infection of Klebiella

Tx with nasal saline and topical antibiotics may need surgery.

Allergic rhinitis - environmental triggers like dust, mold, and pollen.

Gustatory rhinitis - triggered by foods nad beverages. Hot and spicy foods trigger inflammation

Non allergic rhinitis - weather changes, medications, hormone changes, stress and exposure to smoke .

Question 38

how to treat cough related to acute rhinosinusitis?

Answer 38

most upper URI is caused by viral infections and spontaneously resolve

treat acute cough due to acute rhinosinusitis with intranasal glucocorticoids like fluticasone