Allergic Rhinitis, Tinnitus, Urticaria Flashcards
What is barotrauma
Damage to the ear due to pressure differences between the middle ear and outside world
What is the treatment for barotrauma?
Time/patience
Swallowing, valsalva, chew gum
Decongestants
Avoiding flying/diving
What is the other name for acoustic neuroma?
Vestibular schwannoma
What is acoustic neuroma?
Schwann cell tumors that arise from the vesitibular portion of CN VIII.
Slow growing
What is the classic presentation of acoustic neuroma?
Unilateral sensorineural hearing loss
Unilateral tinnitus
+/- gait disturbance or other CN involvement
What is the best initial screening test for an acoustic neuroma?
Audiometry (hearing test)
What is the treatment for acoustic neuroma?
Surgery
Radiation
Observation- grows slow
What percentage of people with tinnitus report interference with daily activities?
25%
What is tinnitus?
Perception of sound in one or both ears
What is the common etiology for pulsatile tinnitus?
Vascular (could be an aneurysm)
When does tinnitus need to be referred to ENT?
If it’s pulsatile
Should you auscultation for bruits in patients with possible vascular tinnitus/.
Yes
What is the goal of tinnitus treatment?
Lessen awareness and impact on quality of life
What are some of the treatments for tinnitus?
Behavioral therapy
Benzos
Masking devices “white noise” machines
Is tinnitus associated with anxiety and depression?
Yes
What are the 3 types of rhinitis?
Allergic rhinitis
Vasomotor rhinitis
Infection rhinitis
What is the key characteristic of allergic rhinitis?
Attacks of sneezing, rhinorrhea, and nasal obstruction
Often accompanies by itchy eyes/nose/mouth
When is the peak incidence of allergic rhinitis?
Childhood/adolescence
What is the pathophysiology of allergic rhinitis?
IgE antibodies sensitize mast cells who are then primed, and freak out on the SECOND exposure to the allergen
What would you see in the periorbital area of a pt with allergic rhinitis?
Allergic shiners
Denie-Morgan lines:skin folds under eyes consistent with allergic conjunctivitis
What would you see in the eyes of a pt with allergic rhinitis?
Palpebral conjunctiva may be pale and swollen
May see conjunctival injection (red eyes)
What would you see in the nose of someone with allergic rhinitis?
Pale, boggy, bluish mucosa**
clear discharge
What would you see in the throat of someone with allergic rhinitis?
Post nasal drainage
“Cobblestoning”
Can systemic medications cause rhinorrhea?
Yes
Meds like alpha-adrenergic blockers, viagra, etc
Can pregnancy cause rhinitis?
Yes, hormone induced
How do you diagnose allergic rhinitis?
Clinically**
Allergy testing helpful but not necessary
What are the two types of allergy testing?
- ) Skin testing-scratch/prick
2. )Serum testing- “ImmunoCAP”
What are the pros and cons of Skin testing for allergies?
PROS:
“Wheal and flare” reactions happen quickly 15-20 min
Cheap
CONS:
Could cause anaphylactic reaction
What are the pros and cons of serum testing for allergies?
PROS:
Detects allergen-specific IgE antibodies
Less risk for anaphylaxis
CONS:
Expensive
Less sensitive
What is a positive “wheal and flare” reaction in a skin allergy test?
The wheal is the same size or bigger than the histamine control, OR it is 3mm
What is the treatment for allergic rhinitis?
Avoidance of allergens
Pharmacotherapy
Immunotherapy (allergy shots)
What is the best way to avoid allergens from cats/dogs/etc
Removing the animal from the home. May take 3-6 months for all the animal particles to clear
What part of the animal are people usually allergic to?
Dander, saliva and urine
Not usually hair
If a patient can not part with their pet that they’re allergic to, what should they do?
Keep it outdoors
Wash it
What are the pharmacotherapy options for allergic rhinitis in children under 2
Cromolyn sodium nasal spray
2nd gen antihistamines- cetrizine and fexofenadine approved for childern over 6 months
What pharmacotherapy is recommended for Mild symptoms of allergic rhinitis or episodic symptoms related to a predictable exposure?
2nd gen oral antihistamines
Antihistamine nasal sprays
Glucocorticoid nasal sprays-start 2-3 days prior to exposure
Cromolyn nasal spray
What are some antihistamine nasal sprays?
Azelastine (Astelin) >5 yrs old
Olopatadine (Patanase) >12 yrs old
What are some 2nd gen oral antihistamines?
Loratadine (Claritin)
Cetirizine (Zyrtec)
Fexofenadine (Allegra)
What is the 1st line treatment for patients with moderate-severe allergic rhinitis?***
Glucocorticoid nasal sprays
Most effective single agent, few side effects
What are some glucocorticoid nasal sprays?
1st gen: Beclomethasone (Beconase) Flunisolide (Nasolide) Triamcinolone (Nasocort) Budesonide (Rhinocort)
2nd gen: Fluticasone proprionate (Flonase) Fluticasone furoate (Veramyst) Mometasone (Nasonex) Ciclesonide (Omnaris)
What is the benefit of 2nd gen glucocorticoid nasal sprays over 1st gen?
Less risk of systemic side effects
If a patient has allergic rhinitis AND asthma, what else should they add to their treatment regimen?
Montelukast (Singulair)
If a patient has allergic rhinitis AND allergic conjunctivitis,what else should they take with their glucocorticoid nasal spray?
Ophthalmic antihistamine drops
Can patients with glaucoma or cataracts use nasal steroid sprays?
No, can worsen these conditions
What should be done if a patient with mod-sever allergic rhinitis does not respond to steroid nasal sprays?
Add a second agent: Antihistamine nasal spray Oral antihistamine Cromolyn Montelukast (Singulair) Oral antihistamine/decongestant combo (allegra-d, sudafed-d, etc)
What are some first generation antihistamines?
Chlorpheniramine
Diphenhydramine
Do antihistamines relieve nasal congestion?
NO
Help w sneezing, rhinorrhea and itching only
What are the side effects of 1st gen antihistamines?
Dry mouth
Constipation
Sedation
What is the benefit of 2nd generation antihistamines?
Less sedating
No more effective than 1st gen
Who should get sympathomimetics (decongestants)?
Patients with marked nasal congestion despite antihistamine use.
Vasoconstriction will decrease edema and secretions
What is a sympathomimetic you can give for patients with nasal congestion despite using antihistamine?
Pseudoephedrine (sudafed) 30-60mg q6-8h or 120mg BID for sustained release
Who should you be careful about recommending a sympathomimetic for nasal congestion?
Patients with hypertension or cardiac disease
How do allergy shots (immunotherapy) work?
Administration of gradually increasing amounts of allergen
Multiple, regularly scheduled visits over 3-5 years
WHat is another name for non-allergic rhinitis?
Vasomotor rhinitis
What is non-allergic rhinitis?
Abnormal autonomic response triggered by stress, sexual arousal, PERFUMES, cigarette smoke, temperature changes
If a patient is always bitching about perfume making their nose run (not sneezing or itching though) what do you think they have
Non-allergic rhinitis
What are the symptoms of non-allergic rhinitis?
Nasal congestion
Rhinorrhea
Post-nasal drainage
NO eye or nose itching
NO sneezing
What are the treatments for vasomotor/non-allergic rhinitis?
Avoidance of triggers
Nasal glucocorticoids
Antihistamine nasal sprays (anticholinergic effect)
Apratropium nasal spray-if rhinorrhea is the prominent symptom
Also can use oral decongestants and FIRST generation oral antihistamines
What is Samter’s triad?
- Allergic rhinitis
- Vasomotor rhinitis
- Chronic sinusitis
- Asthma
COnditions associated with nasal polyps
What are nasal polyps?
Pedunculated, painless, gray soft tissue growths
What is the treatment for nasal polyps?
Nasal glucocorticoids **
Refer to ENT if obstructive
What is rhinitis medicamentosa?
Swollen and erythematous mucous membranes causing rebound congestion due to >3 days of OTC decongestant nasal spray (Afrin)
What is the treatment for rhinitis medicamentosa?
Discontinue Afrin
Start nasal steroid spray
When would you use ipratropium spray for non-allergic/vasomotor rhinitis?
If rhinorrhea is the predominant symptom
What is urticaria?
“Hives”
Circumscribed, raised wheals, pale to bright red, intensely pruritic, transient lesions
What is the difference between acute and chronic urticaria?
Acute: present less than 6 wks
Chronic: s/s recurring most days for more than 6 weeks
WHat is the hallmark trait of urticaria lesions?
Individual lesions are transient and will disappear within 24 hours
What kind of cells mediate urticaria?
Cutaneous mast cells releasing histamine in superficial epidermis**
WHat else may accompany urticaria?
Angioedema (swelling deeper in the skin, usually the face, lips, extremities, or genitals)
How do morphine, codeine, and radiocontrast agents cause urticaria?s
Direct mast cell activation
What should you do if your pt comes to you saying they had urticaria but the lesions are now gone?
Show them pictures of hives and ask them if it looked like that
What is urticarial vasculitis?
Fixed red plaques that are PAINFUL, have BLANCHING HALOS, and last LONGER than 24 hours.
Leave residual hyperpigmentation and are linked with lupus.
*may be confused with regular urticaria
What is the treatment for urticaria?
H1 histamine blockers- 2nd generation antihistamines Gold standard
H2 histamine blockers in combo with above- Zantac, Pepcid, etc . Even though they don’t have heartburn, they block both histamine receptors
Oral steroids if angioedema is present or they have persistent symptoms
Which 2nd generation antihistamines are most effective for urticaria?**
Cetrizine (Zyrtec) and levocetirizine (Xyzal) due to mast-cell stabilizing properties. More effective for skin stuff
