Clin Med - Nasal Cavity Disorders Flashcards
Interesting nose facts (4)
-1 L mucus swallowed each day -nostrils take turns inhaling -most humans differentiate
Functions of the nose
-olfaction - CN I -humidification -protection -speech -respiration
Contents of the nasopharynx
-adenoid tissue (in children) -opening to eustachian tubes -opening to sphenoid sinus -opening to tear ducts -sinus drainage ports
Where are the opening to the tear ducts located within the nasopharynx?
inferior turbinate meatus
If adenoids are large in adults, what should you consider?
HIV
What areas make up the upper respiratory tract?
-nasal cavity -pharynx -larynx
Nares inspection on physical exam looks for what?
discharge, flaring, or narrowing
Flaring of the nares may indicate what?
respiratory distress
Narrowing of the nares may indicate what?
chronic nasal obstruction and mouth breathing
the nasal cavity opens posteriorly into the nasopharynx through what?
the choanae
Mucosa lines the nasal cavity with the exception of what area?
the nasal vestibule - it is lined with skin
Divisions of the nasal mucosa
-superior one third = olfactory area -inferior two thirds = respiratory area
What structure is contained w/i the olfactory area?
the peripheral organ of smell; sniffing draws air to this area
Normal appearance of the nasal mucosa
deep pink color (pinker than mouth mucosa)
Infection/inflammation has what effect on the nasal mucosa?
increased redness
Nasal mucosa appearance in allergies
-decreased color -pale -boggy turbinates **
What turbinates are visible upon examination?
usually only see the inferior, sometimes middle
Sinuses
Air-filled, paired extensions of the nasal cavities within the bones of the skull; only maxillary and ethmoid present at birth, by age 3 all present
Lining of sinuses and its purpose
• Lined with mucous membranes and cilia – Move secretions to passageways that drain into the nose • Openings are called ostia (narrow, tortous openings)
Function of the sinus mucosa
• Heats and humidifies inspired air • Wash the sinuses free of air pollutants, bacteria, dust and other substances
What are the only sinuses that you can examine on physical exam?
frontal and maxillary
maxillary sinuses
• Lateral wall of the nasal cavity in the maxillary bone underneath zygomatic arch • One each side of nose - symmetrical • Pear shaped with opening at top.
Where do the maxillary sinuses drain?
upwards to the middle meatus
Frontal sinuses
• Located in frontal bone superior to the nasal cavities (above eyebrows) • May be small or completely absent (5%) • Unique to each individual (could be asymmetrical)
Where do frontal sinuses drain?
middle meatus
Ethmoid sinuses
• Behind the frontal sinuses on lateral sides of nose at the bridge (medial to the eye) • Many small air containing cells of the ethmoid bone • Can be opacified in healthy adults (allergies) • Challenging to get to for surgery
Where do the ethmoid sinuses drain?
– Anterior ethmoids: to middle meatus – Posterior ethmoids: to superior meatus
Sphenoid sinuses
• Aka “forgotten” sinus • Deep w.i the skull behind ethmoid sinuses –Sits under pituitary (sella turcica) behind the nasopharynx under base of skull • Rarely infected (diabetics)
Where do the sphenoid sinuses drain?
to the sphenoethmoidal recess
If the sphenoid sinuses do become infected, where does the pain occur?
on top of the head
How do you view the sphenoid sinuses on imaging?
• Seen only on lateral sinus view x-rays (rare do we order these) or on CAT Scan
What are ancillary therapies to use along with nasal medications?
• Steam bath/shower • Nasal saline rinses (Neil Med) • Increased fluids (thins nasal secretions) • Vapor therapy • Humidifer • Nasal moisturizers (AYR gel)
NSAIDS as nasal meds
• Indications – Headache – Fever – Pain • Ibuprofen (Advil/Motrin) -decreases swelling of nasal turbinates
Guaifenesin
-GREAT! (mucinex) Class: mucolytic – Basis for many cold medicines – Improves flow (thins thick nasal mucus) – Decreases stasis – Acts as a sinus moisturizer – Need 800-1000mg per day to be effective ( I recommend Mucinex ES 1200 mg BID) – Must be well hydrated for this to be effective.
Antihistamines should only be used for what?
allergies
Actions of anithistamines
• Actions – Dry secretions – Impede flow • Causes drowsiness • May worsen symptoms
Examples of antihistamines
• Benadryl (diphenhydramine) Class 1 - most sedating • Claritin (loratadine), • Allegra (fexofenadine) • Zyrtec (cetirizine – can be given to age 6mos+) - most sedating of Class 2 • Clarinex, Xyzal (RX) • In almost all “cold” medications • Tell them to take at night.
Why do you avoid using antihistamines with a sinus infection?
They cause thickened secretions that grow bacteria
Systemic decongestants
– Symptomatic relief – Shrinks nasal mucosa – Pseudo-ephedrine 60 mg q 4-6 (IR) 120 mg q 12 hrs (ER) – Phenylephrine OTC
Side effects of systemic decongestants
• Tachycardia • Hypertension • Angina • Does not cause drowsiness
Nasal decongestants
– Afrin – Short-term use only - 3 days • Good before flights
Why nasal decongestants should only be used short term
• Rhinitis medicamentosa - rebound nasal congestion (alpha/beta receptors stimulate constriction/dilation - prolonged use ->beta>>vasodilation)
Systemic steroids
– Short course used for severe cases of allergies – Prednisone burst (60 mg QD x 5 days) – Medrol Dose pak
Nasal steroids
– Good for allergies!!!! BEST! – Treats edema and obstruction – Requires up to 2 weeks of consistent use to have effect – Dries nasal mucosa (point away from septum, can cause minor bleeding) – Some taste bad
Examples of nasal steroids
• Fluticasone (Flonase) - has generic, use the most, OTC • Mometasone (Nasonex) - OTC • Budesonide (Rhinocort) - water based, may less likely to cause epistaxis but $$ • Triamcinolone (Nasocort) • Beclomethasone (Beconase)
Nasal antihistamines
– Astelin, Patanase 2 sprays per nostril BID ( I use this for pt’s who complain of constant runny nose/drainage) – Used for allergic rhinitis and vasomotor rhinitis – Dymista (Flonase/Astelin combo)
Parasympathetic blocker
– Used for rhinorrhea associated with a URI or allergies – Nonallergic rhinitis - mostly why I write for this. – Atrovent nasal spray 2 sprays per nostril BID-TID
General guidelines for OTC meds
• Cold and allergy meds – Have antihistamines so be careful • Antihistamines cause drowsiness • Decongestants speed you up (including your heart rate and blood pressure) • Many cough syrups have alcohol • Need large dose of guifenesin to be effective • Meds don’t work if you don’t take them consistently
Sinusitis
• Inflammation of the paranasal sinuses due to viral, bacterial or fungal infection • Sinus mucosa is inflamed in 87% of viral URIs (upper respiratory infections) – Only 2% develop bacterial sinusitis
Relationship of sinusitis and URI in children
– 5-10% of URIs in early childhood are complicated by acute sinusitis – Suggested by the failure of the URI to improve after 7-10 days
If the inflammed mucosal lining of the sinuses d/t rhinitis becomes secondarily infected, what are the common causative organisms?
– Strep. Pneumoniae * – H. influenzae * – M. catarrhalis *
Less common causative organisms in bacterial sinusitis
• Group A strep • Anaerobes • Staph. Aureus usually in chronic sinusitis
Classifications of sinusitis
–Acute: <4 weeks –Subacute: 4 weeks to 3 months –Chronic: >3 months
Steps to acute sinusitis
1.Inflammation of nasal and paranasal cavities 2. Mucosal edema and decreased ciliary action 3. Obstruction of sinus drainage tract 4. Retention of secretions 5. Secondary bacterial infection 6. acute sinusitis
Allergic fungal sinusitis
• Form of chronic sinusitis characterized by diffuse nasal congestion, markedly viscid nasal secretions, and often nasal polyps
Allergic fungal sinusitis is an allergic response to what?
To the presence of topical fungi, often Aspergillus, not invasive.
Invasive fungal sinusitis
• Aggressive, sometimes fatal • Infection in immunocompromised patients • Aspergillus or Mucor species
Sx of sinusitis
– Nasal congestion – Purulent Nasal drainage – Facial pain/pressure – Tooth pain – Headache – Cough (night>day) – Halitosis – Fever – Chills – Malaise – Pharyngitis
Risk factors of sinusitis
•Allergic rhinitis, nasal polyps, immunocompromised states. •Main complication periorbital or orbital cellulitis, brain abscess.
S/S of maxillary sinusitis
Causes pain in maxillary area, toothache and frontal headache
S/S of frontal sinusitis
Pain in frontal area and frontal headache
S/S of ethmoid sinusitis
Pain behind and between the eyes, frontal headache described as splitting, periorbital cellulitis and tearing.
S/S of sphenoid sinusitis
Less well localized pain, referred to the frontal or occipital areas.
Dx of sinusitis
•Clinical/Physical examination and/or nasal endoscopy •Sometimes CT
Tx of sinusitis
•Local measures to enhance drainage • Steam, topical vasoconstriction, sinus irrigation,steroid sprays •Sometimes antibiotics
When to tx sinusitis w/ abx
• Mild to moderate symptoms > 10 days • Severe symptoms, fever, severe maxillary/facial/tooth pain >3-4 days • Worsening symptoms after improving URI
Chronic sinusitis
• Inflammation of the paranasal sinuses lasting >3 months
Etiology of chronic sinusitis
– Inadequate treatment of acute sinusitis (not long enough course, wrong abx) – Untreated nasal allergy – Anatomic abnormality (deviated septum) – Underlying dental disease – Same bugs as acute, think about culture
S/S of chronic sinusitis
(similar to acute but less severe) – Chronic nasal obstruction – Purulent nasal discharge – Pain over sinus or headache – Halitosis – Yellow-brown nasal discharge – Chronic cough – Maxillary dental pain
Dx of chronic sinusitis
•Physical examination, endoscopy, culture, CT
Tx of chronic sinusitis
– Normal antibiotic treatment of 7-10 days is usually not effective • Treat with antibiotic for 3-6 weeks ( I usually tx 21-30 days) – Nasal steroids – Mucolytics – +/- surgery
Allergic rhinitis
• Condition that includes runny nose, sneezing and nasal stuffiness • “Hay fever” • IgE mediated hypersensitivity reaction to foreign allergens
Allergic rhinitis onset
• Age at onset is usually <20: Most common cause of chronic nasal congestion in children • More common in those with a personal or family history of allergies
Factors that affect acute/seasonal allergic rhinitis
• Tree/plant/grass pollens in the spring • Ragweed in the fall • Lasts several weeks, disappears and recurs following year at same time
Factors that affect chronic/perennial allergic rhinitis
• Inhaled – Dust, mites, molds, animal dander, wool, feather, tobacco, hair, food • Ingested – Wheat, eggs, milk, nuts • Often confused with chronic colds – Can occur intermittently for years with no pattern or may be constantly present • Symptoms often aggravated by smoking, pollutants, and temperature/humidity changes
Sx of allergic rhinitis
– Runny nose – Sneezing – Nasal congestion – Bloody nose – Mouth breathing – Itching of nose – Red eyes – Itching of eyes – Snoring – Malaise – Frontal headache and pressure
Sign of allergic rhinitis seen in the nose
• Clear, watery nasal discharge – Contains eosinophils and occasionally blood • Nasal congestion • Nasal speech • Pale, bluish, edematous, boggy turbinates – D/t venous engorgement • “Allergic salute” crease at junction b/w cartilage and bone of the nose from constant itching and wiping
Signs of allergic rhinitis seen in the eyes
• Conjunctival injection • Clear, watery discharge • “Allergic shiners” – Dark circles under eyes, from venous engorgement and congestion
Tx of allergic rhinitis
– ID and avoid suspected allergens – Desensitization – Nasal irrigation with saline – Antihistamines (systemic/nasal) -Decongestants (Systemic/nasal) – Steroids (Systemic/nasal) – Parasympathetic blockers (nasal)
Nonallergic Rhinitis (vasomotor rhinitis)
• Exact cause unknown, not caused by infection or allergy • Hypersensitivity of nasal mucosa
Triggers of nonallergic rhinitis
– Temperature change • usually cold or dry air – Environmental causes • Air pollution- dust, smoke • Strong odors-perfumes, cleaning products – Alcohol – Certain medicines – Spicy foods- some just while eating – Psychological triggers • Stress, anxiety – Endocrine/hormonal conditions • Hypothyroidism, pregnancy, menopause
Sx of nonallergic rhinitis
– Runny nose – Congestion – Post nasal drainage – Pain/pressure over the face – Symptoms are often more severe than physical signs show
Signs of nonallergic rhinitis
– Clear, thin, watery rhinorrhea – Swollen turbinates
Dx of nonallergic rhinitis
– Commonly report that cigarette smoke, hairspray and perfume trigger symptoms – CT scan- to look for chronic sinus infection – Allergy testing- to rule out allergies – If both negative, highly suggestive of non allergic rhinitis
Tx of nonallergic rhinitis
– Avoid irritant – Parasympathetic blocker (Atrovent) – Nasal steroids – Exercise: Increases sympathetic tone-provides symptomatic relief
Danger of foreign body in nose
• Common in toddlers and children (ages 1-8) – Beans, button batteries, beads, pebbles, paper wads, eraser tips • Beans swell • Batteries can leak causing burns – must be removed IMMEDIATELY
S/S of foreign body in nose
– Purulent, foul smelling, unilateral** nasal discharge – Frequent sinusitis/URI not cleared w/ abx or symptomatic meds – Difficulty breathing through affected nare – Halitosis – Choking, wheezing, difficulty breathing or talking signifies the object has been aspirated into airway: - EMERGENCY – Always look in other side of nose and ears for other objects
Tx of foreign body
- use nasal decongestant, local anesthetic 2. blow nose w/ unaffected nare closed 3. hooked probe forceps 4. irrigation - have pt say “ing” to close off throat
Tx of foreign body w/ balloon catheter
Catheter put behind object and inflate balloon slightly, pull both catheter and object out
Tx of foreign body w/ suction catheter
Place suction catheter tip to object and increase suction to pull object out
Describe nasal polyps
- benign, soft growths in the lining of the nose - almost translucent - tend to reoccur - like a grape without skin
What disease are nasal polyps commonly found in
Samter’s Triad - aspirin sensitivity, asthma, polyps
what do nasal polyps respond well to
Nasal steroids - Flonase generally: helps keep polyps from reforming by reducing inflammation
When are nasal polyps more of a concern
<16 unilateral - suspect cystic fibrosis, run sweat chloride test
Symptoms of nasal polyps
- nasal obstruction - thick, discolored nasal drainage - facial pain - post-nasal drip - nasal-y voice - nasla congestion - anosmia
Physical symptoms of nasal polyps
- smooth, translucent, classy lesions - sometimes hang from narrow stalk - soft, mobile, contender to palpation - frequently multiple and bilateral
how to Dx nasal polyp
PE and nasal endoscopy
How to treat nasal polyps
- if asymptomatic: no treatment - systemic and nasal steroids: as bridge until surgery - severe sx: surgery but recurrence is common
what effect do nasal decongestants have on nasal polyps
none :)
Causes of nasal septal perforation
- chronic nasal steroids - chronic nasal decongestants - cocaine - septoplasty - nasal trauma - cancer - Wegner’s granulomatosis (autoimmune disease) - biopsy!
Nasal septal perforation sx
- nasal drainage with crusting - nasal bleeding - whistling when pt breathes
How to dx nasal septal perforation
PE or nasal endoscopy
How to treat nasal septal perforation
- nasal lubrication - septal button - surgical repair (difficult and failure to close is common)
Causes of deviated nasal septum
- congenital deformity - trauma *mild deviation or septal spur is pretty common
Sx of deviated nasal septum
- obstruction - frequent sinus infections - epistaxis - mouth breathing - snoring/sleep apnea - change in voice - decreased sense of smell and taste
Signs of deviated nasal septum
- decreased size of nasal passage - edematous turbinates if have chronic sinus problems
Dx of deviated nasal septum
- PE and or nasal endoscopy - CT scan
Tx of deviated nasal septum
- usually none - treat sinusitis - surgery if severe (snoring, nasal obstruction not improved w/ nasal steroids)
Two types of epistaxis
- anterior - posterior
Causes of epistaxis
- nose picking (most common) - dry nasal mucosa (O2, CPAP, Sjogren’s, meds) - Meds (Coumadin, Xarelto, Plavix, Aspirin) - HTN - cocaine - systemic disorders like coagulopathy, hepatic/renal disease, leukemia - trauma
What percent of epistaxis is anterior or posterior?
anterior - 90% posterior - 10%
Where do anterior epistaxis occur?
- Kiesselbach’s plexus (where cartilage and bone meet) - both internal and external carotid
How to treat anterior nose bleed
- most stop spontaneously in 5 min - pressure to anterior nose (lean forward) - cold pack - chemical cautery - anterior packing (usually in ER) - topical decongestant with 5 min pressure X 3
What use to cauterize anterior nose bleeds
Silver nitrate sticks (chemical cautery)
What device can be used to help with anterior nose bleeds
nasal tampons
Posterior epistaxis source of bleeding
sphenopalatine artery (off the internal maxillary artery) on the posterolateral wall
When suspect posterior bleed?
- Anterior packing didn’t stop bleed - blood continues to run down throat - can’t see bleeding site - harder to control/stop
Sx of untreated posterior epistaxis bleed
- shock: - diaphoresis - tachycardia - hypotension - syncope
When does posterior epistaxis require hospitalization
- needs O2, abx, pain control - constant monitoring of vital signs
What is treatment for posterior epistaxis if doesn’t stop with packing?
surgery - will need labs and clotting times first
What is other name for adenoids
pharyngeal tonsils
When do adenoids fully form? When stop growing? When atrophy?
fully form: 7 months grow until 5 yo atrophy around puberty
what do adenoids produce?
IgA - important for immune system
When is adenoid hypertrophy common?
- children: due to increased growth rate of lymphatic tissue - recurrent infections - lymphoid tissue grows during acute infections and often doesn’t return to original size
Sx of adenoid hypertrophy
- nasal obstruction - mouth breathing - difficulty breathing (esp. infants) - noisy respiration - snoring - sleep apnea - adenoidal facies
what are adenoidal facies
- dull facial expression - open mouth for breathing - nasal-y speech - elongated face - flattened mid face - dark circle under eye (“shiners”)
Complications of adenoid hypertrophy
- eustachian tube obstruction - recurrent acute or serous OM - sleep disordered breathing - chronic rhinitis/sinusitis
Treatment for adenoid hypertrophy
adenoidectomy
Adenoidectomy - absolute indication - relative indications (4)
Absolute: obstructive sleep apnea Relative: - recurrent/chronic middle ear disease - resonant speech - obligate mouth breathing/snoring - oral/facial deformities
Adenoidectomy risks
- anesthesia risks - dehydration (hurts to drink water after) - nasal regurgitation of liquids and small particles (VPI) - voice change (singers) - hemorrhage
When is hemorrhage a risk of adenoidectomy?
- during surgery - immed. after surgery - 5-8 days after surgery when scab falls off *can be severe and life threatening
Sleep apnea characteristics
- upper airway obstruction - apneic period - airway closed for 10 sec to 2 min - end of apnea period release of withheld air = snore, sleep arousal, restlessness - apneic periods may repeat
how does upper airway obstruction lead to snoring?
loss of pharyngeal muscle tone = pharyngeal collapse
how many apneic periods can someone have a night?
several hundred - leads to frequent arousals, sleep fragmentation, sleep deprivation
Clinical disorders related to sleep apnea
- obesity - adenotonsillar hypertrophy - goiter - nasal obstruction (septal deviation, nasla polyps, turbinate hypertrophy) - large uvula - large tongue - redundant posterior pharyngeal wall tissue
how to dx sleep apnea
- PE - nasal endoscopy - sleep study
Three major sx of sleep apnea
- hypersomnolence - am HA - increased blood pressure
potential complications of sleep apnea
- HTN - stroke - cardiac arrhythmias
tx of sleep apnea
CPAP continous positive air pressure applied to upper airway via nasal mask (or oro-nasal mask) very effective
How does CPAP maintain airway potency?
- increases caliber of airway - increases lateral dimensions of upper airway - thins lateral pharyngeal walls
CPAP compliance
usually very poor
Types of adverse effects and complications from CPAP
- machine related - pressure complications - mask-related problems - nasal problems
machine related CPAP problems
- sensation of suffocation - difficulty exhaling - inability to sleep - spousal intolerance
pressure related CPAP problems
- musculoskeletal chest discomfort - sinus discomfort - pneumothorax - TM rupture (rare)
Mask related CPAP problems
skin abrasions rash conjunctivitis
nasal CPAP problems
- rhinorrhea - nasal congestion - epistaxis - nasal/oral dryiness
Uvulopalatopharyngeoplasty (UPPP)
- sx to remove excess tissue in throat = wider airway - decreases apnea
what tissue is removed in UPPP
- uvula - all/part soft palate - tonsils - adenoids - excess throat tissue
effectiveness of UPPP
only 50% are effective
dental prothesis to help mandibular advancement treats what
mild sleep apnea
what do breathe right strips help?
snoring, helps nasal valve collapse
