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Foundations II > Disorders of the Nose and Sinuses > Flashcards

Disorders of the Nose and Sinuses Flashcards

1
Q

Which of the following conditions when found in young children is suggestive of cystic fibrosis?

A. Chronic rhinorrhea
B. Nasal polyps
C. Perennial allergic rhinitis
D. Acute sinusitis

A

B. Nasal polyps!

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2
Q

What are some other names for acute rhinosinusitis?

A

acute rhinitis, acute viral rhinitis, common cold

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3
Q

What is the cause of acute rhinosinusitis?

A

caused by a virus (rhinovirus, adenovirus, others)

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4
Q

Why do we get colds throughout our whole lives?

A

There are many serologic types of each virus, so we are continuously susceptible.

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5
Q

Describe the course of a case of acute rhinosinusitis.

A

usually self-limiting and benign

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6
Q

How would a patient with acute rhinosinusitis present?

A

nasal congestion, decreased sense of smell, watery rhinorrhea, sneezing, malaise, throat discomfort

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7
Q

What would be the physical exam findings of a patient with acute rhinosinusitis?

A

erythematous, edematous nasal mucosa + watery discharge

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8
Q

What are four ways to treat acute rhinosinusitis?

A

Treatment is supportive – there are no antiviral treatments available for viral rhinosinusitis. However, you can suggest zinc, saline nasal irrigation, oral decongestants like pseudoephedrine (Sudafed), and nasal sprays with oxymetazoline or phenylephrine.

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9
Q

Over __ mg of zinc acetate in the form of lozenges reduces symptom duration in acute rhinosinusitis.

A

> 75 mg

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10
Q

Saline nasal irrigation results in a reduced need of…

A

NSAIDs, in a patient with acute rhinosinusitis

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11
Q

What is the dosage of pseudoephedrine (Sudafed) for acute rhinosinusitis? What does this drug help to relieve?

A

30-60 mg q 4-6 hours to give some relief of nasal congestion and rhinorrhea

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12
Q

What are two nasal sprays that can be used for acute rhinosinitus (and their brand names)?

A

oxymetazoline = Afrin, Dristan, Vicks Sinex, or Zicam; OR phenylephrine = Neo-Synephrine, Little Noses

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13
Q

What are the benefits and risks of oxymetazoline or phenylephrine nasal sprays? How long should patients take these to avoid the risks?

A

rapidly effective but should not be used more than three days to prevent rebound congestion; withdrawal after four or more days of use can lead to rhinitis medicamentosa

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14
Q

What is rhinitis medicamentosa?

A

addictive-like need for continuous use of nasal sprays; requires mandatory cessation of the use of the spray, and prescribe topical or oral corticosteroids

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15
Q

What would a gentle formula or extra strength dosage of a phenylephrine nasal spray be?

A

gentle = 0.125%, extra strength = 1.0%

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16
Q

What are some complications of acute rhinosinusitis?

A 
Predisposes people to the development of...
Acute bacterial sinusitis
Acute otitis media
Eustachian tube dysfunction
Bronchitis
Asthma
Cystic fibrosis exacerbation
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17
Q

Acute sinusitis lasts less than __ weeks.

A

4

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18
Q

What is the cause of acute sinusitis?

A

inflammation of sinus cavities due to viruses or bacteria (so could be acute viral rhinosinusitis = AVRS or acute bacterial rhinosinusitis = ABRS)

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19
Q

How is acute bacterial rhinosinusitis caused?

A

Edematous mucosa causes obstruction of the sinus cavity; accumulation of these secretions in the cavity becomes secondarily infected by bacteria

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20
Q

Acute sinusitis usually follows a…

A

URI

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21
Q

The most common causative agent for acute sinusitis is…

A

a virus!

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22
Q

What are the typical bacterial etiologies of acute sinusitis?

A

Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

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23
Q

How would a patient with acute sinusitis present?

A

purulent nasal drainage, nasal obstruction or congestion, facial pain and pressure, altered smell, cough, fever, headache, otalgia, halitosis, dental pain, and fatigue

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24
Q

What would a PE of a patient with acute sinusitis reveal?

A

pain over sinuses when asked to lean forward, diffuse mucosal edema, copious rhinorrhea or purulent discharge

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25
Q

How do we diagnose acute sinusitis?

A

based on clinical signs and symptoms – diagnostic testing is not initially indicated

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26
Q

How do you differentiate bacterial sinusitis from viral?

A

persistance of symptoms more than ten days after onset; worsening of symptoms within ten days after initial improvement

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27
Q

How do you differentiate viral sinusitis from a common cold?

A

Rhinitis (sneezing and rhinorrhea) predominates in the common cold.

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28
Q

What does fluid in the sinuses look like on x-ray?

A

A normal air filled sinus would be darker; a fluid filled sinus would look whitish and hazy.

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29
Q

How do you treat AVRS vs. ABRS?

A

AVRS = relieve nasal congestion and rhinorrea; treatment doesn’t shorten the course of the illness!

ABRS = antibiotics to eliminate the infection and reduce complications

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30
Q

How do we treat acute sinusitis?

A

saline nasal spray, decongestants, antibiotics (if bacterial)

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31
Q

What antibiotics would we use for acute sinusitis? What antibiotics would be BAD to use?

A

(for 10-14 days)
amoxicillin-clavulanate, doxycylcine, levofloxacin or moxifloxacin…NOT macrolides, TMP-SMZ, or 2nd and 3rd generation cephalosporins

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32
Q

What are three complications of sinusitis?

A

osteomyelitis, cavernous sinus thrombosis, orbital cellulitis

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33
Q

When do we offer a referral to a patient with sinusitis?

A

when they have decreased visual acuity, diplopia, periorbital edema, severe headache, altered mental status

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34
Q

What is chronic sinusitis?

A

inflammation of the sinuses that lasts twelve weeks or longer

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35
Q

Who is affected by chronic sinusitis?

A

adults AND kids (but mostly middle aged adults)

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36
Q

What is the onset of chronic sinusitis like?

A

onset can be abrupt (as a URI or acute sinusitis that doesn’t resolve) OR insidious and slow over months!

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37
Q

What are the four cardinal symptoms of chronic sinusitis?

A
  1. mucopurulent drainage
  2. nasal decongestion
  3. facial pain or pressure
  4. reduction in sense of smell
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38
Q

CT of acute vs. chronic sinusitis

A

acute may show fluid levels; chronic could show mucosal thickening

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39
Q

How is chronic sinusitis diagnosed?

A

12 weeks, objective evidence of mucosal inflammation (sinus CT is preferred modality of imaging)

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40
Q

How is chronic sinusitis treated?

A

typically not cured – but the goal is to control symptoms and reduce exacerbations; use intranasal steroids or saline rinses, and antimicrobials as needed

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41
Q

When should we refer patients with chronic sinusitis?

A 
sinus culture
direct visualization (rhinoscopy, nasal endoscopy)
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42
Q

What causes allergic rhinitis?

A

exposure to airborne allergen in a predisposed person

43
Q

What cells are involved in allergic rhinitis?

A

exposure to airborne allergen = activation of B-cell (humoral) and T-cell (cytotoxic) immune system responses; allergen specific IgE responses cause release of inflammatory mediators…response intensifies when allergens reach the lymph nodes where more T-cell activation happens

44
Q

B cells are ___ and T cells are ___.

A

B cells = humoral

T cells = cytotoxic

45
Q

What antibodies cause release of inflammatory mediators?

A

IgE

46
Q

When does an allergic response intensify?

A

when allergens reach the lymph nodes, where more T-cell activation happens

47
Q

Allergic rhinitis has a consistent association with…

A

asthma

48
Q

seasonal vs. perinneal allergic rhinitis

A 
seasonal = usually caused by pollens and spores
perennial = year round symptoms
49
Q

What causes seasonal allergic rhinitis – in the spring? Summer? Fall?

A

most commonly caused by pollen and spores; spring = flowering shrub and tree pollens; summer = flowering plants and grasses; fall = ragweed and molds

50
Q

What allergens cause perennial allergic rhinitis?

A

dust, house mites, air pollution, pet dander

51
Q

A patient with allergic rhinitis may have a similar presentation as someone with ___, but…

A

viral rhinitis – but may be more persistent and may show seasonal variation

52
Q

symptoms of allergic rhinitis (7)

A

clear rhinorrhea, sneezing, tearing, eye irritation, pruritis, allergic shiners (bluish areas below the eyes), the “allergic salute” in kids (horizonal crease on the nose)

53
Q

Many people with allergic rhinitis will have a strong family history of __ or __.

A

atopy or allergy

54
Q

On physical examination, what would a patient with allergic rhinitis look like?

A

pale mucosa of nasal turbinates (venous engorgement), conjunctival erythema, excessive tearing

55
Q

treatment of allergic rhinitis (7)

A
  1. Avoid known allergens (most effective way to alleviate symptoms)
  2. nasal saline irrigation to mechanically flush allergens out
  3. intranasal corticosteroids
  4. antihistamines
  5. antileukotrienes
  6. mast cell stabilizers
  7. immunotherapy
56
Q

What are some ways to maintain an allergen free environment?

A

Plastic covers for pillows and mattresses
Use synthetic material rather than animal products
Remove items in house that collect dust
Carpets, drapes, bedspreads, wicker
Air purifiers
Dust filters

57
Q

Intranasal corticosteroids are more effective than non-sedating ___.

A

anti histamines

58
Q

What are two examples of intranasal corticosteroids?

A

budesonide, fluticasone

59
Q

What do intranasal corticosteroids do?

A

shrink the nasal mucosa to provide better airway and drainage (make sure the patient uses it regularly and applies it correctly)

60
Q

Intranasal corticosteroids are critical for treatment of allergy patients who get recurrence of what?

A

ABRS or chronic rhinosinusitis

61
Q

How long does it take for intranasal corticosteroids to work for allergic rhinitis?

A

There is a delayed onset of about two weeks! Tell patients to keep going!

62
Q

Why are antihistamines good and bad for allergic rhinitis?

A

They provide quick relief, but it is temporary.

63
Q

What are some OTC anti-histamines used for allergic rhinitis (3)?

A

loratadine
cetirizine
brompheniramine

64
Q

What are some prescriptions used for allergic rhinitis? What receptors do they target?

A

prescription oral H1-receptor antagonists like fexofenadine and desloratadine, or H1-receptor antagonist nasal spray like azelastine

65
Q

Antileukotrienes, used in allergic rhinitis treatment, are leukotriene receptor ____.

A

antagonist/inhibitor

66
Q

What is one example of an antileukotriene?

A

Montelukast

67
Q

What do antileukotrienes do?

A

decrease nasal rhinorrhea, sneezing, and congestion (proinflammatory molecules exist in upper airway disease)

68
Q

What is one example of a mast cell stabilizer? How is it delivered into the system?

A

cromolyn solution – ophthalmic preparation is most useful; nasal spray is not as effective as topical corticosteroids

69
Q

Vasomotor rhinitis is also called…

A

nonallergic rhinitis

70
Q

What is the etiology of vasomotor rhinitis?

A

increased nerve sensitivity causing increased mucus from nasal mucosa

71
Q

Vasomotor rhinitis is common in…

A

elderly

72
Q

Vasomotor rhinitis can be precipitated by various nasal stimuli, like…

A

warm/cold air
humidity
odors
alcohol

73
Q

The most common form of nonallergic rhinitis is called ___ rhinitis, and it is associated with…

A

gustatory rhinitis; associated with ingestion of food

74
Q

How would a patient with vasomotor rhinitis present?

A

nasal congestion and rhinorrhea (but symptoms are labile and can disappear quickly)

75
Q

On physical examination, what would a patient with vasomotor rhinitis look like?

A

bogginess of nasal mucosa

76
Q

How do you treat vasomotor rhinitis?

A

Avoid the irritant or use intranasal corticosteroids or intranasal ipatropium (Atrovent) (better for treating vasomotor rhinitis as opposed to allergic rhinitis)

77
Q

What causes epistaxis (9 things)?

A

nasal trauma (like nose picking which is the number one cause), foreign body, forceful nose blowing), rhinitis, dry nasal mucosa, septal deviation, hypertension, atherosclerotic disease, hereditary hemorrhagic telangiectasia, inhaled drugs, alcohol use

78
Q

What can cause dry nasal mucosa?

A

low humidity or supplemental nasal oxygen

79
Q

Epitaxis presents as bleeding from the anterior nasal cavity, __% of the time!

A

95%

80
Q

Is epistaxis more common bilaterally or unilaterally?

A

unilaterally

81
Q

What is the most common location for epistaxis and why?

A

anterior septum – confluence of veins create a superficial venous plexus

82
Q

Kieselbach’s Plexus

A

confluence of veins in the nose create a superficial venous plexus

83
Q

What kinds of epistaxis need to be treated emergently?

A

posterior, bilateral, or large volume

84
Q

Posterior nasal cavity epistaxis accounts for __% of nasal bleeding and is commonly associated with __ or __.

A

5%; hypertension or atherosclerosis

85
Q

How do you treat epistaxis (4 ways)?

A

direct pressure on bleeding side for 15 minutes; short acting topical nasal decongestants; cauterization of bleeding site if visualized (silver nitrate, electrocautery); nasal packing like nasal tamponade or balloon catheters

86
Q

When would you refer a patient with epistaxis to a otolaryngologist?

A

if it is recurrent or large volume – they can do endoscopic evaluation or imaging

87
Q

What causes nasal polyps?

A

It is not clear!=, but they grow from the mucous membranes of the nose and sinuses.

88
Q

Nasal polyps are associated with what two conditions?

A

cystic fibrosis or allergic rhinitis

89
Q

How would a patient with nasal polyps present?

A

pale, edematous masses
nasal congestion
anosmia
infection

90
Q

What is anosmia?

A

decreased sense of smell

91
Q

How are nasal polyps treated (3 ways)?

A

topical steroids for up to three months (if they are little), a short course of oral corticosteroids, or surgery

92
Q

What are two ways to prevent nasal polyps?

A

nasal steroids after removal, allergen testing

93
Q

What are two complications of nasal polyps?

A

chronic nasal obstruction, diminished sense of smell

94
Q

What medication should patients with nasal polyps and a history of asthma avoid? Why?

A

ASPIRIN! It can precipitate a severe bronchospasm called triad asthma.

95
Q

What is the “triad” in triad asthma (severe bronchospasm)?

A

nasal polyps, asthma, aspirin sensitivity

96
Q

Nasal polyps in a child suggests…

A

cystic fibrosis

97
Q

Unilateral polyps with pain or bleeding need to be evaluated to rule out what?

A

a tumor

98
Q

Which of the following conditions is most likely to lead acute sinusitis?

A. Viral URI
B. Intranasal foreign body
C. Barotrauma
D. Nasal steroid use

A

A. Viral URI

99
Q

What is the most common disorder that leads to acute sinusitis?

A

URI

100
Q

Acute sinusitis develops because of __ obstruction due to mucosal __.

A

because of ostial obstruction due to mucosal edema

101
Q

Cystic fibrosis usually manifests itself in ___ with __ involvement. Recurrent ___ and ___ are also seen frequently.

A

early childhood with lung involvement; recurrent sinusitis and otitis media are also seen

102
Q

The onset of nasal polyps in cystic fibrosis pateints is between __ and __ years old.

A

5-14 years old

103
Q

Cystic fibrosis is diagnosed by the __ __ test.

A

sweat chloride test

104
Q

What causes acute rhinosinusitis?

A

VIRUSES!

Foundations II (11 decks)

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