EENT #3 (Nose/Sinus)

Question 1

Acute Rhinosinusitis
-Time Frame: Acute, Subacute, Chronic
-Etiologies (Viral vs Bacterial)
-Risk Factors
-Symptoms
-Diagnostics
-Management
–When do you give ABX
–What ABX are used

Answer 1

-Acute: 1-4 weeks, Subacute: 4-12 weeks, Chronic > 12 weeks
-Viral (most cases are viral in nature). Bacterial (same as AOM = Strep Pneumo MC, H. Flu, Moraxella Cat, GABHS)
-RF: Setting of a viral URI, dental infections, smoking, allergies, Cystic fibrosis
-Facial pain/pressure worse with bending down and leaning forward, headache, purulent nasal discharge, fever. Symptoms worsening after period of improvement. Nasal congestion.
-Clinical most times. CT scan (DOC if needed) = Water’s View sinus radiographs. Biopsy of aspirate = definitive diagnostic.
-Management: Symptomatic = Decongestants (promote sinus drainage), analgesics, antihistamines.
–ABX if symptoms present for > 10-14 days or worsening
—Augmentin TOC
–Doxycycline is 2nd line

Question 2

Chronic Sinusitis
-How long does this need to be present?
-Etiologies: Bacterial, Viral, Fungal
-Symptoms
-Diagnostics
-Management

Answer 2

-At least 12 consecutive weeks
-Bacterial: S. Aureus MCC, Viral, Fungal: Aspergillus MC fungal cause, Mucormycosis is 2nd most common fungal cause.
-Same symptoms as acute sinusitis.
-Diagnostics: Biopsy or histology is the diagnostic of choice.
-Treatment
–Depends on etiology
–ENT follow up and ABX treatment

Question 3

Mucormycosis (Zygomycosis)
-What is it?
-Etiologies
-Risk Factors
-Symptoms
-Diagnostics (what is seen)
-Treatment

Answer 3

-Invasive fungal infection that infiltrates the nasal cavity, lungs, and CNS. Goes quickly into nasal canals, eyes, and brain. High mortality.
-Etiologies: Mucor, Rhizopus, Absidia, Cunninghamella fungal species.
-RF: MC seen in DM (especially DKA), immunocompromised states
-Sinusitis progressing to brain and orbit involvement.
-Exam: black eschar on palate, nasal mucosa, or face.
-Diagnostics: Biopsy shows non-septate broad hyphae with irregular right-angle (90’) branching.
-Treatment: IV Amphotericin B (first line) + Surgical debridement of necrotic areas

Question 4

Allergic Rhinitis
-MC type of rhinitis overall
-Pathophysiology
-Symptoms
-Exam Findings
-Management

Answer 4

-IgE-mediated mast cell histamine release due to allergens (pollen, mold, dust).
-Sneezing, congestion, clear/watery rhinorrhea, eyes/ears/throat may be involved. Bluish discoloration around the eyes.
-Pale or violaceous boggy turbinates, nasal polyps with cobblestone mucosa of conjunctiva. Allergic shiners.
-Intranasal corticosteroids (Mometasone, Fluticasone) if allergic or nasal polyps.

Question 5

Infectious Rhinitis
-MCC
-Exam findings specific to this type
-Treatment

Answer 5

-Rhinovirus
-Erythematous turbinates
-Antihistamines, mast cell stabilizers, short-term decongestants.

Question 6

Intranasal decongestants used > 3-5 days can cause __________.

Answer 6

Rhinitis medicamentosa (rebound congestion)

Question 7

Nasal Polyps
-MCC
-May also be seen with ______
-Symptoms and Exam Findings
-Treatment

Answer 7

-Allergic rhinitis is the MCC
-Can also be seen with cystic fibrosis
-Obstruction, anosmia, pale boggy mass on nasal mucosa. May have allergic rhinitis symptoms.
-Intranasal glucocorticoids (initial TOC)

Question 8

Nasal Foreign Body
-MC seen in children
-Symptoms (classically presents with…)
-Management

Answer 8

-Epistaxis associated with a mucopurulent discharge, foul odor, and nasal obstruction (mouth breathing)
-Removal via positive pressure or instrument
–Occlude opposite nostril, blow out of nose
–Parent blows into mouth while occluding unaffected nostril

Question 9

Anterior Epistaxis
-MC site
-Etiologies
-Management of Anterior

-What are some recommendations for those with nosebleeds or post-treatment?

Answer 9

-MC site is Kesselbach venous plexus
-MC associated with nasal trauma (nose picking in kids, blowing nose forcefully), low humidity, alcohol, cocaine use, foreign body, anti platelet medications.
-Management
–Direct pressure (first line) for 5-15 minutes seated position, leaning forward.
–Adjunct Meds: Topical vasoconstrictors (Oxymetazoline, lidocaine with epinephrine, 4% cocaine) may be added to pressure.
–Cauterization: electrocautery or silver nitrate is next in the order
–Nasal packing: if all else fails

-Avoid exercise for a few days, avoid spicy foods. Bacitracin and humidifiers help moisten nasal mucosa.

Question 10

Posterior Epistaxis
-MC site
-Risk Factors
-Management of Posterior

Answer 10

-Sphenopalatine artery branches and Woodruff’s plexus MC site
-may cause bleeding from both nares and posterior pharynx
-RF: Hypertension, older patients, nasal neoplasms
-Management
–Balloon catheters MC initial treatment
–Foley catheter
–Cotton packing