EENT #7 (Nose/Sinus) Flashcards
With rhino sinusitis, what is considered acute, what is considered subacute, and what is considered chronic.
Acute: 1-4 weeks
Subacute: 4-12 weeks
Chronic: > 12 weeks
Although most cases of acute rhino sinusitis are viral in nature (rhinovirus, influenza, and parainfluenza), what are some bacterial causes of this condition?
A….SMH
Strep Pneumo (MC)
Moraxella Catarrhalis
H. Influenzae
GABHS
Risk factors for acute rhinosinusitis
- Most common in setting of a viral URI
- Dental infections
- Smoking
- Allergies
- Cystic Fibrosis
Symptoms of acute rhinosinusitis
- Facial pain or pressure worse with bending down and leaning forward
- Headache
- Malaise
- Purulent nasal discharge
- Fever
- Nasal congestion
- Worsening symptoms after a period of improvement
Although imaging is not necessary if it is a classic presentation and uncomplicated case of acute rhinosinusitis, what imaging CAN be done and is the diagnostic of choice.
CT scan: imaging of choice
Sinus radiographs are usually not needed, but if ordered, what view is the best for acute rhinosinusitis?
Water’s view
However, what diagnostic gives a definitive diagnosis for acute rhinosinusitis?
Biopsy or aspirate
Management for acute rhinosinusitis
-Symptomatic management: decongestants (promote sinus drainage), analgesics, antihistamines, intranasal glucocorticoids, naval lavage
When are antibiotics indicated in a patient with acute rhinosinusitis?
If symptoms present for 10-14 days and worsening
What ABX is considered in a patient with acute rhinosinusitis if needed?
Amoxicillin-Clavulanic Acid
However, second line ABX for acute rhinosinusitis is
Doxycycline
What is chronic sinusitis defined as?
Inflammation of the nasal cavity and paranasal sinuses for at least 12 consecutive weeks
MC bacterial cause of chronic sinusitis
S. Aureus
What is the MC fungal cause of chronic sinusitis
Aspergillus
-Mucormycosis is the 2nd MCC
What diagnostic should be done for chronic sinusitis?
Biopsy or histology (allows for identification of organism and then determining the management)
What is important to remember about Mucormycosis (Zygomycosis)?
-Fungus rapidly dissects the nasal canals and eye into the brain. High mortality.
What are some common etiologies of mucormycosis?
- Mucor
- Rhizopus
- Absidia
- Cunninghamella
What is the biggest risk factor with mucormycosis?
Seen in diabetes mellitus (especially DKA) and immunocompromised states (post-transplant, chemotherapy, HIV)
Symptoms of mucormycosis
Rhino-orbital-cerebral infections: sinusitis that progresses to orbit and brain involvement
-Swelling, necrosis, black eschar on the palate, nasal mucosa, or face
What is the diagnostic of choice for mucormycosis and what do you see?
Biopsy: non-septate broad hyphae with irregular right-angle (90 degree) branching
Management for mucormycosis
- IV Amphotericin B + surgical debridement of necrotic areas
- Other options: Posaconazole or Isavuconazole
MCC of nasal polyps
Allergic rhinitis
Nasal polyps may also be seen with what condition?
Cystic Fibrosis
Symptoms of a nasal polyp
-Obstruction or anosmia (decreased smell)
What is seen on direct visualization of a nasal polyp?
-Pale boggy mass on nasal mucosa
What is the initial treatment of choice for a nasal polyp?
- Intranasal glucocorticoids
- Surgical removal may be needed if large and medical therapy unsuccessful
What is the MC type of rhinitis?
Allergic
Allergic rhinitis is ______
IgE mediated mast cell histamine release due to allergens (mold, pollen, dust, etc.)
What is seen on physical exam of a patient with allergic rhinitis?
- Pale or violaceous boggy turbinates, nasal polyps with cobblestone mucosa of the conjunctiva
- Allergic shiner: purple discoloration around the eyes or nasal bridge from constant rubbing
Other symptoms of rhinitis
- Sneezing
- Nasal congestion
- Clear, watery rhinorrhea
- Bluish discoloration around eyes in allergic
What is the MCC of infectious rhinitis?
-Rhinovirus
What is seen on physical exam of a patient with infectious (rhinovirus) rhinitis?
-Erythematous turbinates
What is the treatment if the rhinitis is allergic?
- Intranasal corticosteroids (Flonase, Nasacort)
- Avoid environmental exposure
- Antihistamines, mast cell stabilizers, short term decongestants
What is the MOST EFFECTIVE medication for allergic rhinitis?
Intranasal glucocorticoids (Mometasone, Fluticasone)
Intranasal decongestants, if used > 3-5 days, may cause ______
rhinitis medicamentosa (rebound congestion)
What are some examples of intranasal decongestants?
- Oxymetazoline
- Phenylephrine
- Naphazoline
A nasal foreign body classically presents as
epistaxis associated with a mucopurulent discharge, foul odor, and nasal obstruction (mouth breathing)
What is the management of a nasal foreign body (2 techniques).
Removal via positive pressure or instrument
- Positive pressure: patient blow his nose while occluding the good nostril
- Oral positive pressure: parent blows into mouth of patient while occluding good nostril
MC site of anterior epistaxis
Kesselbach Venous plexus
Anterior epistaxis is MC associated with _________ such as (give a bunch of examples)
Nasal trauma
-Nose picking, blowing nose forcefully, low humidity, hot environments, rhinitis, alcohol, cocaine use, anti platelet meds, foreign body
The MC site of a posterior epistaxis
Sphenopalatine artery branches and Woodruff’s plexus
Risk factors for posterior epistaxis
Hypertension, older patients, nasal neoplasms
How do you manage a posterior epistaxis?
- Balloon catheters are the MC initial management
- Foley catheter
- Cotton packing
How do you manage an anterior epistaxis?
- Direct pressure (first line therapy): 5-15 minutes, leaning forward
- Adjunct medications: topical vasoconstrictors (Oxymetazoline, lidocaine with epinephrine)
- Cauterization: electrocautery or silver nitrate if above measures not working
- Nasal packing: if above doesn’t work or severe bleeding
What are some post-treatment care guidelines you should recommend for the patient if they have epistaxis?
- Avoid exercise for a few days
- Avoid spicy foods
- Bacitracin
- Petroleum gauze
- Humidifiers
MCC of pharyngitis/tonsillitis
Viral: Adenovirus, Rhinovirus, Enterovirus, EBV, Influenza A and B, HZV
However, the MC bacterial cause of pharyngitis is
Group A Strep (S. Pyogenes)
Symptoms of pharyngitis
- Sore throat
- Pain with swallowing
- Cough, hoarseness, coryza, conjunctivitis, and diarrhea (Viral cause)
Although pharyngitis is usually a clinical diagnosis, what can be done to rule out bacterial cause if suspected?
Rapid strep or throat culture
Treatment for pharyngitis
-Symptomatic is mainstay: fluids, warm saline gargles, topical anesthetics, lozenges, NSAIDs
