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Foundations II Exam 1 > ENT- Acute and Chronic Rhinosinusitis > Flashcards

ENT- Acute and Chronic Rhinosinusitis Flashcards

1
Q

Acute Rhinosinusitis- epidemiology

A

1 in 7-8 persons annually

women>men

45-74 y/o

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2
Q

Acute Rhinosinusitis- Etiology

A

Viral: Rhinovirus, influenza virus, parainfluenza

Bacterial: 0.5-2% of cases

*Can transition from viral to bacterial*

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3
Q

What are 9 risk factors for Acute Rhinosinusitis?

A
  1. Older age
  2. Smoking
  3. Air travel
  4. Changes in atmospheric pressure (deep sea diving)
  5. Swimming
  6. Asthma
  7. Allergies
  8. Dental disease
  9. Immunodeficiency
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4
Q

Acute Rhinosinusitis- Pathophysiology

A

Normal sterile environment–> mucosal edema and sinus inflammation–> decreased drainage of thick secretions–> Obstruction of sinus ostia –> entrapment of bacteria leads to infection

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5
Q

Symptoms of acute rhinosinusitis?

A
  1. Nasal congestion/ obstruction*
  2. Purulent nasal discharge*
  3. Facial pain or pressure*
  4. Maxillary tooth discomfort
  5. Fever
  6. Fatigue
  7. Cough
  8. hyposmia or anosmia
  9. Ear pressure or fullness
  10. Headache
  11. Halitosis

*= biggest indicators that sxs are due to a sinus infection and not the common cold

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6
Q

Signs/ physical exam

A
  1. Erythema and edema of cheek bone or periorbital
  2. TTP of sinuses
  3. cheek tenderness
  4. Percussion of upper teeth tenderness
  5. purulent drainage in nose or pharynx
  6. sinus pain with percussion
  7. opacity of sinuses with transillumination
  8. diffuse nasal mucosal edema, turbinate hypertrophy
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7
Q

Acute Rhinosinusitis- Red Flags

A
  1. High fever (>102) with severe headache
  2. Abnormal vision (diplopia, blindness)
  3. Abnormal EOMs
  4. Proptosis
  5. Opthalmoplegia
  6. Papilledema
  7. Change in mental status
  8. periorbital edema or erythema
  9. Cranial nerve palsies
  10. Altered mental status
  11. neck stiffness or other meningeal signs
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8
Q

How do you diagnose Acute Rhinosinusitis?

A

Diagnosis is made based on clinical impression (based on H&P).

Imaging should only be ordered if any red flags are present

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9
Q
A
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10
Q

When are radiologic studies indicated in the diagnosis of acute rhinosinusitis?

A
  1. Indicated if suspect complicated ABRS:
    - CT w/ contrast
    - Diminished visual acuity, diplopia, periorbital edema, severe headache, AMS
  2. Recurrent or treatment resistent sinusitis
    - noncontrast CT
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11
Q

What are features of acute rhinosinusitis due to a bacterial cause?

A
  1. Persistent symptoms or signs lasting 10 or more days with no clinical improvement
  2. Onset with severe symptoms (fever > 102; purulent nasal discharge, facial pain) lasting at least 3 consecutive days at the beginning of illness
  3. Onset with worsening symptoms following a viral URI that lasted 5-6 days and was initially improving (“double-worsening”)
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12
Q

What is the treatment for Acute Rhinosinusitis for days 1-9?

A

Supportive care:

  1. Analgesics/antipyretics
  2. Saline irrigation**- very important!
  3. Intranasal glucocorticoids
  4. oral decongestants
  5. topical decongestants
  6. Mucolytics
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13
Q

What is first line treatment for antimicrobial management of acute rhinosinusitis?

A

Amoxicillin-clavulanate (Augmentin) 500/125mg TID or 875/125mg BID

Can give higher doses in special situations (>65y/o, recent hospitalization, abx tx in past month, immunocomprimised, S. pneumo pencillin resistance >10%)–> give 2g PO BID

Duration of treatment: IDSA guidelines recommend 5-7 days

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14
Q

What is NOT recommended treatment for acute rhinosinusitis?

A

Macrolides (Z-pack)

Trimethoprim-sulfamethoxazole (Bactrim)

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15
Q

Acute rhinosinusitis- Indications for referral

A
  1. Need for urgent endoscopy or surgical biopsy:
  • Severe infection
  • Fungal sinusitis or granulomatous disease is suspected
  • Nosocomial infection
  • Anatomic defects causing obstruction
  • Immunocompromised
  • Failure to respond to 1st and 2nd line antimicrobial tx
  1. Multiple recurrent episodes
  2. Chronic rhinosinusitis w/ recurrent exacerbations of ABRS
  3. Allergic rhinitis and candidate for immunotherapy
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16
Q

What are complications of Acute rhinosinusitis?

A
  1. Preseptal (periorbital) or orbital cellulitis
  2. Meningitis
  3. Osteomyelitis of sinus bones
  4. Intracranial abscess
17
Q

What are the risk factors for Chronic Rhinosinusitis?

A
  1. Allergic rhinitis (due to chronic inflammation)
  2. Chronic exposure to environmental irritants or ciliostatic substances (smoking)
  3. Immunodeficiency
  4. Defects in mucociliary clearance
  5. Recurrent viral URIs
  6. Anatomic abnormalities predisposing to sinus obstruction
  7. Iatrogenic (complications from repeated sinus surgery)
18
Q

Signs and symtpoms of Chronic Rhinosinusitis?

A
  • Anterior and/or posterior nasal mucopurulent drainage
  • Nasal obstruction/nasal blockage/congestion
  • Facial pain, pressure, and/or fullness
  • Reduction or loss of sense of smell
  • Purulent mucus or edema in the middle meatus or ethmoid regions
  • Polyps in the nasal cavity or the middle meatus
  • Radiographic imaging demonstrating mucosal thickening, or partial or complete opacification of the paranasal sinuses
19
Q

How do you manage chronic Rhinosinusitis?

A
  1. Nasal irrigation
  2. Intranasal glucocorticoids
  3. Topical antimicrobials
  4. Oral antimicrobials
  5. Oral glucocorticoids
  6. Antileukotriene agents
  7. Endoscopic sinus surgery (by ENT)
20
Q

What antimicrobial management is recommended for someone who is penicillin allergic and has Acute Rhinosinositus?

A

Doxycycline or 3rd generations cephalosporin with or without Clindamycin

Could also give a respiratory fluoroquinolone, but guidelines are going away from this due to side effects

Foundations II Exam 1 (25 decks)

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