Exam 4, Treatments only Flashcards
URI (upper respiratory tract infection)
NO ANTIBIOTICS !!!
Symptomatic tx:
* NSAIDS/Acetaminophen
* Fluids
* Nasal saline irrigation
* Oral decongestants
* Nasal decongestants - limited to a few days
Acute Bacterial Rhinosinusitis - general
- Careful observation is acceptable “treatment”
- Observation is recommended for 7-10 days in uncomplicated cases for people who are immune competent with reliable follow up
Symptomatic tx:
* NSAIDS, nasal saline sprays and intranasal decongestants have shown to help with symptom reduction
* Oxymetazoline 1-2 sprays q6-8h for 3 days (Afrin) .Watch for rebound congestion (rhinitis medicamentosa)
* Intranasal steroids have shown benefit in reducing symptoms (Flonase)
(Antibiotic treatment controversial in uncomplicated cases of ABRS) because only 5% experience shortening of symptoms
Complicated:
* May be considered complicated when symptoms last more than 7-10 days
* Or when symptoms including fever, facial pain, or swelling are severe
* Immunodeficiency, complicated (spreading to other places/tissues)
Acute Bacterial Rhinosinusitis Risk factors?
- 65+
- hospitalized in last 5 d
- antibiotic use in previous month
- ICP
- multiple comorbit (diabetes, cardiac, hepatic, renal)
- severe infection
- living in a geographic area with rate of S. pneumonia exceeding 10%
Medications for Acute Bacterial Rhinosinusitis
what meds to give if risk factors or no risk factors
If no risk factors- Amox-Clavulanate (augmentin). Clavulanate covers H flu M cat esp in kids.
if risk factors- Augmentin high dose 2 g PO dose is BIG
For both
Antibiotics for 7 - 10 days
Intranasal corticosteroids
NSAIDS for pain
Nasal saline lavage
Acute Bacterial Rhinosinusitis - If PCN allergy anaphylaxis
Doxycycline
Levofloxacin (Levaquin)
Moxifloxacin (Avelox)
Azithromycin (Zithromax)
Antibiotics for 7 - 10 days
Intranasal corticosteroids
NSAIDS for pain
Nasal saline lavage
D ANA MAL
Doxy Anaphylaxis MAL
Sounds like dranamal
Acute Bacterial Rhinosinusitis - if can tolerate cephalosporins and allergic
Clindamycin or 300 mg PO PLUS
* 3rd generation Cephalosporin
Cefixime (Suprax) -
Cefpodoxime (Vantin)
Antibiotics for 7 - 10 days
Intranasal corticosteroids
NSAIDS for pain
Nasal saline lavage
Clean and Fix
Well give you a clean fixing
ABR - Orbital cellulitis and abscess - ethmoid
CT scan or MRI
Drainage of abscess
IV antibiotics
Vancomycin plus Ceftriaxone (Rocephin)
Drain Ivy using a Axe in the Van
ABR -
Frontal subperiosteal abscess -
Pott’s Puffy Tumor -
frontal bone osteomyelitis
- Tender, doughy swelling over forehead
- Treatment
- Drainage of abscess and frontal sinus
- IV antibiotics for 6 weeks - culture sensitive
First drain then eat the
Doughy IVY green cookies for 6 weeks
ABR - Intracranial complications
are as follows: Epidural abscess, subdural empyema, meningitis, dural-vein thrombophlebitis - frontal or sphenoid
Cavernous sinus thrombophlebitis - blood clot within cavernous sinus (base of brain)
Drains deoxygenated blood from brain back to heart
Invasive Fungal Sinusitis
- Surgical debridement
- IV Amphotericin B
- Can switch to oral Itraconazole for 3-6 months after improvement
Mushroom surgeon vs me in amphitheater, then military gives me a blue uniform and discharges me for 6 months
Chronic Sinusitis
- Refer to ENT
Antibiotics - culture guided, prolonged courses 3 - 4 weeks - Augmentin empirically
- Clindamycin for penicillin allergic
Intranasal corticosteroids
Nasal saline irrigation
Sinus surgery
* Failure of medical tx
* Restoration of ventilation
* Improve penetration of topical medications
* Opens pathways, clears blockages
Old Augmented empire, cleans allergies for 3 to 4 weeks
Chronic Fungal Sinusitis
- Difficult to cure
- Overall survival poor, long-term survivors may have significant sinonasal complications
- IV Amphotericin B initial
- Switch to Itraconazole for at least 3-6 months, some possibly lifelong
Old Fungal IVY amphitheater
Then step into a blue suit
for the rest of your life or 6 months
Chronic Fungal Sinusitis allergic subtype
- Endoscopic sinus surgery to remove mucin and debris, created drainage
- Post-op systemic steroids mainstay
- Tapering course over 3 month period
Old allergic mushroom surgeon
On steroids 3 months
Wegeners Granulomatosis
Steroids
Immunosuppressants (for maintenance as well)
Allergic Rhinitis - general management
Correct Diagnosis
Patient Education
Allergen Avoidance
Pharmacotherapy
Immunotherapy
Allergic Rhinitis - Prevention
- Removal of pets
- Air filtration devices
- Travel to non-pollinating areas
- Elimination of cockroaches
- Plastic-lined covers for mattresses, pillows
- Wash bedding weekly
- Dust frequently
- Elimination of carpets and drapes
- Avoid cigarette smoking
Allergic Rhinitis Classifications
- Sleep disturbance
- Impairment of daily activities, leisure, and/or sport (impair funct)
- Impairment of school or work
- Troublesome symptoms
- Mild = none
- intermittent = less than 4 d/week or for less than 4 weeks
- Moderate-severe = means 1 or more present
- persistent = more than 4 d/week, and more than 4 weeks
Allergic Rhinitis Medications Treatment
Intranasal Glucocorticoids - most effective and mainstay of treatment:
-FOR classifications: persistent/ moderate to severe ONLY
intranasal glucocorticoids down regulates inflammatory response - decreases swelling of nasal mucosa
Topical nasal sprays - safe, effective
Fluticasone, mometasone, beclomethasone (1-2 sprays QD or BID)
- Side effects - local irritation, epistaxis, nasal septum perforation, Candida overgrowth (rare) nasal Perf due to vasoconstrictive activity of steroid
- Seasonal, perennial, vasomotor rhinitis
- Start with maximum dose for age and then step down at one week intervals once symptoms controlled
- May take up to 2 weeks for full benefit
Not a prn medication
Intranasal glucocorticoids directions & education
Directions for intranasal glucocorticoids - Tilt head forward, point bottle to ipsilateral ear (away from septum) - very important to give proper usage to avoid dangerous SE
Pt Ed: make sure to immediately report any increasing or bothersome bleeding or crusting
Work best when administered properly and med remains in nose and not draining down back of throat
IF nose is crusted or has thick mucus
Should first clean or do nasal rinse
Once symptoms are controlled, daily dose can be reduced to lowest that maintains control
H1 antagonist indications
Allergic Rhinitis
Allergic Conjunctivitis
Urticaria
Angioedema
Pruritus
Allergic Rhinitis mild symptoms or intermittent classifications
H1 1st gen: diphenhydramine, hydroxyzine, chlorpheniramine, bromopheniramine. SE: sedate, dry mouth, wt gain
H1 2nd gen: 1st line - for mild or intermittent.
Cetirizine (Zyrtec), Loratadine (Claritin)
Cetirizine is sedating in 10% of patients.
Fexofenadine (Allegra), Desloratadine (Clarinex), Levocetirizine (Xyzal)
SE: dry mouth, antihistamine tolerance
Can “rotate” medications
Nasal Antihistamines
Nasal Antihistamines
Azelastine (Astelin), Olopatadine (Patanase)
Rapid onset
Can improve nasal congestion
O is one nare, o is the other nare, l is the septum
Azelastine sounds like the lion. Picture his nose
Decongestants - oral
Oral - Pseudoephedrine (Sudafed)
Contraindications - narrow angle glaucoma, urinary retention, uncontrolled HTN, marked CAD or CVD, hyperthyroidism
SE: Insomnia, tremor, tachycardia, hypertension
Decongestants - Topical
Phenylephrine (Sudafed), Oxymetazoline (Zicam/Afrin))
Rebound vasodilation, rhinitis medicamentosa
Oral antihistamine/decongestant combinations
- Allegra D / Claritin D
- Non-sedating antihistamines combined with Pseudoephedrine
- Phenylephrine substituted now in OTC preparation due to substance abuse of pseudoephedrine* Not as effective
the fake one left, now the real one is here
Mast cell stabilizer
Cromolyn sodium (NasalCrom): mast cell stabilizer
* Topical nasal spray
* Mast cell stabilizer
* Prophylactic
* 3 - 4 times / day
* Less potent, very few side effects
Leukotriene antagonist
Leukotrienes - inflammatory mediators produced by mast cells, basophils, and eosinophils, that are accompanied by the production of histamines and prostaglandins
* Trigger smooth muscle contraction
* Neuropsychiatric changes - dreams, insomnia, anxiety, depression, suicidal thinking
Used as monotherapy or combination therapy
Montelukast can also treat asthma
Anticholinergics topical
Ipratropium bromide -
- Useful for post nasal drip and rhinorrhea & perennial symptoms
- Combined with intranasal steroids
- Useful in vasomotor rhinitis
Adjunctive: +/- nasal saline irrigation
Allergic Rhinitis Referral?
Patient with prolonged and severe AR and any of the following:
- Comorbidity
- Symptoms affecting quality of life
- Pharmacological treatment that is ineffective or that causes adverse reactions
Allergic Rhinitis - Allergist Treatments?
Subcutaneous immunotherapy - “allergy shots”
Indications - Severe allergic rhinitis
Procedure:
Each shot contains a tiny amount of specific substance(s) that trigger your allergic reactions. Just enough to stimulate immune system, but not enough to cause full blown reaction
Over time, the dose of allergens increases, which helps your body get used to the allergens (desensitization), building up a tolerance
- 3 - 5 years long. Discontinuation - minimal symptoms over 2 consecutive years of seasonal exposure
Adverse effects-
* Localized or systemic - adjust dose
* Patient monitored for 20 min after injection
- Contraindications
Significant CVD, uncontrolled asthma
Caution if on Beta Blockers**
- Contraindications
Vasomotor Rhinitis
Intranasal steroid or antihistamine
Ipratropium
Daily nasal saline lavage
viridian city
Rhinitis Medicamentosa
- Discontinue use of nasal decongestant
- Start intranasal corticosteroids
don’t use afrin once a day. use for three days max. patient education.
Chronic nasal obstruction due to overuse of nasal decongestants
Epistaxis - anterior
Pressure on site
Firmly compress for 15 minutes
Sit, leaning forward
Short acting topical nasal decongestants (Vasoconstrictors - phenylephrine)
if bleeding doesn’t stop
Topical anesthetic vasoconstrictor
4% topical cocaine solution OR
4% lidocaine and epinephrine (1:10,000)
If bleeding point identified, chemical cauterization with silver nitrate stick
Thermal cauterization for more aggressive bleeding and done under anesthesia
Continued bleeding –>
Nasal packing
* Sponge or Balloon OR
* Absorbable material - oxidized cellulose, gelatin foam, gelatin and thrombin combination
