HEENT - Allergic Rhinitis, Tinnitus, and Urticaria - Exam 2 Flashcards
What is barotrauma?
Discomfort or damage due to pressure differences between the middle ear and outside world
What are common causes of barotrauma?
Flying and driving
What are symptoms of barotrauma?
- Pressure
- Pain
- Hearing loss
- Tinnitus
What are typical exam findings with barotrauma?
- Middle ear effusion
- Hemotympanum
- TM rupture
What is the treatment for barotrauma?
- Avoidance
- Oral or nasal decongestants
- Swallowing, valsalvia, chewing gum (to equalize middle ear pressure)
- Treatment of injury is usually time/patience
- If perilymphatic fistula (vertigo and senroineural hearing loss) refer to ENT
What is Acoustic neuroma (Vestibular Schwannoma)?
Slow growing Schwann cell tumors that arise from the vestibular portion of CN VIII
What are risk factors for Acoustic neuroma?
- Childhood exposure to radiation of the head/neck
- Neurofibromatosis Type 2
What is the presentation of Acoustic neuroma?
- Unilateral sensorineural hearing loss and tinnitus (classic presentation)
- +/- gait disturbance or other CN involvement
How is Acoustic neuroma diagnosed?
- Audiometry is best initial test
- MRI (diagnostic imaging of choice)
What is the treatment for Acoustic neuroma?
- Surgery
- Radiation
- Observation
What are symptoms associated with tinnitus?
- Perception of buzzing, ringing, hissing or other noise
- Continuous or intermittent; pulsatile or non-pulsatile
Which type of tinnitus is most commonly vascular in etiology?
Pulsatile tinnitus
Which type of tinnitus needs an ENT referral for possible imaging?
Pulsatile tinnitus
What is the treatment for tinnitus?
- Main goal: lessen impact on quality of life
- Behavioral therapy: biofeedback, stress reduction, CBT
- Benzodiazepines - alprazolam (Xanax)
- Masking devices such as white noise machines
What is the etiology associated with tinnitus?
- Ototoxic medications
- Presbycusis (SN hearing loss with aging)
- Otosclerosis
- Vestibular Schwannoma
- Chiari malformations
- Barotrauma
What is the pathophysiology behind allergic rhinitis?
- Response to allergen exposure by production of IgE
What are symptoms associated with allergic rhinitis?
- Rhinorrhea
- Sneezing
- Nasal congestion
- +/- Itchy eyes, itchy nose, post nasal drip, cough
What are risk factors for allergic rhinitis?
- FHx of atopy (biggest factor)
- Male sex
- Birth during pollen season
- Firstborn status
- Early use of abx
- Maternal smoking exposure in 1st year of life
- Exposure to indoor allergens
- Presence of allergen-specific IgE
How will the periorbital area appear on physical exam in individuals with allergic rhinitis?
- “Allergic Shiners”: bluish purple rings around both eyes
- Dennie-Morgan Lines: skin folds under eyes consistent with allergic conjunctivitis
How will the eyes appear on physical exam in individuals with allergic rhinitis?
- Diffuse redness involving the bulbar and palpebral conjunctiva
- Tearing or clear watery discharge
- Chemosis
- Eyelid edema
symptoms are usually bilaterally
How will the nose appear on physical exam in individuals with allergic rhinitis?
- Pale, boggy, “bluish” mucosa
- Clear nasal discharge
- Nasal crease from “allergic salute”
How will the throat appear on physical exam in individuals with allergic rhinitis?
- Post-nasal drainage in posterior pharynx
- “Cobblestoning”
How will the ears appear on physical exam in individuals with allergic rhinitis?
Retracted TMs and/or serous otitis media (OME)
While allergy testing can be confirmatory, but not necessary for the initial diagnosis of allergic rhinitis, what are its benefits?
- Helps to identify and facilitate avoidance of allergens
- Identifies candidates for immunotherapy
What are you looking for in a Scratch (Prick) Test?
What is a risk with this testing?
Looking for a positive “Wheal and Flare” reaction
Risk for anaphylactic reaction (should have epi available)
What symptoms do 1st generation antihistamines help with? Which symptoms do they not help with?
What are examples of 1st generation antihistamines?
What are side effects?
Helps to alleviate sneezing, rhinorrhea, and itching; no relief of nasal congestion
- Chlorpheniramine (Chlor-trimeton)
- Diphenhydramine (Benadryl)
Side effects: dry mouth, constipation, sedation
When would you recommend 2nd generation antihistamines instead of 1st generation?
What are examples of 2nd generation antihistamines?
You would recommend 2nd generation for patients that do not want sedating/drowsy side-effect of a 1st generation antihistamine
- Loratadine (Claritin) QD
- Fexofedadine (Allegra) QD or BID
- Cetirizine (Zyrtec) QD
What do antihistamine nasal sprays target?
How are they dosed?
Are they used alone or in combination with other therapies?
Target H1 antagonist
Dosed BID
May be used alone or in combination with steroid nasal spray
Are nasal steroid sprays more or less effective than oral antihistamines?
What are its side effects?
More effective
Side effects: Epistaxis
What is an example of a leukotriene receptor antagonist?
What can these be used in conjunction with to provide more relief of symptoms?
Montelukast (Singulair)
Used with 2nd generation oral antihistamine provides more relief then either agent alone
When should sympathomimetics (decongestants) be used?
What is its mechanism?
What is an example?
Use if marked congestion despite antihistamine use
Causes vasocontriction that will decrease edema and secretions.
Pseudoephredrine (Sudafed)
What populations should sympathomimetics (decongestants) be used with caution?
Patients with hypertension or cardiac disease
What is immunotherapy (allergy shots) an effective treatment for?
Allergic conjunctivitis, rhinitis, and asthma
What is the pharmacotherapy for allergic rhinitis in children less than 2 years old?
- Cromolyn sodium nasal spray
- 2nd generation antihistamines [Cetirizine (Zyrtec)]
What is the pharmacotherapy for adults and children > 2 years old with mild symptoms of allergic rhinitis or episodic symptoms?
- 2nd generation oral antihistamines (loratadine/Claritin, cetirizine/Zyrtec, fexofenadine/Allergra)
- Antihistamine nasal sprays (Azelastine/Astepro, Olopatadine/Patanase)
- Glucocorticoid nasal sprays
- Cromolyn nasal spray
What is the pharmacotherapy for adults and children > 2 years old with moderate to severe symptoms of allergic rhinitis?
Glucocorticoid nasal sprays (1st line)
- Mometasone (Nasonex) and Fluticasone furoate (Veramyst) - children 2 or older
- Fluticasone proprionate - children 4 and older
What should you prescribe for allergic rhinitis with concomitant asthma?
Montelukast (Singulair)
What should you prescribe for allergic rhinitis with allergic conjunctivitis?
- Steroid nasal spray and ophthalmic antihistamine drops
- AVOID nasal steroid spays in patients with glaucoma or cataracts
What are triggers for non-allergic rhinitis (AKA “Vasomotor Rhinitis”?
- Stress
- Sexual arousal
- Perfumes
- Cigarettes smoke
- Temperature changes
What are typical characteristics of non-allergic rhinitis?
- Nasal congestion
- Rhinorrhea
- Postnasal drainage
- No ocular/nasal itching or sneezing
What is the typical treatment for Vasomotor Rhinitis?
- Avoidance of triggers
- Nasal steroid sprays
- Antihistamine nasal sprays
- Ipratropium nasal spray (anticholinergic) if prominent symptom is rhinorrhea
What are nasal polyps?
What are symptoms associated with them?
Non-tender, grey soft tissue nasal growths
Symptoms: nasal congestion/obstruction
What is treatment for nasal polyps?
- Nasal steroid spray
- Refer to ENT
What is Rhinitis Medicamentosa?
How many days does it take to lead to rebound congestion?
The result of regular use of a decongestant spray such as Afrin.
> 3 days leads to rebound
What is treatment for Rhinitis Medicamentosa?
- Discontinue decongestant spray
- Start nasal steroid spray
Describe urticaria.
- Hives/wheals
- Pruritic
- Pale to bright erythema
- Lesions are transient
What is the pathophysiology behind urticaria?
Release of histamine from mast cells of the superficial epidermis
How can you differentiate urticarial vasculitis from urticaria?
Urticarial vasculitis:
- Lasts longer than 24 hours
- Erythematous, painful plaques with blanching halos
- Leaves hyperpigmentation
- Link with SLE
What is the preferred 1st line treatment for urticaria?
2nd generation H1 histamine blocker:
- Cetirizine (Zyrtec)
- Levocetirizine (Xyzal)
What should be given for urticaria with persistent symptoms or associated angioedema?
Oral glucocorticoids
