HEENT Week 1 Flashcards

Question

Medication overuse HA - Triggers - Frequency - Duration - Concomitants - Standout Features

Answer 1

- Triggers: overusing analgesic - Frequency: HA>15day/mo - Duration: - - Concomitants: Worse upon waking, with exercise. N/V, cramps, other GI distress, anxiety, restlessness, sweating, sleep problems - Standout Features: HA worse than before overusing anagesic, overuse> 3mo.

Answer 2

- Sex: - - Age of Onset: often young - Location: generalized, worst in occiput - Pain Intensity: very severe - Pain Quality: Throbbing

Answer 3

- Triggers: - - Frequency: 1x - Duration: - Concomitants: Triad: Nuchal rigidity, change in mental status, fever. - Standout Features: Rash on legs; Kernig's and brudzinski's sign positive

Answer 4

Concomitants: epistaxis, bruits in carotids | Standout Features: Sudden severe increase in BP

Answer 5

- Pain Intensity: mild, but becomes worse - Pain Quality: deep, aching - Triggers: posture change, laying down - Duration: up to 3 hours - Standout Feature: Worse upon laying, abrupt posture change

Answer 6

- Age of Onset: after lumbar pucture or dural tear - Triggers : Sitting upright - Stand Out Features: Better laying down than sitting upright

Answer 7

- Sex - Age of Onset: 72 yo - Location: temporal, occipital, orfFrontal-occipital - Pain Intensity: variable - Pain Quality: not throbbing

Answer 8

- Triggers: aging, heavy smoking, northern European - Concomitants: fever, anorexia, weight loss, declining visual acuity, jaw and arm claudication, polymyalgia rheumatica - Standout Features: Better sitting upright than laying down, palpable nodules over artery, superficial tenderness

Answer 9

- Sex - Age of Onset - Location: generalized, worst in occiput - Pain Intensity: sudden; worst and worsening - Pain Quality: Throbbing

Answer 10

- Triggers: head trauma, spontaneous - Frequency: 1x - Duration: continuous - Concomitants: personality changes, hemiparesis, and altered consciousness if subdural* - Standout Features: Similar to meningitis

Answer 11

mal-position, inflammation or arthritis in TMJ, post-whiplash injury - Sex: usu F - Age of Onset: young - Location: unilateral, TMJ radiating to ear - Concomitants; bruxism - Standout Feature: limited ROM, tenderness in area, popping or clicking

Answer 12

- Location: generalized, vague | - Concomitants: Other somatic complaints

Answer 13

- Concomitants: Glaucoma, conjuctivitis, iritis, uveitis, strabismus, errors of refraction causing eye strain

Answer 14

1. Mild Traumatic Brain Injury (Simple Concussion) 2. Moderate diffuse TBI 3. Severe diffuse TBI (traumatic brain injury)

Answer 15

3 grades of severity (Grading scale: American Academy of Neurology guidelines) GRADE I: Confusion, sx last < 15 min, no LOC GRADE II: Symptoms last >15 min, no LOC GRADE III: LOC for seconds to minutes

Answer 16

- Signs & Sxs: none-to-brief loss of consciousness, dilated pupils, breathing stops, muscles flaccid, heart slows. Recovery in seconds to minutes- may have days to weeks of giddiness, anxiety, poor concentration, headaches, sleep disturbance - PE: perform neuro exam; CT scan may be needed if persistent symptoms

Answer 17

Unconsciousness for up to an hour with slower recovery of orientation and behavior. Wider area of the brain involved.

Answer 18

- Signs & Sxs: Lethargic for 1-7 days. Many have agitation or anxiety

Answer 19

- Imaging: CT may be normal or may show scattered petechiae or contusion in brain. May show hematoma at contra-coup position

Answer 20

- Tx: hospitalization to watch for complications; rest (physical & cognitive), NO alcohol or drugs - Prognosis: complete recovery in days to weeks in those under 40yrs. Those > 40 may have permanent intellectual and psychological effects. Worse prognosis in alcohol/drug abusers.

Answer 21

- unconsciousness - altered mental status - convulsions - persistent HA (constant or intermittent) - extremity weakness - bleeding from ear(s) - loss of hearing

Answer 22

categorized by patient response rather than the injury. - Severe brain edema, ischemic infarction, hemorrhages-immediate or delayed several hours (20%) - usu. deep unconsciousness from the start - Respiratory obstruction due to aspiration of vomit or saliva - Brain stem damage shown by bilateral pupillary fixation, slow responses to light, or anisocoria Tx: emergency hospitalization required

Answer 23

Sx can include: HA (headache), fatigue, anxiety, dizziness, memory problems, attention problems, sleep disturbance, irritability, nausea, vomiting. Duration: weeks to years.

Answer 24

after primary injury: further brain swelling and can lead to secondary brainstem damage and death—from hypotension, hypoxia, infection, hematoma

Answer 25

head or neck pain; may be a disorder in its own right or caused by underlying medical condition Common! 5 -10% US population seek medical help for headache, 20% kids have significant HA Brain tissue itself does not have sensory nerves, so headache pain comes from outside the brain (meninges, scalp, blood vessels and muscles)

Answer 26

1. Primary or secondary | 2. Vascular or nonvascular

Answer 27

not caused by underlying medical diagnosis 90% of all HAs Examples: migraine (with or without aura) – primary and vascular; tension-type (episodic or chronic) – primary and non-vascular; cluster

Answer 28

caused by/accompany underlying medical condition - Head and neck trauma – eg. post-concussion syndrome - Cranial or cervical vascular disorders – eg. temporal arteritis, hematoma, hemorrhage - Nonvascular intracranial disorders - either high CSF pressure (e.g., secondary to tumors) or low CSF pressure; benign intracranial hypertension - Infection – eg meningitis or systemic infection - Disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, etc - Disorders of homeostasis - diving, high altitude, hypoxia, hypertension, hypothyroidism, fasting, heat stroke, “sphenopalantine ganglioneuralgia” - Substance use or its withdrawal – i. Acute substance use (e.g., nitric oxide, alcohol, food additives, cocaine, cannabis, histamine). ii. Medication overuse headache (e.g., from triptans, analgesics, opioids, combinations). iii Substance withdrawal headaches (e.g., from caffeine, opioids) - Psychiatric conditions – eg depression, anxiety disorders, somatization disorders - Cranial neuralgia - both trigeminal and glossopharyngeal neuralgias - Iatrogenic: lumbar puncture, manipulation, physiotherapy

Answer 29

“Sphenopalantine ganglioneuralgia”

Answer 30

various triggers lead to rapid changes in artery size; from spasm/ constriction. Other arteries in the brain and scalp then dilate, and throbbing pain is perceived in the head - Examples: migraine with or without aura, cluster, fever, hypertension, exertion, hangover - quality of pain: throbbing or pounding, sharp)

Answer 31

quality of pain: steady, constant, dull | - Examples: tension-type, TMJ, brain tumor, sinus or dental infection, inner or middle ear

Answer 32

* Onset after age 50: temporal arteritis, intercranial mass * Incr. frequency and severity: subdural hematoma, mass, medication overuse * Sudden onset of headache: subarachnoid hemorrhage, vascular malformation, mass * Pain moves to lower neck and thoracic spine: meningial irritation * First or worst headache: intercranial hemorrhage, CNS infection * History of head trauma: intracranial hemorrhage, subdural hematoma, epidural hematoma * History of HIV or cancer: meningitis, brain abscess, metastasis, opportunistic infx * Any change in mental status, personality, level of consciousness

Answer 33

vital signs (BP, temp) head and neck – carotid and temporal artery pulsations cervical ROM tenderness of muscles of head and neck palpate cranium, jaw, neck, sinus perform oral and ear exam neurological exam (cranial nerves, motor/sensory, reflexes, coordination) HEENT exam (opthalmascopic/fundoscopic exam extremely important, to check for papilledema)

Answer 34

* Fever: intercranial, systemic or local infection * Neck stiffness/rigidity: meningitis * Papilledema: meningitis, mass, pseudotumor cerebri, increased intracranial pressure * Focal neurological signs * Signs of systemic illness or infection: meningitis, encephalitis, lyme dz, systemic infx, * collagen vascular disease

Answer 35

Often familial. Recurrent attacks, variable in intensity, frequency, duration. Usually unilateral and associated with anorexia, nausea and vomiting. Photophobia Aura may or may not occur

Answer 36

* Migraine without aura * Migraine with aura * Subtypes of Migraine with Aura

Answer 37

Patient: decreased energy and vitality; decreased social functioning - 50% of pts miss at least 2 workdays/mo; avg at least 6 days of impaired ability/mo; 43% reduction in performance effectiveness Family: negative impact on family and partner, eg missed activities

Answer 38

neurovascular, vasoactive neuropeptides (substance P), cortical spreading depression, role of serotonin? genetics? Combination Poly-factoral means multiple vectors of treatment approaches!

Answer 39

Mainly through the Medical History—get clear picture and chronology of symptoms --> HA DIARY Record: Date(s) of attack, what time the attack began, what time the attack ended, any warning signs?, previous few days (activity, triggers), medications/dose taken, symptoms including aura, if present

Answer 40

Self administered 3 question test has >90% accuracy at detecting migraine. 1. Has a headache limited your activities for a day or more in the last 3 months? 2. Are you nauseated or sick to your stomach when you have a headache? 3. Does light bother you when you have a headache?

Answer 41

``` EEG CT and/or MRI EMG TMJ radiography Cervical spine films CMP Psychometric testing ```

Answer 42

at least 5 attacks with the following: •HA lasting 4-72 hr. (untreated or unsuccessfully treated) •At least 2 of the following characteristics: - unilateral location - pulsating quality - moderate to severe pain - worse with routine activity •During headache at least one of the following occurs: - nausea and/or vomiting - photophobia and phonophobia •History, physical exam, and neuro exam show no evidence of organic dz.

Answer 43

``` at least two attacks of: Aura includes at least 1 of the following (reversible sx) •visual - scintillating scotoma (area of loss of vision, irregular luminous patch) - photopsia (flashing lights) •sensory –paresthesia on face - numbness - unilateral weakness - olfactory hallucinations •dysphasic- speech disturbance (aphasia) ``` Aura develops over 5-20 min, usu lasting < 60 min. HA follows during or after aura, lasts 4-72 hr History, physical exam, and neuro exam show no evidence of organic dz. May also be prodromal symptoms occurring hours/day before migraine: hyperactivity, lethargy, depression, cravings, frequent yawning Headache has similar features to above migraine, starting during the aura or w/in 60 min

Answer 44

- Infrequent episodic TTH—headache episodes less than one day a month (30-80% of pop) - Frequent episodic TTH—headache episodes 1-14 days a month - Chronic TTH—headaches 15 or more days a month (3% of pop)

Answer 45

- multifactorial Heightened sensitivity of pain pathways in CNS and peripheral nervous system. Sensitization of dorsal horn neurons due to increases nociceptive imputs from pericranial myofascial tissue. Innocuous stimuli misinterpreted as pain. Nitric oxide and genetics may play a role.

Answer 46

At least 2 of the following 4 features: • bilateral in head or neck • Quality of the pain is steady (pressing/tightening), nonthrobbing • Intensity is mild to moderate • HA pain not aggravated by normal physical activity - Duration of pain between 30 minutes to 7 days - No evidence of organic dz. - may be associated pericranial (neck, shoulder) tenderness

Answer 47

* Assess triggers/stressors | * Neurologic and Mskel PE- typically all findings will be normal

Answer 48

neurovascular headache with severe pain attacks which recur daily for prolonged periods

Answer 49

not well understood, some proposed mechanisms include: a. Hemodynamic: Vascular dilatation may play a role b. Trigeminal nerve: may be responsible for neuronal discharge causing cluster headaches. Substance P neurons carry sensory and motor impulses in the maxillary and ophthalmic divisions of the nerve. c. Autonomic nervous system: Sympathetic (e.g., Horner syndrome, forehead sweating) and parasympathetic (e.g., lacrimation, rhinorrhea, nasal congestion) effects occur. d. Circadian rhythm: often recur at the same time every day, suggesting that the hypothalamus, which controls circadian rhythms, may be the site of activation. e. Mast cells: Increased numbers of mast cells have been found (inconsistently) in the skin of painful areas of some patients (quercitin is good for this)

Answer 50

Episodic cluster headache: - at least 2 cluster periods lasting 7 days to 1 year - separated by pain-free periods lasting ≥ 1 month Chronic cluster headache: - attacks occur for >1yr without remission or with remission for <1mo

Answer 51

• Onset: sudden - peaks in 10-15 minutes; typically awakens a person from sleep 1 to 2 hours after going to bed. "alarm clock headaches" often awaken the person at the same time at night. These nocturnal attacks can be more severe than the daytime attacks.

Answer 52

``` At least 1 of the following on ipsilateral side: anisoria • conjunctival injection • lacrimation (84-91%) • miosis • ptosis • eyelid edema • facial sweating (26%) • nasal congestion (48-75%) • rhinorrhea ```

Answer 53

Course: Remission - long symptom-free intervals occur in some patients. Avg 2 yrs, but can range from 2 mos to 20 yrs. Work-up: initial diagnosis, CT or MRI - warranted to rule out brain or pituitary pathology DDX: paroxysmal hemicrania, trigeminal neuralgia, HA with intracranial lesion, SUNCT (Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing) syndrome

Answer 54

Paroxysmal (comes and goes), severe attacks of lightning-like pain in the branches of the trigeminal nerve Pathogenesis: compression of trigeminal nerve root by aberrant loop of an artery or vein (80-90%), acoustic neuroma, meningioma, cyst, AV malformation. Compressed area demyelinates, setting up ectopic impulse generation

Answer 55

• Paroxysmal attacks of facial or frontal pain occur, lasting a fraction of a second to 2 minutes. • Pain has at least one of the following characteristics: - sudden, intense, sharp, superficial, stabbing, or burning in quality - precipitation from trigger areas or by trigger factors • Attacks are stereotypical for each individual patient • Not attributed to another disorder

Answer 56

head CT or MRI is indicated in: - Patients with trigeminal sensory loss (light touch) - Patients with bilateral symptoms - Patients under the age of 40 Electrophysiologic trigeminal reflex testing DDX: SUNCT syndrome, cluster-tic syndrome, jabs and jolts syndrome, post-herpetic neuralgia (varicella zoster virus) and other neuralgias

Answer 57

(a type of trigeminal autonomic cephalagia) Headache of unknown origin. Different from cluster HA in higher frequency/shorter duration of attacks; higher incidence in women, 2:1; indomethacin is effective treatment (COX 1&2 inhibitor)

Answer 58

1. Daily headache for > 3 mos with 3 other criteria 2. All of the following features: unilateral pain without side-shift daily or continuous, without pain-free periods moderate intensity, with some exacerbations of severe pain (short, “jabbing” pain) 3. At least one of the following occurring on ipsilateral side: • conjuntival injection and/or lacrimation • nasal congestion and/or rhinorrhea • ptosis and/or miosis 4. treatment with indomethacin is effective Other SSX can include: eyelid edema, forehead sweating, nausea, vomiting, photophobia Work-up may include head CT to rule out other causes

Answer 59

(Short lasting, unilateral neuralgiform headache attacks with conjuctival injection and tearing) Rare. Unknown cause. A type of trigeminal autonomic cephalagia Sudden brief attacks of severe unilateral head pain in orbital, periorbital, or temporal areas, with concomitant ipsilateral cranial automonic symptoms Attacks last 5-240 seconds, with 3-200 attacks a day; 1-2 bouts a year, with remissions lasting mos Triggers: touching the area: the face, bathing, washing/brushing hair, shaving, chewing, coughing Workup may include head CT or MRI to rule out other causes

Answer 60

worsening of head pain in chronic HA sufferers due to frequent and excessive use of analgesics Criteria: - HA > 15 days/mo - regular overuse of > 3 mos: ergotamine, triptans, opioids, combination analgesics > 10d a month for > 3 mos - HA has developed or worsened during medication overuse

Answer 61

3) Characteristics of medication overuse headache: • Daily or almost daily headache, with daily use of analgesic medication (possible multiple drugs) • Headache is often worst on waking and often increased after physical exertion. • The history may begin with episodic headache months or years earlier. • Sx often include N/V, abd. cramps, diarrhea, restlessness, anxiety, sleeplessness, sweating • depression and sleep disturbances frequently co-exist. 4) DDx: migraine, tension-type headache, chronic rhinosinusitis, intracranial pathology and space occupying lesions.

Answer 62

flushed face

Answer 63

tightness of skin on head, GI problems

Answer 64

alcohol w/d with dehydration and general toxicity; fine tremor in extremities; mild nausea or stomach pain; mental dullness with mild in-coordination

Answer 65

variable HA, similar to tension-type HA, relieved by eating, worse fasting or after foods (i.e. 2 hours or less after sugar)

Answer 66

Meningitis | Other causes: Sinus headache, dental pain (more later)

Answer 67

Etiology: microbial infx/ inflam. of pain sensitive structures around the brain. Often in young folks Organisms: Streptococcus pneumoniae, Neisseria meningitides (Meningococcal meningitis), staphylococci • Haemophilus influenza type B (in those not vaccinated), Mycobacterium tuberculosis • Viral, fungal, parasitic, and non-infectious cases Onset: rapid or gradual (occiput) Signs & Sxs: generalized HA (may be worse in occiput), throbbing, very severe Triad: nuchal rigidity (neck stiffness); change in mental status, fever. (not all have 3!) LOOK SICK (later sign = rash, often on their legs)

Answer 68

- Kernig's sign –positive= guarding in hamstrings to prevent traction of spinal cord - Brudzinski's sign – positive = involuntary flexion of hip/ knee and neck pain - fundoscopic exam to check for papilledema - Mental status exam - dermatologic exam to assess for rash (later sign) Associated sx and signs: seizure, collapse, loss of consciousness, vomiting, petechial rash Diagnosis by lumbar puncture, blood culture/gram stain

Answer 69

Eg: Pituitary tumor: (compressing on sella turcica) Signs & Sxs: pain is referred to frontal and temporal regions (bilateral), or vertex or occiput • as tumor gets larger, it compresses optic chiasm or nerves & hypothalamus leading to visual field defects bilateral or unilateral • Associated signs of pituitary hormone deficits Dx by CT or MRI of cranium A mass that is found incidentally: incidentiloma.

Answer 70

Chronic inflammation of large and medium sized vessels; thrombosis may develop at sites of active inflammation-- temporal, occipital or frontal-occipital head pain Signs & Sxs: unilateral or bilateral - usu superficial tenderness (temple area), not throbbing, variable intensity. - Pain worse brushing hair, pressure, when lying, possibly on exposure to cold Associated symptoms: o fever, anorexia, weight loss o declining visual acuity (occlusion of retinal artery), ptosis, diplopia o jaw and arm claudication o may have polymyalgia rheumatica (muscle and joint-shoulder,hip- pain/stiffness) o chronic nonproductive cough

Answer 71

PE: palpable nodules over the artery, temporal artery tenderness, pulse often absent Lab: marked increase in ESR (erythrocyte sedimentation rate) , Elevated CRP CBC: May be leukocytosis and mild normochromic anemia Elevated liver enzymes, decreased serum albumin Procedure: Arterial biopsy is diagnostic. Complications: permanent blindness, stroke, aortic aneurism and dissection, MI, peripheral arterial insufficiency

Answer 72

Bleeding due to head trauma or spontaneous rupture of a congenital intracranial aneurysm Onset: sudden, followed by chronic, persistent intense HA (worst and worsening) Signs & Sxs: see meningitis Subdural hematoma: onset gradual, steady aching, gradual personality changes, altered consciousness, hemiparesis (vein?)

Answer 73

Physical Exam: - Nose: use nasal illuminator or otoscope to examine nasal vestibule and turbinates - Sinus: palpate or percuss for tenderness. Transilluminate for patency

Answer 74

loss of sense of smell. Consider CN I abnormality if unilateral, with accompanying visual problems, behavior change; Consider local problem if bilateral, with concomitant nasal symptoms. Also seen in neurological conditions (eg Alzheimer’s disease or Parkinson’s disease

Answer 75

i. Anterior → ( Kiesselbach plexus) most common in children and young adults Risk factors: winter weather: low temps and exposure to dry air, irritants; following URI (nose blowing), acute rhinitis, chronic sinusitis, allergies, trauma, nose-picking ii. Posterior → (Woodruff’s plexus) more likely in older adults; More prolonged bleeding and difficult to control Risk factors: HTN , arteriosclerosis, cocaine use, liver disease, alcoholism, blood thinners (coumadin, ASA) Also consider: bleeding disorders- hemophilia, cancer, anemia

Answer 76

infection of mucus membranes of nose with stuffy, obstructed, runny nose

Answer 77

bilateral, chronic, recurrent, very common! Etiology: Ag triggers IgE on mast cells which releases histamine cascade seasonal: usu pollens of trees, grass, weeds perennial (year-round)--animal dander, dust, mold Signs & Sxs: itchy nose and eyes, watery lacrimation episodic nasal obstruction, sneezing, nasal voice allergic salute (crease above bridge of nose) allergic shiners - bluish discoloration under eyes 2° to obstruction of venous drainage of nasal and sinus congestion; halitosis from mouth breathing PE: red mucosa (paler than bacteria; rhinitis), if chronic - pale, bluish mucosa, enlarged adenoids, may also have atopic dermatitis (eczema), asthma

Answer 78

bilateral; common cause—Rhinovirus; usually self-limiting to 7 days Signs & Sxs: watery, profuse discharge with sneezing, clear and later yellow or green, malaise, mouth breathing PE: erythematous, swelling of mucosa, low fever

Answer 79

bilateral, Nasal mucous membrane to stratified squamous epithelium Etiology: unknown, although bacterial infection frequently plays a role. Signs & Sxs: anosmia or hyposmia and epistaxis may be recurrent and severe, nasal congestion, unpleasant smell (ozoena) resulting from a progressive atrophy of the nasal mucosa and underlying bone, painful nasal passage, may be foul smelling d/c PE: membranes dry & shiny, atrophy of tissues; yellow and green crusts that bleed when removed

Answer 80

bilateral; Non-allergic, non-infectious syndrome caused by parasympathetic dominance.—leading to vasodilation and edema of nasal vasculature Signs & Sxs: similar to allergic rhinitis with rhinorrhea: sneezing, pruritus, congestion. May alternate sides Triggers: emotions, smoke, weather changes (very common) cold air strong odors stress inhaled irritants recumbency trauma spicy foods alcohol rates of anxiety and depression are higher in women with vasomotor rhinitis PE: swollen inferior nasal turbinates, dark red to bluish mucosa Labs: all allergy tests negative, nasal smear negative for organisms

Answer 81

Signs & Sxs: constant runny nose; watery d/c when drug affected, congested when not, chronic sore throats, hoarseness PE: may see chemical burns, septal perforation

Answer 82

Acute, allergic, atrophic, vasomotor, cocaine use

Answer 83

a. Trauma- ominous sign for possible skull fracture if trauma involved; may be CS fluid (blood- tinged) ; check with Benedict’s solution—should remain clear if no sugar (CSF has sugar in it) b. Choanal Atresia- congenital defect in septal development Test: infant will become distressed if block unaffected nares c. Foreign body- discharge, odor d. Neoplasm- bloody discharge

Answer 84

a. Trauma- ominous sign for possible skull fracture if trauma involved; may be CS fluid (blood-tinged); check with Benedict’s solution—should remain clear if no sugar (CSF has sugar in it)

Answer 85

- congenital defect in septal development | Test: infant will become distressed if block unaffected nares

Answer 86

Look for discharge, odor

Answer 87

bloody discharge

Answer 88

Soft, pedunculated lesions that emanate from any portion of the nasal mucosa or paranasal sinuses Linked to chronic inflammation, ANS dysfunction, genetic predisposition, chronic infection or allergy predispose M:F incidence 2 - 4:1 in adults - more common in pts > 40 years ``` Conditions associated with multiple benign polyps: bronchial asthma cystic fibrosis allergic rhinitis allergic fungal sinusitis chronic rhino-sinusitis ``` Signs and Sxs: (depends on the size of the polyp) no sx to nasal obstruction, postnasal drainage, Dull headaches, snoring, rhinorrhea, epistaxis, hyposmia or anosmia Often surgically removed and then return unless real cause is managed

Answer 89

Deviation from trauma- eg. boxers Perforation from chronic infection, crusting, nasal surgery, TB, syphilis, cocaine use Abscess - rare, dangerous, may lead to cavernous sinus thrombosis

Answer 90

Enlarged, bulbous, reddened nose; may obstruct breathing or vision Granulomatous infiltration/hypertrophy of sebaceous glands Associated with untreated acne rosacea, worsened by (but not caused by) alcoholism More common in men >50; significant psychological toll

Answer 91

> 30 million pts in the US have sinus disease Organisms: Viral (common, less severe); Bacterial (Staph, Strep, H. flu; more severe); Fungal (Mucor, Aspergillis) Predisposing factors: decongestants, fatigue, dental problems, food sensitivities, GI issues, septal deviation, large adenoids, foreign bodies

Answer 92

Acute and Chronic supperative sinusitis

Answer 93

Signs & Sxs: >1 week, but < 3 weeks duration (most improve within 7-10 days so the complaint of persistent or worsening symptoms may indicate a developing bacterial sinusitis.) nasal congestion, purulent drainage, and facial pain with headache pain is often exacerbated by leaning forward or any head movement may have dental pain or altered smell Kids: may complain of a daytime cough and persistent nasal discharge Symptoms by involved sinus: i. Maxillary: dull, throbbing pain in cheek, tender, painful max. teeth, tenderness over maxilla DDX infected tooth ii. Frontal: tenderness over forehead area, swelling of eyelids, frontal h/a iii. Ethmoid: pain more medial to eye, feels deep in head or eye, splitting h/a on one side, swelling of eyelids iv. Sphenoid: pain behind eye or in occiput or vertex, deeper pain, not local tenderness PE: purulent secretions in the middle meatus (highly predictive of maxillary sinusitis) fever is rare unless bacterial cause. (usu no fever if viral), facial tenderness to palpation or percussion, complete opacification of sinus on transillumination—sinus not patent partial opacification is a nonspecific finding, and it is not as reliable.

Answer 94

approximately 32 million cases/ year Etiology: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis > 70% of cases Osteo-meatal obstruction, allergies, polyps, immunodeficiency states, and dental problems Signs and Sxs: manifests more subtly than acute sinusitis; typical sx of acute sinusitis (facial pain and fever) are usually absent. nasal stuffiness, nasal discharge, postnasal drip, facial fullness headache, hyposmia, sore throat, chronic unproductive cough, fetid breath, malaise, exacerbation of asthma, unpleasant taste, dental pain, visual disturbances, sneezing stuffy ears PE: tenderness on palpation over frontal or maxillary sinuses - transillumination of maxillary or frontal sinuses shows little opacity - oropharyngeal erythema, purulent secretions check for dental caries Endoscopic (rhinoscopic) examination: Nasal mucosal erythema, edema, purulent secretions; check for nasal obstruction from deviated nasal septum or hypertrophied turbinates, check for nasal polyps Eye examination: conjunctival congestion, lacrimation, Check extraocular movements

Answer 95

i) orbital or periorbital cellulitis- edema, pain moving the eye, chemosis (conj. edema) - very sick pt. ii) cavernous sinus thrombosis - very dangerous, mortality 50% - high fever, chills, prostrated, comatose, change in mental status - arly signs - have deep eye pain, ocular palsy (III, IV, VI), diplopia - late sign- both eyes involved, edema, death within 2-3 days.

Answer 96

common sequellae to rhinosinusitis, “post-nasal drip” SSX: cough, rhinorrhea, frequent swallowing, halitosis, frequent spitting, tickling in throat, constant clearing of throat, chronic sore throat PE: may see tonsilloliths, cobblestoning of oropharyneal mucosa, tenderness of sinuses