L12 Allergic Rhinitis, Tinnitus, Urticaria Flashcards
Barotrauma
Damage/discomfort to the ear due to pressure differences b/w middle ear and outside world
Symptoms of barotrauma
pressure, pain, hearing loss, or tinnitus, possible hemotympanum, middle ear effusion, TM rupture
Treatment of barotrauma
avoidance, oral/nasal decongestants, swallowing, valsalva, chewing gum, time
if perilymphatic fistula (sensorineural hearing loss and vertigo) refer to ENT
Acoustic neuroma
vestibular schwannoma
Schwann cell tumors, arise from vestibular portion of CN VIII, slow growing, could result in facial nerve palsies due to compression
clinical presentation of Acoustic neuroma
unilateral sensorineural hearing loss and tinnitus, may cause gait disturbance or other CN involvement
Dx of Acoustic neuroma
audiometry as initial screening test
mri
Treatment of Acoustic neuroma
surgery, radiation, observation due to slow growth
Tinnitus
perception of sound in one or both ears, occurs more in males, associated with depression/anxiety
Tinnitus Etiology
Auditory causes: ototoxic medications, presbycusis, otosclerosis, vestibular schwannoma, chiari malformations, barotrauma,
pulsatile: vascular etiology
Ototoxic medications
aminoglycosides
presbycusis
SN hearing loss w/ aging
otosclerosis
hereditary disorder where bones fuse together
Chiari malformations
cerebellar tinnitus are lower than usual
Pulsatile tinnitus is most commonly caused by?
vascular etiology
Dx of tinnitus
Hx, Physical perform a complete head and neck exam, Auscultate for bruits in patients with possible vascular tinnitus, if pulsatile, refer to ENT
Tinnitus Tx
goal is to lessen awareness and impact on quality of life
behavioral therapy, benzos, white noise
Allergic rhinitis
PAROXYSMS OF SNEEZING, RHINORRHEA, AND NASAL OBSTRUCTION, and nasal obstruction, usually accompanied by itchy eyes, nose and palate
“hay fever” aka seasonal, vs perennial which occurs year round
Allergic rhinitis epidemiology
PEAK INCIDENCE IN CHILDHOOD/ADOLESCENCE, one of the most common chronic diseases in the U.S.
Lots of money and time lost due to this
pathophysiology of Allergic Rhinitis
PRODUCTION OF IGE ANTIBODIES triggering an immune response cascade
IgE binds to mast cells carrying histamine, next time exposed to allergen, histamine is released
Clinical presentation of Allergic rhinitis
RHINORRHEA, SNEEZING, NASAL CONGESTION, itchy eyes/nose/palate, postnasal drip, cough, fatigue
Risk factors of allergic rhinitis
FH of atopy, male, atopic triad, serum IgE above 100 before age 6, first born, early use of abs, maternal smoking
clinical evaluation of allergic rhinitis
personal or FH of allergic rhinitis, asthma, or eczema? 2nd hand smoke? potential triggers? impact on pt?
allergic rhinitis physical exam
Eyes: allergic shiners and denie-morgan lines, pale palpebral conjunctiva may be pale, swollen, conjunctival injection
Nose: pale boggy “BLUISH” mucosa, clear discharge, nasal crease
Throat: post-nasal drainage in posterior pharynx, cobblestoning
Ears: serous otitis media
“allergic shiners”
bluish purple rings around both eyes
Denie-morgan lines
skin folds under eyes consistent with allergic conjunctivitis
Diagnostic evaluation of Allergic Rhinitis
CLINICAL, allergy testing to confirmatory, but not necessary for initial dx
Allergy testing
skin testing: scratch or prick skin testing “wheal and flare” rxns normally occur 15-20 min, quick & cost effective, RISK FOR ANAPHYLACTIC RXN
Serum testing: immunoCAP, detects allergen-specific IgE antibodies, less risk but less sensitive, more expensive
Allergic rhinitis therapy
avoidance of allergens, INTRANASAL GLUCOCORTICOIDS, oral or intranasal antihistamines, sympathomimetics/decongestants, leukotriene receptor antagonists, immunotherapy
Avoidance of allergens
allergy is often caused more by the dander, saliva, & urine than hair
pharmacology of Allergic rhinitis for children <2 years old
cromolyn sodium nasal spray
2nd generation antihistamines: Zyrtec and allegra approved for children 6mo or older
pharmacology of allergic rhinitis for children 2 years to adults: Mild symptoms
EPISODIC SYMPTOMS
2nd generation oral antihistamines, antihistamine nasal sprays: azelastine > 5 yrs old, olopatadine (patinas) > 12 yrs, glucocorticoid nasal sprays, cromolyn nasal spray
pharmacology of allergic rhinitis for children 2 years to adults: Moderate-to Severe symptoms
GLUCOCORTICOID nasal sprays are considered 1st line treatment. risk for epistaxis, stay away from septum
special pharmacological considerations for Allergic Rhinitis
w/ asthma: montelukast (Singulair) useful additive therapy
w/ allergic conjunctivitis: glucocorticoid nasal spray and ophthalmic antihistamine drops (avoid nasal sprays in its with glaucoma or cataracts
special pharmacological considerations for pregnant & lactating pts with allergic rhinitis
allergen avoidance
use 2nd gen antihistamines (claritin or zyrtec), glucocorticoid nasal spray (rhinocort, flonase, nasonex)
lactating women: budesonide or cromolyn w/ or w/o cetirizine or loratadine
pharmacology of allergic rhinitis for children 2 years to adults: PERSISTENT moderate-to severe symptoms
in pts who FAIL TO RESPOND to initial glucocorticoid nasal spray…
antihistamine nasal spray, oral antihistamine, cromolyn nasal spray, montelukast (singular), oral antihistamine/decongestant combo
classifications of rhinitis
allergic, vasomotor, infectious
1st generation antihistamines
help alleviate sneezing, rhinorrhea, and itching
no relief of nasal congestion
chlorpheniramine 4mg q4-6 or 8-12mg BID
diphenhydramine 25mg BID-TID
side effects: dry mouth, constipation, SEDATION
2nd generation antihistamines
LESS SEDATING, same effect as gen 1, Loratadine 10 mg/d Fexofedadine 60 mg BID or 180 mg QD Cetirizine 5-10 mg/d *nasal antihistamines have the same effectiveness
sympathomimetics
decongestants, indicated for pts with marked nasal congestion despite antihistamine use
Vasoconstriction will decrease edema and secretions
pseudoephedrine 30-60mg q6-8h or 120 mg BID for sustained release
CAUTION: PTS WITH HYPERTENSION OR CARDIAC DISEASE BC OF VASOCONSTRICTION
immunotherapy
allergy shots
effective treatment for allergic conjunctivitis, rhinitis, and asthma
gradual admin of increasing amounts of allergen
requires lots of visits, treatment period lasts 3-5 years
pt education for allergic rhinitis
dust mine & mold avoidance
clean the house
humidifiers worsen sxs
close windows, HEPA filter
When to refer if pt has allergic rhinitis
severe or refractory sxs
allergic rhinitis AND asthma: consider pulm or allergist
recurrent sinusitis or otitis media: refer to ENT
Non-allergic rhinitis etiology
aka VASOMOTOR RHINITIS
abnormal AUTONOMIC responsiveness,
TRIGGERED BY STRESS, SEXUAL AROUSAL, PERFUMES, CIGARETTE SMOKE, TEMPERATURE CHANGES, usually occurs later in life, >20 y/o
Non allergic rhinitis, symptoms
NASAL CONGESTION, RHINORRHEA, POSTNASAL DRAINAGE, USUALLY NO OCULAR OR NASAL ITCHING, nasal mucosa may appear normal, erythematous, or boggy/edematous
treatment of non allergic rhinitis
avoid triggers, nasal glucocorticoids, antihistamine nasal sprays, IPRATROPIUM NASAL SPRAY (USE IF RHINORRHEA IS THE PROMINENT SYMPTOM) can also use oral decongestants, 1st generation oral antihistamines (anticholingergics)
Nasal polyps clinical presentation
pedunculate, non tender, gray soft tissue growths,
Nasal polyp symptoms
nasal congestion/obstruction, seen with allergic rhinitis, vasomotor rhinitis, chronic sinusitis, and asthma
Samter’s triad
Aspirin Exacerbated Respiratory Disease (AERD), aka Samter’s Triad or Aspirin Sensitive Asthma
Chronic medical condition that consists of asthma, recurrent sinus disease with nasal polyps, and a sensitivity to aspirin and other NSAIDs.
Treatment of nasal polyps
NASAL GLUCOCORTICOIDS
refer to ENT for obstructive symptoms
Rhinitis medicamentosa
regular use of OTC decongestant nasal spray (afrin) causes mucous membranes to become swollen and erythematous
>3 DAYS OF USE –> REBOUND CONGESTION
pts will increase freq of use and become dependent
Treatment of rhinitis medicamentosa
DISCONTINUE AFRIN, START NASAL GLUCOCORTICOID SPRAY
Urticaria
“hives”, welts, wheals
CIRCUMSCRIBED, RAISED, ERYTHEMATOUS PLAQUES, WITH OR WITHOUT CENTRAL PALLOR, intensely PRURITIC, raised wheals, pale to bright erythema
individual LESIONS ARE TRANSIENT (disappearing within 24 hrs)
acute urticaria
present less than 6 weeks
chronic urticaria
s/s recurring most days of the week for 6 wks or greater
pathophysiology of urticaria
mediated by CUTANEOUS MAST CELLS in superficial epidermis, RELEASE OF HISTAMINE, vasodilatory mediators causes itching and localized swelling, might be accompanied by angioedema
causes of urticaria
infections-viral, bacterial, parasitic allergic rxns to meds, foods insect stings/bites direct mast cell activation (morphine, codeine, radio-contrast agents) nsaids
diagnosis of urticaria
clinical based on H&P
review events in the hours before the rxn
there might not be lesions by the time of the visit, use pictures to verify type of irriation
urticaria might be confused with…
urticarial vasculitis, fixed (last longer than 24 hours), erythematous, painful, urticarial plaques, with blanching halos, leaves residual hyperpigmentation or purport, linked with SLE
treatment of urticaria
H1 HISTAMINE BLOCKER
1st gen-diphenhydramine, chlorapheniramine, hydroxyzine
2ND GENERATION - CETRIZINE, LORATIDINE, FEXOFENADINE* preferred first line treatment b/c of less side effects
can be combined with h2 histamine blocker (ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet)), or oral glucocorticoids if angioedema or persistent symptoms
Treatment of urticaria more specifically…
Cetirizine and levocetirizine may be more effective due to mast cell-stabilizing properties
if allergic etiology of urticaria is suspected
refer to allergist or may need epipen
