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Clinical Medicine > Lecture 11 Smith > Flashcards

Lecture 11 Smith Flashcards

1
Q

immunotherapy for allergic rhinitis

A

AKA allergy vaccine  Very effective  Long term plan  Expensive  Some risk: <1 death/million  Many never complete the course of tx

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2
Q

rhinitis is marked by presence of what?

A

sneezing, rhinorrhea, nasal congestion, nasal itching

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3
Q

non allergic rhinitis

A

• Characterized by chronic presence of one or more o Nasal congestion o Rhinorrhea o Postnasal drainage

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4
Q

causes of nosocomial bacterial rhinitis

A

extended ICU stays, bur vistins, nasotrach intubation

affects 1:8 ICI patients, fever with unknown origin

  • Gram negative: pseudomonas, GNRs (klebsiella, Enterobacter, proteus, serratia) or GP Staph
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5
Q

three types of nonallergic rhinitis

A

o Vasomotor rhinitis  Intermittent symptoms of congestion and/or watery discharge  Exaggerated reaction to non specific irritants o Mixed Rhinitis  Combo of allergic and non allergic  Most common form, 45% of population o Gustatory Rhinitis  Episodic condition  Prominent watery rhinorrhea • Triggered most often by hot or spicy foods Caused by vagally mediated reflex

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6
Q

hallmark of ature rhinosinusitis? other sx?

A

FAICIAL PAIN/PRESSURE BENDING FORWARD  Symptoms: < 4 weeks (often <10 days) • Nasal congestion/ obstruction • Purulent nasal discharge • Fever and fatigue • Cough • Hyposmia/anosmia • Ear pressure • HA • maxillary tooth discomfort: Won’t have mandibular tooth discomfort because no sinuses by mandible • Halitosis • Facial pain/pressure worse with bending forward • Tenderness to sinus percussion • +/- fever • TM erythema/pus

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7
Q

anatomy of epistaxis

A
  • Classified as anterior or posterior Depending on source
    • Anterior far more common
  • Large proportion self limited and can be managed definitively in primary care
  • Up to 90% occur within vascular watershed area of the nasal septum Known as Kiesselbach’s plexus
  • Posterior bleeds
    • Sphenopalatine artery supplies posterolateral wall and posterior choana
      • Most common source of posterior bleeds
    • Posterior bleeds can result in significant hemorrhage
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8
Q

epistaxis risk factors

A
  • Risk Factors
    • Anticoagulated patients: High risk
    • Patient with hereditary hemorrhagic telangiectasia disease (Osler-Weber-Rendu)
    • Bleeding can be difficult to control in these individuals
    • Patient with familial blood dyscrasia
      • Platelet disorders: Von Willebrand, Hemophilia
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9
Q

anterior nose bleeds etiology

A
  • By far most common
  • Nose picking very common
  • Mucosal trauma/irritationàLow moisture content in ambient air results in mucosal dryness and irritation
  • Allergic or viral rhinitis à mucosal hyperemia
  • Foreign body àEsp. if bleeding accompanied by purulent discharge
  • Facial trauma from MVC àBlunt facial impact of ANTERIOR bleed
  • Chronic excoriation: CocaineàLeads to small septal perforations
  • OTC nasal sprays
  • Nasal steroids:
  • Alcohol
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10
Q

what are the 4 H1 blockers you can use for allergic rhinitis?

A

Diphenhydramine, Chlorpheniramine, Hydroxyzine, Brompheniramine

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11
Q

physical exam findings for allergic vs non allergic vs viral rhinitis

A

o Allergic rhinitis: Nasal mucosa is edematous and pale, o Nonallergic rhinitis: normal in color o Acute viral rhinosinusitis/medicamentosa: beefy red

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12
Q

three subtyupes of chronic rhinitis

A
  • CRS with nasal polyposis: 20-33% of cases
  • CRS without nasal polyposis: 60-65% of cases
  • Allergic fungal rhinosinusitis: 8-12% of cases
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13
Q

diff btw allergic rhinits and nonalelrgic rhinitis

A

allergic rhinitis: sneezing, rhinorrhea, nasal congestion, nasal itching nonallergic rhinitis: CHRONIC presence ofnasal congestion, rhinorrhea and/or post nasal drip

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14
Q

ohysicial exam findisngs for epistaxis

A
  • Airway
  • Vital signs: Shock?
  • Mental Status
  • Anterior/Posterior
  • Evidence of trauma
  • Pt. with recurrent: Look for signs of coagulopathy ecchymoses, petechiae, telangiectatic lesions
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15
Q
  • Posterior Nosebleeds Etiology
A
    • Carotid artery aneurysm
      * Particular concern for: Pt with prior Hx of head and neck surgery
      * Following trauma: Pseudoaneurysm
      • Most often posterior arise spontaneously
      • Nasal neoplasm
        • SCC, Common
        • Adenoid cystic carcinoma
        • Melanoma
        • Inverted papilloma
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16
Q

chronic rhinitis

A
  • Inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer
  • May begin as nonspecific URI that fails to resolve
  • May develop slowly and insidiously over months-years\
  • Risk Factors
    • Allergic Rhinitis
    • Asthma: 20% of pts. have asthma
    • CRS patients are typically sensitized to perennial rather than seasonal allergies All year long
    • Smoking
    • Immunodeficiency
    • Defects in mucociliary clearance: CF, Nasal polyps
    • Anatomic abnormalities
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17
Q

advantage of 2nd gen H1 over first gen?

A

less sedating and longer acting loratidine, cetirizine, fexofenadine ect zyrtec, allegra, claratin

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18
Q

most common cause of acute rhinocinusitis

A

• o Most common is viral infection o Complicated by bacterial infection only 0.5-2% of episodes  Most common viruses • Rhinovirus: Most common • Influenza • Parainfluenza

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19
Q

clinical presenration of chronic sinitis with nasal polyps

A
  • Clinical Presentation
    • Gradually worsening nasal congestion/obstruction
    • Sinus fullness and pressure
    • Fatigue
    • Posterior nasal drainage
    • Hyposmia or anosmia
    • Fever and severe facial pain are uncommon
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20
Q

drugs that can cause rhinitis

A

o Nasal decongestantsRhinitis medicamentosa o Systemic meds  AntiHTN: alpha blockers, ACEs, BBlockers, CCBs, HCTZ  Erectile dysfunction drugs  Some antidepressants, benzos, psychotropics, antiepileptics  NSAIDs  Estrogens

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21
Q

what Helps distinguish allergic rhinitis from most other forms of rhinitis?

A

NASAL ITCHING

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22
Q

physical exam findings of allergic rhinitis

A

o Patients may have allergic shiners o Nasal crease from repeated rubbing nose and pushing tip of nose up with hand in response to nasal itching  “Allergic Salute” o Pale or bluish boggy mucosa o Clear mucous o Polyps o Septal issues

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23
Q

differennce in imaging with chronic rhinits subtypes

A
  • Imaging for CRS with NP
    • CT shows characteristically marked and bilateral mucosal thickening
    • CT density of polyps is similar to that of thickened mucosa
      • Polyps are differentiated by shape
    • Sinus opacification in the absence of facial pain/pressure/HA
      • Typical of CRS with NP and unlikely to represent chronic bacterial infection
  • Imaging for CRS without NP
    • CT shows sinus opacification or sinus obstruction with non polypoid mucosal thickening of the associated sinus cavity
  • Imaging for Allergic Fungal Rhinosinusitis
    • CT reveals nasal polyposis with opacification of one or more sinuses
    • Characteristic finding
      • Hyperattenuated mucin with opacified sinuses
        • Indicate dense accumulations of allergic mucin
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24
Q

structural abnormalities caushing rhnitiis

A

 Congenital or acquired: Enlarged adenoids, foreign bodies, septal deviation and perf, nasal polyps, Tumors

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25
Q
A
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26
Q

nasal polyps

A

large polups visioble with anterior rhinoscopt

smaller polyos require nasal endo or imaging

insenate

swollen nasal turbinates sometimes misten for nasal polyps

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27
Q

three types of NONallergic rhinitis?

A

vasomotor rhinitis, mixedrhinitis and gustatory rhinitis

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28
Q

how to dx fungal rhinitis

A
  • Based on positive pathology of fungal invasion in affected areas
  • Urgent surgical evaluation for both diagnostic biopsy and debridement
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29
Q

Systemic diseases causing rhinitis

A

o : CF, Sarcoidosis

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30
Q

what puts you at a big risk for chronic rhinitis?

A

asthma (20% pateients) or allergic rhinitis

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31
Q

ABX of choice for rhinitis

A

ammox previously, now Augmentin, increase Hflu and Mcat coverage

can be BID/TID, and high dose recommended

or Doxy is good choice, less on the macrolides and perhaps FQ

  • Amoxicillin
    • Previously recommended 1st line because narrow spectrum and low cost
    • Increasing emergence of resistance Particularly to H. flu and pneumo
    • Rates vary regionally: 27-43% resistance
  • Augmentin
    • Improved coverage for H. flu resistance as well as M. cat
    • BID or TID
    • High dose recommended
      • In regions with S. pneumo resistance greater than 10%
      • 65 years or older
      • Recently hospitalized
      • Failed abx treatment in previous month
      • Immunocompromised
    • Doxycycline
      • Reasonable alternative for first line therapy
      • DOC for PCN allergy
      • Remember to tell patient to avoid direct sunlight
      • Other
        • Macrolides
          • Would not use
        • Resp. FQ’s (levo or moxi)
          • Another option for PCN allergy
          • Last line if pt has failed doxy or augmentin or is really sick
        • Bactrim
          • Rarely used
        • 2nd or 3rd generation cephalosporins
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32
Q

how do children manifest nasal itching in allergic rhinitis?

A

 Children often manifest this with nose rubbing Rather than complaining of itch

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33
Q

3 2nd gen H1 blockers

A

Loratidine, Cetirizine, fexofenadine

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34
Q

general pharm options for allergic rhinitis?

A

1 Topical intranasal glucocortioids: MOST EFFECTING SINGLE MAINTENANCE TX FOR ALLERGIC RHINITIS oral histamines 1st gen H1 blockers 2nd gen H1 blockers leukotriene receptor antagonists mast cells stabilizers combo of the above

35
Q

demonstatarion of mucosal disease in fungal rhinitis

A
  • Purulent mucus or edema in middle meatus or ethmoid regions
  • Polyps in nasal cavity or middle meatus
  • Anterior rhinoscopy may see
    • Purulent mucus emanating from middle meatus
    • Edematous hyperemic mucosa
    • Polypoid mucosal changes
    • Frank polyposis
36
Q

ADR of 1st gen H1blockers?

A

 1st generation: Significant sedation (lipophilic, BBB) • Adverse effects on intellectual and motor function o Even in absence of subjective awareness of sedation o Prohibited in many states for transportation workers

37
Q

4 classifications of rhinosinusitis

A

o Acute rhinosinusitis: Symptoms <4 weeks  Acute Viral (AVRS)  Acute Bacterial (ABRS) o Subacute Rhinosinusitis: Symptoms 4-12 weeks o Chronic rhinosinusitis: >12 weeks o Recurrent acute rhinosinusitis: Four or more episodes of ARS/year with interim sx resolution

38
Q

imaginging of choice for Acute rhinosinisitis with orbital intracranial or soft tissue involvement?

A

CT

39
Q

Allergic Fungal Rhinosinusitis

A
    • Believed to result from chronic, intense allergic inflammation directed against colonized fungi
      • Patients are Immunocompromised and Show evidence of allergy to one or more fungi
      • AFRS is distinguished from CRS with NP by
        • Presence of allergic mucin that contains viable fungal hyphae
40
Q

clinical presentation of fungal rhinitis

A
  • Immunocompromised patient with sinus complaints, Particularly facial pain
  • Nasal congestion
  • +/- Fever
  • Epistaxis
  • Facial numbness/diplopia if CNs involved
  • Necrotic tissue in nares/oropharynx
    • Can appear as Palatal or gingival eschars or Sloughing of the nasal septum with perforation
41
Q

treatment for fungal rhinitis

A

amphoteracin B

voriconazole

42
Q

environmental control options for allergic rhinitis

A

o Close windows and doors o Shower before bed o Change AC filters and use good ones o Mattress and pillow covers o Pest control o Avoid known triggers

43
Q

smith notation: 99.8/72/118/72/16/98

A

T/P/BP/RR/O2

44
Q

treatment for 3 subtypes of fungal rhinits

A
  • Treatment for all three
    • Many cases cannot be cured
    • Goal of therapy is to reduce symptoms and improve quality of life
    • CRS with NP
      • Oral steroids to shrink polyps
        • Sometimes can shrink enough that surgery isn’t necessary
      • Nasal steroids to follow
      • Add leukotriene inhibitor for maintenance therapy
        • Decrease congestion
    • CRS without NP
      • Oral steroids
      • ABX for approx. 6 weeks (7 days after symptoms clear)
      • Follow with nasal steroids
      • 2nd gen H1 antihistamines
        • Zyrtec
        • Allegra
      • Leukotriene inhibitors
    • Allergic Fungal
      • Surgery to remove inspissated mucus
        • Thickened mucus
      • Prolonged course of oral steroids
45
Q

chronic rhinitis with nasal polubs

A

NON TENDER

  • Characterized by presence of bilateral nasal polyps
  • Polyps are
    • Translucent
    • Yellowish-gray to white
    • Glistening massed filled with gelatinous material, which may form in nasal cavity or paranasal sinuses
    • Gray-white color due to relatively avascular nature of the polyps
    • Large polyps are often visible with anterior rhinoscopy
      • Smaller polyps require nasal endoscopy or imaging
    • Insensate
    • Swollen nasal turbinates sometimes mistaken for nasal polyps
      • Similar in appearance, but these are VERY sensitive to touch
46
Q
A
47
Q

criteria forchronic rhinitis

A
  • 12 week duration
  • 4 cardinal symptoms must be present for diagnosis
    • Anterior and/or posterior mucopurulent drainage
    • Nasal obstruction, Bilateral
    • Facial pain/pressure/fullness
    • Hyposmia: Decreased sense of smell
    • **At least 2 of these symptoms must be present to consider diagnosis**
    • **In children, fourth sign is cough NOT hyposmia**
  • Also there must be evidence of mucosal inflammation to confirm CRS
  • The four cardinal symptoms may be present with any subtype of CRS and do not differentiate the subtypes
48
Q

occupational factors for allergic rhinitis?

A

animals, grains, chemicals, pollens, latex, carpeting

49
Q

epistaxis tx

A
  • Treatment
    • Anterior
      • Compression of nares continuously for 15 minsà Pt sitting/leaning forward
      • Short-acting topical nasal decongestants : Neosynephrine, Phenylephrine
      • Topical 4% cocaine applied either as a spray or on a cotton stripàAnesthetic and vasoconstrictor
      • Bleeding site may be cauterized with silver nitrate or electrocautery
    • Posterior
      • Topical sympathomimetics and various nasal tamponade methods are usually effective
      • In emergency, double balloon packs may facilitate rapid control with little or no mucosal trauma
      • NT consult for a pack to occlude the choana before placing pack anteriorly
          • ABX coverage is to avoid Toxic Shock
50
Q

key points for acute BACTRERIAL sinusitis

A
  • Symptoms usually >10 days
  • Purulent discharge
  • Often unilateral, painful sinus, Worse with bending forward
  • Frequently described as URI which began to improve, then worsened
51
Q

pathogenesis of acute viral rhinitis

A

 Acute viral rhinitis begins with viral inoculation via contact with conjunctiva or nasal mucosa • Viral replication leads to detectable levels in 8-10 hours • If symptoms develop it is usually first day after inoculation  Viral Rhinitis then spreads to sinuses by direct or indirect routes • Nose blowing propels fluid from nasal cavity to sinuses inflammation • Direct toxic effect on nasal cavity cilia causing decreased motility • Mucosal edema, thick secretions, and ciliary dyskinesia obstruct sinuses and perpetuate process

52
Q

topical intranasal glucocorticoids

A

 Most effective single maintenance for allergic rhinitis  Work on congestions  Onset: Few hours; Maximal effect may require several days/weeks  Should be tapered to lowest effective dose once sx controlled  1st generation • 10-50% bioavailability • Beclomethasone, Flunisolide, Bedesonide  2nd generation • Less bioavailability, less systemic effects • Fluticasone propionate, Mometasone furoate, Fluticasone furoate

53
Q

whats more effective on nasal congesting in allergic rhinitis?

A

GCs more effective than H1

54
Q

rhinosinusitis vs sinusitis

A

rhinosinusitis is preferred over sinusitis as inflammation of sinuses rarely occurs without concurrent inflammation of hte nasal mucosa

55
Q

diagnostic imaging for chornic rhinitis

A
  • Diagnostics for all three types
    • Sinus CT is imaging modality of choice
    • Most common findings: Mucosal thickening Suggestive of infection/obstruction of a sinus ostum
      • Obstruction of ostiomeatal complex
        • Variable degrees of sinus ostial obstruction are common in CRS
      • Sinus opacification
        • Complete filling of sinus with inflammatory material or fluid
        • May be seen with
          • Persistent bacterial infection
          • Purulent secretions, mucus
          • Insipissation
          • Polypoid mucosal thickening
          • Or an accumulation of allergic mucin
56
Q

Three classifications of allergic rhinitis

A

Intermittent: Symptoms occur in response to specific exposur such as cats Seasonal: Symptoms occur at certain times of year  Patients with his have associated allergic conjunctivitis in 70% of cases Itchy, red, watery eyes Persistent/Perennial: Symptoms occur year round

57
Q

2nd gen H1 blockers

A

• Developed to avoid CNS effects: Lipophobic • Onset: 1 hour, Peak in 2-3 • Longer acting: Dosed once or twice daily • Reduces itching, sneezing, and rhinorrhea o Less impact on nasal congestion as steroids • Meds: Loratidine, Cetirizine, fexofenadine

58
Q

Sampter’s triad

A

Asthma

CRS with NP

Aspirin sensitivity

  • Aspirin exacerbated respiratory disease
  • Hypersensitivity is COX-1 basedà Blockage leads to excess of leukotrienes
  • AKA triad asthma
  • Pts with CRS with NP
    • 30-40% report wheezing and respiratory discomfort
    • 15% have aspirin associated respiratory disease
  • For patients whose asthma begins as an adult
    • The cause is not true allergy
  • Condition in which patients have a combo of symptoms
    • Such as airway problems like asthma
    • Nasal problems like blockage and polyps
    • Then develop a hypersensitivity to aspirin
59
Q

three general tx options for allergic rhinitis?

A

evnironmental control (avoid allergens) pharmacotherapy immunotherapy

60
Q

criteria for acute rhinosinusitis dx: major vs minor sx

A
  • Major symptoms
    • Purulent anterior/posterior nasal discharge
    • Nasal congestion or obstruction
    • Facial congestion or fullness
    • Hyposmia or anosmia
    • Fever (for acute sinusitis only)
  • Minor symptoms
    • HA
    • Ear pain/pressure/fullness
    • Halitosis
    • Dental pain
    • Fever: For subacute or chronic type
    • Fatigue
61
Q

comorbitities of allergic rhinitis

A

increased frequency of HA, Rhinosinusitis, Asthma

62
Q

leukotriene receptor antagonist for allergic rhinitis

A

 Nasal congestion correlates best with leukotriene levels  Sneezing and itching correlate with histamine levels  In US, three are approved for asthma use • Only montelukast is approved for allergic rhinitis o Less effective than nasal steroids  Once daily pill

63
Q

mast cell cstabilizer for allergic rhinitis

A

Inhibit mast cell release of histamine and other inflammatory mediators  Cromolyn sodium  Blocks Sx associated with intermediate and late phase nasal allergen challenge  Effective in doing so when used shortly before allergen inhalation  No serious ADRs  OTC as nasal spray  Less effective than steroids  Very safe, Safe in kids • BUT must be dosed often and is less effective o Can try if other agents aren’t tolerated well

64
Q

non allergic rhinitis is distinguished from allergic rhinitis by what?

A

o Onset at later age o Absence of nasal and ocular itching and prominent sneezing o Nasal congestion and postnasal drainage are prominent Sx o Symptoms are perennial, Year round

65
Q

what are the 1st gen vs 2nd gen topical intranasal GCs?

A

1st generation • 10-50% bioavailability Beclomethasone, Flunisolide, Bedesonide  2nd generation • Less bioavailability, less systemic effects Fluticasone propionate, Mometasone furoate, Fluticasone furoate

66
Q

environmental factors for allergic rhiniits/

A

perennial allergies seasonal allergies in/outdoor air quality bugs, carpeting

67
Q

one feature that separates allergic fungal rhinitis from CRS with nasal polyps

A

presence of alelrgic mucin that contains visible fungal hyphae

68
Q

predisposing factors to bacterial rhinitis

A
  • Allergy, Nasal mechanical obstruction, Tooth infection, Impaired mucociliary clearance (CF), immdef, smoker
69
Q

treatment algorithm for bacterial rhinitis

A
  • May resolve spontaneously within first 10 days
  • Patients with <10 days of symptoms get supportive care
    • Analgesics, Intranasal steroids, Oral decongestants, Antihistamines, Mucolytics
  • Patients with >10 days of symptoms get antibiotics
    • Decision based on severity and reliability of patient for follow up
    • Most often initiated empirically Assuming its S. pneumo or H. Flu
      • Although culture guided is optimal, obtaining suitable cultures requires endoscopy or antral puncture
        • Generally reserved for patients with complications
70
Q

2 things that increase risk of allergic rhinitis?

A

eczema and asthma

71
Q

CRS without polyposis

A
  • Persistent sx with periodic exacerbations characterized by Inc. facial pain And/or inc. drainage
    • Fatigue
    • Fever is usually absent or low grade
    • Subset have recurrent acute rhinosinusitis symptoms: Respond well to antibiotics
72
Q

nasal functions

A

olfaction filtration humidification (air warming) vocal resonance aesthic function

73
Q

what is the MOST EFFECTING SINGLE MAINTENANCE TX FOR ALLERGIC RHINITIS?

A

topical intranasal glucocorticoids MOST EFFECTING SINGLE MAINTENANCE TX FOR ALLERGIC RHINITIS

74
Q

rhinitis of pregnancy

A

 Nasal congestion in last six or more weeks, Without signs of respiratory tract infection  No known allergic cause  Disappears completely within 2 weeks after delivery

75
Q

what are the 4 sinusues? which cant be palpated?

A

maxillary frontal ethmoid CANT PALPATE ETHMOID

76
Q

most ocmmon type of nonallergic rhinitis?

A

mixed: combo of allergic and nonalelrgic rhinitis: 45% of population

77
Q

prognosis for rhinitis

A
  • Expect to see response to abx after 3-5 days
  • If fails to respond, or worsens after 2-3 days à high dose augmentin
    • Some response should be seen to this
  • If pt has orbital, epidural, or brain abscess OR meningitis à prompt hospital admission
78
Q

most common cause of bacterial sinusitis?

A

strep pneumo and H. flu (75%) other MCAT

79
Q

tx for acute viral rhinosinustitis

A

resolves in 1o days, treat for nasal obstruction and rhinorrhea

fluids + OTC decongestions (3-5 days)

intranasal steroids

tx does not shorten clinical corse

other tx: analgesics, decongestants, H1s, mucolytics, itnransal steroids, saline irragation (netipod)

80
Q

allergic fungal rhinositisus presentation

A
  • Presentation
    • Subtly over years
    • Symptoms similar to CRS with NP
    • Patients usually have nasal polyposis
    • May report semi-solid nasal crusts or rubbery gobs of dark colored mucus periodically expelled
    • Fever uncommon
    • Occasionally presents dramatically: Complete nasal obstruction, Gross facial asymmetry And/or visual chg
81
Q
A
82
Q

acute fungal rhinitis

A
  • Disease of immunocompromised patients
  • Patients with poorly controlled diabetes
  • Most common species: Mucor, Rhizopus, aspergillus, absidia, basidiobolus
    • Aspergillus Most common colonizers of sinuses
83
Q

diagnostics of rhinosinusitis

A
  • Nasal Culture
    • viral unnecessary, bacterial unreliable, cant swab sinus
    • treat empiracally
  • endoscopic cx
    • performed by ENT when patient not responding to empiric tx
  • XR: not indicated in initial eval, cant distinguish viral vs bacterial
  • CT : can see air fluid levels, air in sinuses, mucosal abnormaity
    • IMAGING OF CHOICE for involvement of orbit, intracranial or soft tissue
  • MRI: not indicated
84
Q

physical exam findings for acute rhinosinusitis

A
  • Otoscopic exam
  • Findings
    • Diffuse mucosal edema
    • Narrowing of middle meatus
    • Inferior turbinate hypertrophy
    • Copious rhinorrhea or purulent discharge
    • Polyps or septal deviation
      *

Clinical Medicine (11 decks)

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