Lecture 11 Smith Flashcards
immunotherapy for allergic rhinitis
AKA allergy vaccine Very effective Long term plan Expensive Some risk: <1 death/million Many never complete the course of tx
rhinitis is marked by presence of what?
sneezing, rhinorrhea, nasal congestion, nasal itching
non allergic rhinitis
• Characterized by chronic presence of one or more o Nasal congestion o Rhinorrhea o Postnasal drainage
causes of nosocomial bacterial rhinitis
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
three types of nonallergic rhinitis
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
hallmark of ature rhinosinusitis? other sx?
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
anatomy of epistaxis
- 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
- Sphenopalatine artery supplies posterolateral wall and posterior choana
epistaxis risk factors
-
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
anterior nose bleeds etiology
- 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
what are the 4 H1 blockers you can use for allergic rhinitis?
Diphenhydramine, Chlorpheniramine, Hydroxyzine, Brompheniramine
physical exam findings for allergic vs non allergic vs viral rhinitis
o Allergic rhinitis: Nasal mucosa is edematous and pale, o Nonallergic rhinitis: normal in color o Acute viral rhinosinusitis/medicamentosa: beefy red
three subtyupes of chronic rhinitis
- CRS with nasal polyposis: 20-33% of cases
- CRS without nasal polyposis: 60-65% of cases
- Allergic fungal rhinosinusitis: 8-12% of cases
diff btw allergic rhinits and nonalelrgic rhinitis
allergic rhinitis: sneezing, rhinorrhea, nasal congestion, nasal itching nonallergic rhinitis: CHRONIC presence ofnasal congestion, rhinorrhea and/or post nasal drip
ohysicial exam findisngs for epistaxis
- Airway
- Vital signs: Shock?
- Mental Status
- Anterior/Posterior
- Evidence of trauma
- Pt. with recurrent: Look for signs of coagulopathy ecchymoses, petechiae, telangiectatic lesions
- Posterior Nosebleeds Etiology
- 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
- Carotid artery aneurysm
chronic rhinitis
- 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
advantage of 2nd gen H1 over first gen?
less sedating and longer acting loratidine, cetirizine, fexofenadine ect zyrtec, allegra, claratin
most common cause of acute rhinocinusitis
• 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
clinical presenration of chronic sinitis with nasal polyps
-
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
drugs that can cause rhinitis
o Nasal decongestantsRhinitis medicamentosa o Systemic meds AntiHTN: alpha blockers, ACEs, BBlockers, CCBs, HCTZ Erectile dysfunction drugs Some antidepressants, benzos, psychotropics, antiepileptics NSAIDs Estrogens
what Helps distinguish allergic rhinitis from most other forms of rhinitis?
NASAL ITCHING
physical exam findings of allergic rhinitis
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
differennce in imaging with chronic rhinits subtypes
-
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
- Hyperattenuated mucin with opacified sinuses
structural abnormalities caushing rhnitiis
Congenital or acquired: Enlarged adenoids, foreign bodies, septal deviation and perf, nasal polyps, Tumors
nasal polyps
large polups visioble with anterior rhinoscopt
smaller polyos require nasal endo or imaging
insenate
swollen nasal turbinates sometimes misten for nasal polyps
three types of NONallergic rhinitis?
vasomotor rhinitis, mixedrhinitis and gustatory rhinitis
how to dx fungal rhinitis
- Based on positive pathology of fungal invasion in affected areas
- Urgent surgical evaluation for both diagnostic biopsy and debridement
Systemic diseases causing rhinitis
o : CF, Sarcoidosis
what puts you at a big risk for chronic rhinitis?
asthma (20% pateients) or allergic rhinitis
ABX of choice for rhinitis
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
- Macrolides
how do children manifest nasal itching in allergic rhinitis?
Children often manifest this with nose rubbing Rather than complaining of itch
3 2nd gen H1 blockers
Loratidine, Cetirizine, fexofenadine
general pharm options for allergic rhinitis?
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
demonstatarion of mucosal disease in fungal rhinitis
- 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
ADR of 1st gen H1blockers?
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
4 classifications of rhinosinusitis
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
imaginging of choice for Acute rhinosinisitis with orbital intracranial or soft tissue involvement?
CT
Allergic Fungal Rhinosinusitis
-
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
-
Believed to result from chronic, intense allergic inflammation directed against colonized fungi
clinical presentation of fungal rhinitis
- 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
treatment for fungal rhinitis
amphoteracin B
voriconazole
environmental control options for allergic rhinitis
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
smith notation: 99.8/72/118/72/16/98
T/P/BP/RR/O2
treatment for 3 subtypes of fungal rhinits
-
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
- Oral steroids to shrink polyps
-
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
- Surgery to remove inspissated mucus
chronic rhinitis with nasal polubs
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
criteria forchronic rhinitis
- 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
occupational factors for allergic rhinitis?
animals, grains, chemicals, pollens, latex, carpeting
epistaxis tx
-
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
-
Anterior
key points for acute BACTRERIAL sinusitis
- Symptoms usually >10 days
- Purulent discharge
- Often unilateral, painful sinus, Worse with bending forward
- Frequently described as URI which began to improve, then worsened
pathogenesis of acute viral rhinitis
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
topical intranasal glucocorticoids
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
whats more effective on nasal congesting in allergic rhinitis?
GCs more effective than H1
rhinosinusitis vs sinusitis
rhinosinusitis is preferred over sinusitis as inflammation of sinuses rarely occurs without concurrent inflammation of hte nasal mucosa
diagnostic imaging for chornic rhinitis
-
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
-
Obstruction of ostiomeatal complex
Three classifications of allergic rhinitis
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
2nd gen H1 blockers
• 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
Sampter’s triad
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
three general tx options for allergic rhinitis?
evnironmental control (avoid allergens) pharmacotherapy immunotherapy
criteria for acute rhinosinusitis dx: major vs minor sx
- 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
comorbitities of allergic rhinitis
increased frequency of HA, Rhinosinusitis, Asthma
leukotriene receptor antagonist for allergic rhinitis
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
mast cell cstabilizer for allergic rhinitis
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
non allergic rhinitis is distinguished from allergic rhinitis by what?
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
what are the 1st gen vs 2nd gen topical intranasal GCs?
1st generation • 10-50% bioavailability Beclomethasone, Flunisolide, Bedesonide 2nd generation • Less bioavailability, less systemic effects Fluticasone propionate, Mometasone furoate, Fluticasone furoate
environmental factors for allergic rhiniits/
perennial allergies seasonal allergies in/outdoor air quality bugs, carpeting
one feature that separates allergic fungal rhinitis from CRS with nasal polyps
presence of alelrgic mucin that contains visible fungal hyphae
predisposing factors to bacterial rhinitis
- Allergy, Nasal mechanical obstruction, Tooth infection, Impaired mucociliary clearance (CF), immdef, smoker
treatment algorithm for bacterial rhinitis
- 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
- Although culture guided is optimal, obtaining suitable cultures requires endoscopy or antral puncture
2 things that increase risk of allergic rhinitis?
eczema and asthma
CRS without polyposis
- 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
nasal functions
olfaction filtration humidification (air warming) vocal resonance aesthic function
what is the MOST EFFECTING SINGLE MAINTENANCE TX FOR ALLERGIC RHINITIS?
topical intranasal glucocorticoids MOST EFFECTING SINGLE MAINTENANCE TX FOR ALLERGIC RHINITIS
rhinitis of pregnancy
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
what are the 4 sinusues? which cant be palpated?
maxillary frontal ethmoid CANT PALPATE ETHMOID
most ocmmon type of nonallergic rhinitis?
mixed: combo of allergic and nonalelrgic rhinitis: 45% of population
prognosis for rhinitis
- 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
most common cause of bacterial sinusitis?
strep pneumo and H. flu (75%) other MCAT
tx for acute viral rhinosinustitis
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)
allergic fungal rhinositisus presentation
-
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
acute fungal rhinitis
- Disease of immunocompromised patients
- Patients with poorly controlled diabetes
- Most common species: Mucor, Rhizopus, aspergillus, absidia, basidiobolus
- Aspergillus Most common colonizers of sinuses
diagnostics of rhinosinusitis
- 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
physical exam findings for acute rhinosinusitis
- Otoscopic exam
- Findings
- Diffuse mucosal edema
- Narrowing of middle meatus
- Inferior turbinate hypertrophy
- Copious rhinorrhea or purulent discharge
- Polyps or septal deviation
*