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CM 1B: ID/EENT > Lecture 8: Nose and Paranasal Sinuses > Flashcards

Lecture 8: Nose and Paranasal Sinuses Flashcards

1
Q

Define coryza.

A

Symptoms of a cold.
* Inflammation of mucous membranes lining the nasal cavity.
* Usually involves nasal discharge

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2
Q

Define Rhinitis vs rhinosinusitis.

A
  • Rhinitis: Symptomatic disorder to the nose itself, characterized by itching, discharge, sneezing and obstruction.
  • Rhinosinusitis: Symptomatic inflammation of the nasal cavity and paranasal sinuses.
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3
Q

What is the medical term for a common cold?

A

URI, upper respiratory tract infection.

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4
Q

How common is an URI?

A
  • 40% of all sick time is due to it
  • 6-12 episodes in children annually.
  • 2-3 episodes in adults annually.
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5
Q

What is the most common virus to cause an URI?

A

Rhinovirus.

30-50%

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6
Q

How is an URI transmitted?

A
  • Contact
  • Droplet
  • Surface to surface
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7
Q

When is someone at peak levels of viral shedding for an URI?

A

2nd-3rd day of illness.

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8
Q

What are the main risk factors for contracting an URI?

A
  • Expsure to children in daycare
  • Psychological stress
  • Less sleep and pre-existing sleep disturbances
  • Moderate physical exercise decreases the risk
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9
Q

What are the 3 most common symptoms of an URI?

A
  • Rhinitis
  • Nasal Congestion
  • Runny nose (rhinorrhea)
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10
Q

What should NOT be present in an URI?

A

Abnormal lung sounds.

That would suggest lower.

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11
Q

What are some common signs of an URI on PE?

A
  • Nasal mucosal swelling
  • Nasal discharge or congestion
  • Pharyngeal erythema
  • Conjunctival injections
  • Possible fluid in TM.
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12
Q

What is the treatment for an URI?

A
  • NO ABX
  • NSAIDs/acetaminophen
  • Fluids
  • NS
  • Oral/nasal decongestants
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13
Q

Clinical

What are the first two sinuses present at 1 year old?

A

Maxillary and ethmoid only.

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14
Q

Clinical

Which sinuses develop after age 2?

A

Sphenoid: start develop during first two years of life, completing full growth and size at age 12

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15
Q

Clinical

Which sinuses develop after age 12?

A

Frontal: full completion not until adolescence

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16
Q

What is the most common sinus infected in acute bacterial rhinosinusitis?

A

Maxillary

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17
Q

What is the MC cause of acute bacterial rhinosinusitis?

A

Previous viral URI will predispose someone.

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18
Q

What are the 4 MC causes of acute bacterial rhinosinusitis?

A
  • Viral URI (MC)
  • Allergic rhinitis
  • NG tube
  • Dental infections
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19
Q

What is the most common bacteria to cause acute bacterial rhinosinusitis?

A

Strep Pneumo

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19
Q

What 3 pathophysiologies contribute to the development of acute bacterial rhinosinusitis?

A
  • Impaired mucociliary clearance
  • Inflammation of the nasal mucosa
  • Obstruction of the ostiomeatal complex (sinus pore)
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20
Q

How does maxillary sinus rhinosinusitis present in terms of pain?

A
  • UNILATERAL facial fullness, pressure, tenderness over cheek
  • Referred pain to upper incisor or canine teeth.
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20
Q

How does ethmoid rhinosinusitis present in terms of pain?

A
  • Usually accompanies maxillary.
  • Pain or pressure on high lateral wall of nose, often referred to the orbits.
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21
Q

How does sphenoid rhinosinusitis present in terms of pain?

A
  • Pansinusitis (all sinuses on one side)
  • Pain referred to vertex of head.
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22
Q

How does frontal rhinosinusitis present in terms of pain?

A
  • Pain and tenderness on forehead.
  • Pain elicited by palpation of orbital roof below medial end of eyebrow.
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23
Q

What is halitosis?

A

Bad-breath caused by bacteria.

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24
Q

What is the diagnostic criteria for acute bacterial rhinosinusitis?

A
  • S/S of acute rhinitis lasting 10+ days without improvement.
  • Onset of severe S/S with high fever and purulent discharge lasting 3-4 days
  • Symptoms of typical viral URI slowly improving but then worsening with more severe S/S after 5-6 days.

At least 1 of these present.

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25
Q

How do we diagnose acute bacterial sinusitis?

A

Clinically

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26
Q

What is the diagnostic tool of choice for acute bacterial sinusitis?

A

CT Scan.

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27
Q

Why are nasal cultures not preferred for acute bacterial rhinosinusitis?

A
  • Not reliable
  • Not useful
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27
Q

What is nosocomial sinusitis? MCC 3 bacteria?

A

Complication of a critically ill patient.
MCC 3 causes:
* S. aureus
* P. aeruginosa
* Anaerobes

CT scan to confirm

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28
Q

When are ABX indicated for acute bacterial rhinosinusitis?

A
  • When S/S persist past 7-10 days.
  • When S/S start including severe fever, facial pain, or swelling
  • Immunodeficient or complications (spreading)
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29
Q

What is rhinitis medicamentosa? What generally causes it?

A

Oxymetazoline drops, which are decongestants but may cause rebound congestion, which is rhinitis medicamentosa.

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30
Q

What is the ABX of choice for acute, uncomplicated, bacterial rhinosinusitis? Complicated?

A
  • Uncomplicated: Augmentin 500mg/125mg PO TID or 875mg PO BID.
  • Complicated: Augmentin 2g PO BID.
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31
Q

What are the alternatives to augmentin if a patient is allergic (anaphylaxis) for acute bacterial rhinosinusitis?

A
  • Doxycycline
  • Levofloxacin
  • Moxifloxacin
  • Azithromycin
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32
Q

What are the alternatives to augmentin for acute bacterial rhinosinusitis if a patient can tolerate a cephalosporin?

A

Clinda + 3rd gen cephalosporin (cefixime or cefpodoxime)

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33
Q

What other management is indicated for acute bacterial rhinosinusitis?

A
  • ABX for 7-10 days
  • Intranasal corticosteroids
  • NSAIDs for pain
  • Nasal saline lavage
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34
Q

What are the most concerning complications associated with acute bacterial rhinosinusitis and the sinuses involved?

A
  • Orbital cellulitis and abscess (ETHMOID)
  • Front subperiosteal abscess (Pott’s puffy tumor - frontal bone osteomyelitis)
  • Intracranial complications
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35
Q

What kind of patients typically develop invasive fungal sinusitis?

A

Immunocompromised patients

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36
Q

What findings would be suggestive of invasive fungal sinusitis?

A
  • Clear nasal discharge
  • Black eschar on middle turbinate
  • Orbital and cavernous sinus symptoms
  • CN V and VII involvement in severe cases
  • Bony erosions
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37
Q

What qualifies as chronic sinusitis?

A
  • Symptoms persisting > 12 weeks
  • Constant sinus pressure
  • Constant nasal congestion
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38
Q

How do we diagnose chronic sinusitis?

A

CT scan

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39
Q

How do we treat chronic sinusitis?

A
  • ENT
  • ABX with culture guidance (usually augmentin empirically)
  • Intranasal corticosteroids
  • Nasal saline irrigation
  • Sinus surgery (if tx failed)
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40
Q

Who is chronic fungal sinusitis MC in?

A
  • Older patients
  • Mild immunocompromised patients (DM2, low dose steroids)
41
Q

How does chronic fungal sinusitis typically present?

A
  • Mycetoma
  • Non-specific mucosal changes on CT
  • Opaque sinus (single)
42
Q

How do we confirm chronic fungal sinusitis?

A
  • Histiopathologic confirmation via biopsy from nasal endoscopy.
  • CT to determine extent of the disease
43
Q

How do we treat chronic fungal sinusitis?

A
  • Ampho B, then itraconazole
44
Q

What are the risk factors for allergic fungal sinusitis?

A
  • Hx of nasal polyposis and asthma
  • Multiple sinus surgeries
  • Thick, esosinophilic mucous and fungal debris
  • High levels of IgE
44
Q

How do we treat allergic fungal sinusitis?

A
  • Endoscopic sinus surgery to remove mucin and debris
  • Post-op systemic steroids
45
Q

What is Wegener’s Granulomatosis?

A
  • Granulomatosis with polyangitis
  • Inflammation of the blood vessels
46
Q

What are the symptoms of Wegener’s?

A
  • Sinus pain
  • Cough
  • Fever
  • Joint aches
  • Blood in urine
  • Hearing loss
47
Q

What is the key physical finding that indicates Wegener’s?

A

Saddle-nose deformity

48
Q

How do we workup Wegener’s?

A
  • Rheumatology workup
  • PFT
  • Imaging of sinus tract (CT) and CXR
  • Biopsy
49
Q

How do we treat Wegener’s?

A

Steroids
Immunosuppressants

50
Q

What are the MCC of allergic rhinitis?

A
  • Seasonal pollens
51
Q

What risk factors predispose someone to having atopy?

A
  • Family MHx of similar symptoms
  • Personal hx of eczematous dermatitis, urticaria, and/or asthma.

Both must be present.

52
Q

What is the definition of allergic rhinitis?

A

Complex inflammatory disease of the upper airways, mediated by IgE.

53
Q

What condition generally results in secondary allergic rhinitis?

A

Asthma

54
Q

What are the common clinical findings on the face that suggest allergic rhinitis?

A
  • Allergic shiners (dark shadows under eyes)
  • Allergic salute and crease (transverse nasal creases)
  • Accentuated lines of the lower eyes (Dennie-Morgan)
  • Allergic faces
55
Q

What are some specific clinical findings of the nose and pharynx that suggest allergic rhinitis?

A
  • Boggy, blue, and pale nasal mucosa
  • Cobblestoning pharynx
  • Nasal polyps
56
Q

How do we diagnose allergic rhinitis?

A
  • Nasal secretions with eosinophils
  • Serum IgE level elevated
  • Allergy skin test (usually last resort)
57
Q

What qualifies as a positive wheal on an allergy prick test?

A

> = 5mm with no antihistamine use in past 5 days.

58
Q

What is the alternative to prick testing for allergic rhinitis?

A

Allergen specific IgE serum testing. (same efficacy)

59
Q

How do we manage allergic rhinitis?

A
  • Correct diagnosis
  • Patient education
  • Allergen avoidance
  • Pharmacotherapy
  • Immunotherapy
60
Q

What qualifies as intermittent vs persistent allergic rhinitis?

A
  • Intermittent: symptoms present less than 4 days a week OR less than 4 weeks total.
  • Persistent: symptoms present 4+ days a week OR 4+ weeks in total.
60
Q

What qualifies as mild vs moderate-severe allergic rhinitis?

A
  • Mild: NO sleep disturbance, impairment of daily activities, impairment of school/work, or troublesome symptoms.
  • Moderate-severe: At least 1+ of sleep disturbance, impairment of daily activities/school/work, or troublesome symptoms.
60
Q

How do we treat persistent, moderate-severe allergic rhinitis?

A

Intranasal glucocorticoids (take daily, not PRN)

61
Q

What should we suggest to a patient to improve efficacy of their nasal spray?

A
  • Rinse out nose
  • Make sure med stays in nose and not down back of throat.
62
Q

What is the preferred treatment for mild, intermittent allergic rhinitis?

A

Antihistamines (preferred 2nd gen)

63
Q

What are the 2nd gen antihistamines?

A
  • Cetirizine (Zyrtec)
  • Loratadine (Claritin)
  • Fexofenadine (Allegra)
  • Desloratadine (Clarinex)
  • Levocetirizine (Xyzal)
64
Q

Which 2nd gen antihistamine sometimes has sedating effects?

A

Cetirizine/zyrtec

65
Q

What are the nasal antihistamines?

A
  • Azelastine
  • Olopatadine
66
Q

What are the decongestants? CI/SE?

A
  • Sudafed: oral, avoid in narrow angle glaucoma, urinary retention, uncontrolled HTN, CVD, CAD, or hypothyroidism.
  • Phenylephrine/oxymetazoline: topical, rebound vasodilation, rhinitis medicamentosa
  • Common SE: Insomnia, tremor, tachycardia, HTN
67
Q

What are the combination drugs for allergic rhinitis?

A
  • Oral antihistamine/decongestant: Claritin D or Allegra D.
  • Usually made via the antihistamine + Pseudephedrine (Sudafed)
  • Often used with phenylephrine now to prevent abuse, but not as efficacious.
68
Q

What are the other medications indicated for allergic rhinitis?

A
  • Mast cell stabilizer (cromolyn nasal spray)
  • Leukotriene antagonists (montelukast)
  • Anticholinergics (Ipratropium bromide)
69
Q

What should a parent be counseled on regarding montelukast usage?

A

Neuropsychiatric changes such as dreams, insomnia, anxiety, depression, suicidal thinking

70
Q

What is ipratropium bromide often combined with?

A

Intranasal steroids

Best in vasomotor rhinitis

71
Q

What is the allergist specific treatment for allergic rhinitis? CI?

A

Allergy shots.

Only CId in significant CVD, uncontrolled asthma, or BB use.

Severe AR only.

72
Q

When can allergy shots be d/c’d?

A

Minimal symptoms over 2 consecutive years.

73
Q

How long should you use nasal decongestants?

A

Up to 3 days max, due to risk of rhinitis medicamentosa.

74
Q

What is vasomotor rhinitis?

A
  • Similar presentation to allergic rhinitis
  • No specific etiology, suspected vidian nerve etiology.
75
Q

Who is MC for vasomotor rhinitis?

A

Elderly, who will present with rhinitis symptoms without any allergy symptoms.

76
Q

How do we treat vasomotor rhinitis?

A
  • Intranasal steroids/antihistamines
  • Ipratropium
  • Daily nasal saline lavage
77
Q

What is gustatory rhinitis?

A
  • Subtype of non-allergic rhinitis
  • Presents as watery rhinorrhea in response to eating.
78
Q

What is rhinitis medicamentosa?

A

Inflammation of the nasal mucosa caused by overuse of nasal decongestants.

AKA occurs from Afrin use > 3 days.

79
Q

How do we treat rhinitis medicamentosa?

A
  • D/C nasal decongestant
  • Start intranasal corticosteroids
80
Q

Clinical

15 year-old female presents with “runny nose”
HPI: Symptoms for just 2 days. Started with a “scratchy” throat, which has resolved. Drainage is purulent. She denies fever or body aches. Some malaise. Slight occasional headache. Family members with similar symptoms.
PE: Nasal mucosa congested with hyperemic mucosa. TMs clear. Pharynx slightly erythematous No adenopathy. No sinus tenderness.

Diagnosis and Tx?

A

Common Cold
Supportive care
* Tylenol/advil
* Fluids
* Rest

81
Q

Clinical

5 year-old boy presents with “runny nose”
HPI: Symptoms for about 2 days a week for 2 weeks. Clear rhinorrhea. Sneezing. Occasional cough. No fever. Not overly bothersome
PE: Pale, boggy nasal mucosa. Pharynx and TMs clear. No adenopathy.

Diagnosis and treatment?

A
  • Intermittent, mild allergic rhinitis
  • Oral antihistamines (2nd gen preferred)
82
Q

Clinical

65 year-old man presents with “runny nose”
HPI: Started 2 weeks ago. Has gotten worse over the past few days. Headache, facial pressure. Feels tired. Fever noted
PE: Swollen nasal mucosa. Frontal and maxillary sinus tenderness; does not transilluminate.

Diagnosis and treatment?

A
  • Acute bacterial rhinosinusitis
  • Augmentin
83
Q

Where does most epistaxis occur? Why?

A

Anterior nasal cavity due to Kiesselbach’s plexus (high vascularity)

84
Q

What clinical findings might suggest posterior epistaxis?

A
  • Unable to visualize the anterior source.
  • Bilateral nasal bleeding
  • Bleeding from anterior into posterior after anterior controlled
85
Q

How do we manage anterior epistaxis?

A
  • Topical anesthetic vasoconstrictor (cocaine or lido+epi)
  • Silver nitrate (chemical) or thermal cauterization (severe)
  • Nasal Packing (continued bleeding)
86
Q

How do we manage posterior epistaxis?

A
  • ENT
  • Usually associated with HTN and atherosclerotic disease
  • Packing
  • Narcotic analgesics
  • Ligation of nasal arterial supply (internal maxillary and ethmoid)
  • Endovascular embolization of internal maxillary)
87
Q

What ABX are indicated for nasal packing? Why?

A

ABX prophylaxis: Augmentin, clinda, keflex
Risk of Toxic Shock Syndrome

88
Q

What patient counseling should we give after epistaxis is controlled?

A
  • Avoid vigorous exercise for a few days
  • Avoid hot/spicy foods/tobacco
  • Avoid trauma
  • Lubricate with petroleum or bacitracin ointment
  • Increase home humidity
89
Q

What are nasal polyps? MC etiology?

A
  • Pale, edematous, mucosally covered masses.
  • MC in allergic rhinitis d/t prolonged irritation
90
Q

If a child has nasal polyps, what might be the cause?

A

Cystic fibrosis

91
Q

How do we treat nasal polyps?

A
  • Topical nasal steroids for 1-3 months.
  • Short course of oral steroids.
  • Surgical removal if pharmacological therapy fails.
92
Q

What would suggest a nasal foreign body?

A
  • Unilateral nasal obstruction
  • Foul-smelling, copious rhinorrhea
  • Persistant unilateral epistaxis
93
Q

How do we remove a nasal foreign body?

A
  • Suction
  • Forceps
  • Hooked catheters
  • Positive pressure
  • ENT if all else fails
94
Q

What are the MC etiologies of nasal fractures?

A
  • Assault
  • MVC
  • Sports injury
95
Q

What should we always consider if someone has a nasal injury/fracture?

A
  • Consider airway
  • R/o any C-spine injuries
96
Q

What are the general clinical features for a nasal fracture?

A
  • Epistaxis
  • Deformity
  • Airway obstruction
  • Septal hematoma
  • Periorbital swelling and ecchymosis
97
Q

What is a septal hematoma?

A
  • Widening of anterior sepum
  • Bluish, fluid filled sacs on septum
98
Q

How do we treat a septal hematoma? Why?

A
  • I&D with anterior nasal packing
  • Antistaphylococcal oral ABX
  • Risk of abscess of necrosis of septum.
99
Q

If a nasal fracture presents with no deformity, what is the management?

A
  • Ice
  • Analgesics
  • OTC decongestants
  • Maintain airway patency and cosmesis
100
Q

If a nasal fracture presents with cribiform plate fracture, what are concerns? Treatment?

A
  • Subarachnoid space and cause CSF rhinorrhea
  • Need a CT to confirm, along with neurosurgery consult
  • ABX needed.

CM 1B: ID/EENT (27 decks)

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