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
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.
3
Q
What is the medical term for a common cold?
A
URI, upper respiratory tract infection.
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.
5
Q
What is the most common virus to cause an URI?
A
Rhinovirus.
30-50%
6
Q
How is an URI transmitted?
A
- Contact
- Droplet
- Surface to surface
7
Q
When is someone at peak levels of viral shedding for an URI?
A
2nd-3rd day of illness.
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
9
Q
What are the 3 most common symptoms of an URI?
A
- Rhinitis
- Nasal Congestion
- Runny nose (rhinorrhea)
10
Q
What should NOT be present in an URI?
A
Abnormal lung sounds.
That would suggest lower.
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.
12
Q
What is the treatment for an URI?
A
- NO ABX
- NSAIDs/acetaminophen
- Fluids
- NS
- Oral/nasal decongestants
13
Q
Clinical
What are the first two sinuses present at 1 year old?
A
Maxillary and ethmoid only.
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
15
Q
Clinical
Which sinuses develop after age 12?
A
Frontal: full completion not until adolescence
16
Q
What is the most common sinus infected in acute bacterial rhinosinusitis?
A
Maxillary
17
Q
What is the MC cause of acute bacterial rhinosinusitis?
A
Previous viral URI will predispose someone.
18
Q
What are the 4 MC causes of acute bacterial rhinosinusitis?
A
- Viral URI (MC)
- Allergic rhinitis
- NG tube
- Dental infections
19
Q
What is the most common bacteria to cause acute bacterial rhinosinusitis?
A
Strep Pneumo
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)
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.
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.
21
Q
How does sphenoid rhinosinusitis present in terms of pain?
A
- Pansinusitis (all sinuses on one side)
- Pain referred to vertex of head.
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.
23
What is halitosis?
Bad-breath caused by bacteria.
24
What is the diagnostic criteria for acute bacterial rhinosinusitis?
* 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.
25
How do we diagnose acute bacterial sinusitis?
Clinically
26
What is the diagnostic tool of choice for acute bacterial sinusitis?
CT Scan.
27
Why are nasal cultures not preferred for acute bacterial rhinosinusitis?
* Not reliable
* Not useful
27
What is nosocomial sinusitis? MCC 3 bacteria?
Complication of a critically ill patient.
MCC 3 causes:
* S. aureus
* P. aeruginosa
* Anaerobes
| CT scan to confirm
28
When are ABX indicated for acute bacterial rhinosinusitis?
* When S/S persist past 7-10 days.
* When S/S start including severe fever, facial pain, or swelling
* Immunodeficient or complications (spreading)
29
What is rhinitis medicamentosa? What generally causes it?
Oxymetazoline drops, which are decongestants but may cause rebound congestion, which is rhinitis medicamentosa.
30
What is the ABX of choice for acute, uncomplicated, bacterial rhinosinusitis? Complicated?
* Uncomplicated: Augmentin 500mg/125mg PO TID or 875mg PO BID.
* Complicated: Augmentin 2g PO BID.
31
What are the alternatives to augmentin if a patient is allergic (anaphylaxis) for acute bacterial rhinosinusitis?
* Doxycycline
* Levofloxacin
* Moxifloxacin
* Azithromycin
32
What are the alternatives to augmentin for acute bacterial rhinosinusitis if a patient can tolerate a cephalosporin?
Clinda + 3rd gen cephalosporin (cefixime or cefpodoxime)
33
What other management is indicated for acute bacterial rhinosinusitis?
* ABX for 7-10 days
* Intranasal corticosteroids
* NSAIDs for pain
* Nasal saline lavage
34
What are the most concerning complications associated with acute bacterial rhinosinusitis and the sinuses involved?
* Orbital cellulitis and abscess (ETHMOID)
* Front subperiosteal abscess (Pott's puffy tumor - frontal bone osteomyelitis)
* Intracranial complications
35
What kind of patients typically develop invasive fungal sinusitis?
Immunocompromised patients
36
What findings would be suggestive of invasive fungal sinusitis?
* Clear nasal discharge
* Black eschar on middle turbinate
* Orbital and cavernous sinus symptoms
* CN V and VII involvement in severe cases
* Bony erosions
37
What qualifies as chronic sinusitis?
* Symptoms persisting > 12 weeks
* Constant sinus pressure
* Constant nasal congestion
38
How do we diagnose chronic sinusitis?
CT scan
39
How do we treat chronic sinusitis?
* ENT
* ABX with culture guidance (usually augmentin empirically)
* Intranasal corticosteroids
* Nasal saline irrigation
* Sinus surgery (if tx failed)
40
Who is chronic fungal sinusitis MC in?
* Older patients
* Mild immunocompromised patients (DM2, low dose steroids)
41
How does chronic fungal sinusitis typically present?
* Mycetoma
* Non-specific mucosal changes on CT
* Opaque sinus (single)
42
How do we confirm chronic fungal sinusitis?
* Histiopathologic confirmation via biopsy from nasal endoscopy.
* CT to determine extent of the disease
43
How do we treat chronic fungal sinusitis?
* Ampho B, then itraconazole
44
What are the risk factors for allergic fungal sinusitis?
* Hx of nasal polyposis and asthma
* Multiple sinus surgeries
* Thick, esosinophilic mucous and fungal debris
* High levels of IgE
44
How do we treat allergic fungal sinusitis?
* Endoscopic sinus surgery to remove mucin and debris
* Post-op systemic steroids
45
What is Wegener's Granulomatosis?
* Granulomatosis with polyangitis
* Inflammation of the blood vessels
46
What are the symptoms of Wegener's?
* Sinus pain
* Cough
* Fever
* Joint aches
* Blood in urine
* Hearing loss
47
What is the key physical finding that indicates Wegener's?
Saddle-nose deformity
48
How do we workup Wegener's?
* Rheumatology workup
* PFT
* Imaging of sinus tract (CT) and CXR
* Biopsy
49
How do we treat Wegener's?
Steroids
Immunosuppressants
50
What are the MCC of allergic rhinitis?
* Seasonal pollens
51
What risk factors predispose someone to having atopy?
* Family MHx of similar symptoms
* Personal hx of eczematous dermatitis, urticaria, and/or asthma.
| Both must be present.
52
What is the definition of allergic rhinitis?
Complex inflammatory disease of the upper airways, mediated by IgE.
53
What condition generally results in secondary allergic rhinitis?
Asthma
54
What are the common clinical findings on the face that suggest allergic rhinitis?
* Allergic shiners (dark shadows under eyes)
* Allergic salute and crease (transverse nasal creases)
* Accentuated lines of the lower eyes (Dennie-Morgan)
* Allergic faces
55
What are some specific clinical findings of the nose and pharynx that suggest allergic rhinitis?
* Boggy, blue, and pale nasal mucosa
* Cobblestoning pharynx
* Nasal polyps
56
How do we diagnose allergic rhinitis?
* Nasal secretions with eosinophils
* Serum IgE level elevated
* Allergy skin test (usually last resort)
57
What qualifies as a positive wheal on an allergy prick test?
>= 5mm with no antihistamine use in past 5 days.
58
What is the alternative to prick testing for allergic rhinitis?
Allergen specific IgE serum testing. (same efficacy)
59
How do we manage allergic rhinitis?
* Correct diagnosis
* Patient education
* Allergen avoidance
* Pharmacotherapy
* Immunotherapy
60
What qualifies as intermittent vs persistent allergic rhinitis?
* 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
What qualifies as mild vs moderate-severe allergic rhinitis?
* 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
How do we treat persistent, moderate-severe allergic rhinitis?
Intranasal glucocorticoids (take daily, not PRN)
61
What should we suggest to a patient to improve efficacy of their nasal spray?
* Rinse out nose
* Make sure med stays in nose and not down back of throat.
62
What is the preferred treatment for mild, intermittent allergic rhinitis?
Antihistamines (preferred 2nd gen)
63
What are the 2nd gen antihistamines?
* Cetirizine (Zyrtec)
* Loratadine (Claritin)
* Fexofenadine (Allegra)
* Desloratadine (Clarinex)
* Levocetirizine (Xyzal)
64
Which 2nd gen antihistamine sometimes has sedating effects?
Cetirizine/zyrtec
65
What are the nasal antihistamines?
* Azelastine
* Olopatadine
66
What are the decongestants? CI/SE?
* 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
What are the combination drugs for allergic rhinitis?
* 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
What are the other medications indicated for allergic rhinitis?
* Mast cell stabilizer (cromolyn nasal spray)
* Leukotriene antagonists (montelukast)
* Anticholinergics (Ipratropium bromide)
69
What should a parent be counseled on regarding montelukast usage?
Neuropsychiatric changes such as dreams, insomnia, anxiety, depression, suicidal thinking
70
What is ipratropium bromide often combined with?
Intranasal steroids
| Best in vasomotor rhinitis
71
What is the allergist specific treatment for allergic rhinitis? CI?
Allergy shots.
Only CId in significant CVD, uncontrolled asthma, or BB use.
| Severe AR only.
72
When can allergy shots be d/c'd?
Minimal symptoms over 2 consecutive years.
73
How long should you use nasal decongestants?
Up to 3 days max, due to risk of rhinitis medicamentosa.
74
What is vasomotor rhinitis?
* Similar presentation to allergic rhinitis
* No specific etiology, suspected vidian nerve etiology.
75
Who is MC for vasomotor rhinitis?
Elderly, who will present with rhinitis symptoms without any allergy symptoms.
76
How do we treat vasomotor rhinitis?
* Intranasal steroids/antihistamines
* Ipratropium
* Daily nasal saline lavage
77
What is gustatory rhinitis?
* Subtype of non-allergic rhinitis
* Presents as watery rhinorrhea in response to eating.
78
What is rhinitis medicamentosa?
Inflammation of the nasal mucosa caused by overuse of nasal decongestants.
| AKA occurs from Afrin use > 3 days.
79
How do we treat rhinitis medicamentosa?
* D/C nasal decongestant
* Start intranasal corticosteroids
80
# 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?
Common Cold
Supportive care
* Tylenol/advil
* Fluids
* Rest
81
# 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?
* Intermittent, mild allergic rhinitis
* Oral antihistamines (2nd gen preferred)
82
# 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?
* Acute bacterial rhinosinusitis
* Augmentin
83
Where does most epistaxis occur? Why?
Anterior nasal cavity due to Kiesselbach's plexus (high vascularity)
84
What clinical findings might suggest posterior epistaxis?
* Unable to visualize the anterior source.
* Bilateral nasal bleeding
* Bleeding from anterior into posterior after anterior controlled
85
How do we manage anterior epistaxis?
* Topical anesthetic vasoconstrictor (cocaine or lido+epi)
* Silver nitrate (chemical) or thermal cauterization (severe)
* Nasal Packing (continued bleeding)
86
How do we manage posterior epistaxis?
* 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
What ABX are indicated for nasal packing? Why?
ABX prophylaxis: Augmentin, clinda, keflex
Risk of Toxic Shock Syndrome
88
What patient counseling should we give after epistaxis is controlled?
* Avoid vigorous exercise for a few days
* Avoid hot/spicy foods/tobacco
* Avoid trauma
* Lubricate with petroleum or bacitracin ointment
* Increase home humidity
89
What are nasal polyps? MC etiology?
* Pale, edematous, mucosally covered masses.
* MC in allergic rhinitis d/t prolonged irritation
90
If a child has nasal polyps, what might be the cause?
Cystic fibrosis
91
How do we treat nasal polyps?
* Topical nasal steroids for 1-3 months.
* Short course of oral steroids.
* Surgical removal if pharmacological therapy fails.
92
What would suggest a nasal foreign body?
* Unilateral nasal obstruction
* Foul-smelling, copious rhinorrhea
* Persistant unilateral epistaxis
93
How do we remove a nasal foreign body?
* Suction
* Forceps
* Hooked catheters
* Positive pressure
* ENT if all else fails
94
What are the MC etiologies of nasal fractures?
* Assault
* MVC
* Sports injury
95
What should we always consider if someone has a nasal injury/fracture?
* Consider airway
* R/o any C-spine injuries
96
What are the general clinical features for a nasal fracture?
* Epistaxis
* Deformity
* Airway obstruction
* Septal hematoma
* Periorbital swelling and ecchymosis
97
What is a septal hematoma?
* Widening of anterior sepum
* Bluish, fluid filled sacs on septum
98
How do we treat a septal hematoma? Why?
* I&D with anterior nasal packing
* Antistaphylococcal oral ABX
* Risk of abscess of necrosis of septum.
99
If a nasal fracture presents with no deformity, what is the management?
* Ice
* Analgesics
* OTC decongestants
* Maintain airway patency and cosmesis
100
If a nasal fracture presents with cribiform plate fracture, what are concerns? Treatment?
* Subarachnoid space and cause CSF rhinorrhea
* Need a CT to confirm, along with neurosurgery consult
* ABX needed.
