Lecture 8: Nose and Paranasal Sinuses Flashcards
Define coryza.
Symptoms of a cold.
* Inflammation of mucous membranes lining the nasal cavity.
* Usually involves nasal discharge
Define Rhinitis vs rhinosinusitis.
- Rhinitis: Symptomatic disorder to the nose itself, characterized by itching, discharge, sneezing and obstruction.
- Rhinosinusitis: Symptomatic inflammation of the nasal cavity and paranasal sinuses.
What is the medical term for a common cold?
URI, upper respiratory tract infection.
How common is an URI?
- 40% of all sick time is due to it
- 6-12 episodes in children annually.
- 2-3 episodes in adults annually.
What is the most common virus to cause an URI?
Rhinovirus.
30-50%
How is an URI transmitted?
- Contact
- Droplet
- Surface to surface
When is someone at peak levels of viral shedding for an URI?
2nd-3rd day of illness.
What are the main risk factors for contracting an URI?
- Expsure to children in daycare
- Psychological stress
- Less sleep and pre-existing sleep disturbances
- Moderate physical exercise decreases the risk
What are the 3 most common symptoms of an URI?
- Rhinitis
- Nasal Congestion
- Runny nose (rhinorrhea)
What should NOT be present in an URI?
Abnormal lung sounds.
That would suggest lower.
What are some common signs of an URI on PE?
- Nasal mucosal swelling
- Nasal discharge or congestion
- Pharyngeal erythema
- Conjunctival injections
- Possible fluid in TM.
What is the treatment for an URI?
- NO ABX
- NSAIDs/acetaminophen
- Fluids
- NS
- Oral/nasal decongestants
Clinical
What are the first two sinuses present at 1 year old?
Maxillary and ethmoid only.
Clinical
Which sinuses develop after age 2?
Sphenoid: start develop during first two years of life, completing full growth and size at age 12
Clinical
Which sinuses develop after age 12?
Frontal: full completion not until adolescence
What is the most common sinus infected in acute bacterial rhinosinusitis?
Maxillary
What is the MC cause of acute bacterial rhinosinusitis?
Previous viral URI will predispose someone.
What are the 4 MC causes of acute bacterial rhinosinusitis?
- Viral URI (MC)
- Allergic rhinitis
- NG tube
- Dental infections
What 3 pathophysiologies contribute to the development of acute bacterial rhinosinusitis?
- Impaired mucociliary clearance
- Inflammation of the nasal mucosa
- Obstruction of the ostiomeatal complex (sinus pore)
How does ethmoid rhinosinusitis present in terms of pain?
- Usually accompanies maxillary.
- Pain or pressure on high lateral wall of nose, often referred to the orbits.
How does sphenoid rhinosinusitis present in terms of pain?
- Pansinusitis (all sinuses on one side)
- Pain referred to vertex of head.
How does frontal rhinosinusitis present in terms of pain?
- Pain and tenderness on forehead.
- Pain elicited by palpation of orbital roof below medial end of eyebrow.
What is halitosis?
Bad-breath caused by bacteria.
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.
How do we diagnose acute bacterial sinusitis?
Clinically
What is the diagnostic tool of choice for acute bacterial sinusitis?
CT Scan.
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
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)
What is rhinitis medicamentosa? What generally causes it?
Oxymetazoline drops, which are decongestants but may cause rebound congestion, which is rhinitis medicamentosa.
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.
What are the alternatives to augmentin if a patient is allergic (anaphylaxis) for acute bacterial rhinosinusitis?
- Doxycycline
- Levofloxacin
- Moxifloxacin
- Azithromycin
What are the alternatives to augmentin for acute bacterial rhinosinusitis if a patient can tolerate a cephalosporin?
Clinda + 3rd gen cephalosporin (cefixime or cefpodoxime)
What other management is indicated for acute bacterial rhinosinusitis?
- ABX for 7-10 days
- Intranasal corticosteroids
- NSAIDs for pain
- Nasal saline lavage
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
What kind of patients typically develop invasive fungal sinusitis?
Immunocompromised patients
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
What qualifies as chronic sinusitis?
- Symptoms persisting > 12 weeks
- Constant sinus pressure
- Constant nasal congestion
How do we diagnose chronic sinusitis?
CT scan
How do we treat chronic sinusitis?
- ENT
- ABX with culture guidance (usually augmentin empirically)
- Intranasal corticosteroids
- Nasal saline irrigation
- Sinus surgery (if tx failed)
Who is chronic fungal sinusitis MC in?
- Older patients
- Mild immunocompromised patients (DM2, low dose steroids)
How does chronic fungal sinusitis typically present?
- Mycetoma
- Non-specific mucosal changes on CT
- Opaque sinus (single)
How do we confirm chronic fungal sinusitis?
- Histiopathologic confirmation via biopsy from nasal endoscopy.
- CT to determine extent of the disease