Nasal and Sinus Disorders Flashcards
Blood test for Allergic Rhinitis
RAST replaced by Fluorescence Enzyme-Labeled Assay, Expensive
Peripheral blood tests for AR
CBC, IgE but not descriptive
1st Gen Intranasal Corticosteroids for AR
10-50% Bioavailability(more SE). Beclomethasone(4yoa), Budesoinide-(Rhinocort 6yoa), Flunisolide(6) Triamcinolone(2)
2nd Gen Intranasal Corticosteroids for AR
Fluticasone propionate (<2%bioav)(4yoa), mometasone(nasonex) (<0.1%bioav) (2), Ciclesonide (Omnaris)(<0.1%bioav)(6), Fluticasone furoate(Veramyst)(<1%)(2)
Antihistamines that cause sedating, anticholinergic(Dry mouth)
1st Gen, Diphenhydramine, Chlorpheniramine(6yoa), Hydroxyzine
Antihistamines that are a lower risk for systemic effects
2nd and 3rd gen, Loratidine(2yrs), Cetrizine(Sedating in 10% of pts)(6mo), Fexofenadine 3rd gen (2yrs), Desloratidine (Clarinex 3rd gen (6mo)
Azelastine(Astelin), Olopatadine(Patanse)
AR tx: Intranasal Antihistamines
Combo intranasal antihistamine
Only Dymista (azelastine/fluticasone) shows better results than inhaled steroid alone.
AR and oral steroids
won’t relieve symptoms acutely, use sparingly. but may be needed to treat r. medicamentosa, severe, AR, sinusitis with allergic component
Oral Decongestant (AR Tx section)
pseudophedrine (Sudafed)
Pseudophedrine MOA SE
alpha/beta agonist (Vasocon), arrhythmia, hypertension, palpitations, tachy, HA, nervousness, stimulation, anorexia, tremor, ect.
Intranasal Cromolyn MOA and notes
Keeps mast cells from releasing histamines, but inferior to nasal steroids and antihistamines
Leukotriene receptor antagonist(approved for over 6mo of age) and notes
Montelukast (singular) Helps most with congestion, also used in pt’s with asthma, safe, but some rare psych SE
Phenylephrine, oxymetazoline, xylometazoline, nephazoline(Afrin, Neo-Synephrine) (risks) (aid in tx of epistaxis)
Nasal Decongestant Sprays. (only to be used for a day or two, otherwise risk of rebound)
AR Tx “not to be used as monotherapy”
Nasal Decongestant Sprays like Phenylephrine, oxymetazoline, xylometazoline, nephazoline(Afrin, Neo-Synephrine)
First Dose in office to observe. Grastek, O, R. (Daily through season-start 12 weeks)
SL Immunotherapy for AR. Oralair Ragwitek, 12 weeks before season starts
SQ Immunotherapy for AR
Testing done first, tailored to allergy, effects last 7-12 years
Expensive as hell immunotherapy for AR
Omalizumab (Xolair), Anti-immunoglobin E antibody, approved for use in asthma, not FDA approved for AR,
What conditions are Nasal Polyps associated with
Chronic sinusitis, asthma, aspirin sensitivity
Nasal Polyps in young children
Think possible CF
Tx for Nasal Polyps
Intranasal Corticosteroids, treat underlying allergies, consider other AR tx’s, oral glucocorticoids in refractory cases, surgical tx often recur
Order of sinus developement
MESF. F-after age 2 and last to pneumatize
Definition of Acute Rhinosinusitis
Symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than 4 weeks
What are the common viruses that cause Acute Rhinosinusitis
Rhinovirus, Adenovirus, Influenza virus, Parainfluenza virus
What are the common bacteria that cause Acute Rhinosinusitis
Streptococcus pneumoniae, Haemophilus influenza, Moraxella Catarrhalis, Staphylococcus Aureus
What is the signs and presentation of Viral Rhinosinusitis
Day 1-2 Sore throat, day 2-3 nasal symptoms, scratchy throat subsides, day 4-5 cough, nasal sx subside, lasts ~5-10 days but may last up to 2 weeks in 1/4 of pt’s
DiffDx for Viral Rhinosinusitis
Tonsillitis, Bacterial(Facial pain, dental pain, significant HA, facial swelling, prolonged sx, prior surgery), Influenza(Fevers, HA, Myalgia), Pertussis(Prolonged, severe cough)
Tx Viral R
Sx relief. Pain, Nasal saline irrigation, Decongestants, topical vasocon(oxymetzaoline 2-3 days only), oral decongestants, anti-hist, mucolytics guaifenesin to thin secretions(no evidence), Zinc zicam risk anosmia
Bacterial R: if sx do not improve in ___days of tx or recur within ___ of tx, then ___ needs to be considered
3-5 days, 2 weeks, resistant organism
Abx for R, 1st LINE, then ____ Ped, adult, and then ___,___,___abx if allergic to ___
Amoxicillin x 10 -14 days, Augmentin - peds if moderate-severe illness, <2 yoa, daycare or recent tx with an antibiotic, adults if pt’s not improving or hx of repeated infections or prior sinus sx. Bactrim, azithromycin and other macrolides if allergies to PCN
Dx and signs of Chronic R (3, PND, C, NC, poss no running)
Sx >3mo, persistent oropharyngeal drainage, chronic cough, nasal congestion, may not have runny nose
Refer! CR. But frequent Rhinosinusitis diffdx is
CF(cilia decreased), Wegener’s Granulomatosis(inflammation of blood vessels, and effects kidneys, eyes and upper RT), HIV(fungus), Primary ciliary dyskinesia, neoplasm
Wegner’s Granulomatosis
inflammation of blood vessels, and effects kidneys, eyes and upper RT. may cause frequent R
Pott’s Puffy Tumor
Frontal sinus osteomyelitis reaches soft tissue and looks like a tumor
Orbital Cellulitis risks
could travel into cavernous sinus and make the brain want to decrease flow there which leads to more problems
Define time for Acute Rhinosinusitis
Up to 4 weeks
Define time for Subacute Rhinosinusitis
at least 4 weeks but less than 12 weeks
Define Recurrent acute Rhinosinusitis
Four or more episodes per year with complete resolution between episodes; each episode lasts at least 7 days
Define time for Chronic Rhinosinusitis
12 weeks or longer
First step with Epistaxis
Check ABCDE’s, airway, breathing, circulation, disability, exposure
Contraindications for Nasal packing ca,c,c,ft
Clotting abnormalities, COPD(can’t interfier with airway), Known or suspected CSF leak, Facial Trauma
Dangerous possibility with nasal fx
septal hematoma, if not tx could cause damage to septum
Drugs for nasal fx with epistaxis
abx-cephalexin, amox, ampicillin
Drugs and tx for nasal fx without epistaxis
topical nasal decongestants, analgesia and ice (ENT refer for plastic sugery)
