Nasal Obstruction 2 Flashcards
primaru causes of ars
rhinovirus, adenovirus, influenza
symptomatology of ars
sudden onset of two or more symptoms:
- nasal blockage, obstruction, congestion
- nasal discharge (ant/post)
- +/- facial pain or pressure
- +/- reduction or loss of smell
for <12 wks, with symptom free intervals if recurrent
what is the common cold or acute viral rs
duration of symptoms less than 10 days
what is acute post-viral rhinosinusitis
- increased or worsening of symptoms after 5 days
- persistent symptoms after 10 days
- with less than 12 wks duration
what is acute bacterial rs
at least 3:
- discolored discharge with unilateral predominance and purulent secretion
- severe local pain
- fever >38c
- elevated esr/crp
- double sickening
predisposing factors for abrs
- dental procedures
- iatrogenic causes
- immunodeficiency
- mechanical obstruction
- mucosal edema
respiratory viruses linking with receptors on nasal epithelium
icam1, tl3, rig-i, nlrp3, tlr7
if there are immune defense function defects you have __
prolonged course resulting to post-viral rhinosinusitis
secondary bacterial infection leads to acute bacterial rhinosinusitis
t/f some viruses like rsv can cause direct epithelial damage
true
epithelial dysfunction from inflammatory cascade
cilia loss
altered ciliary function
increased mucus production
barrier breakdown
t/f xray and ct is recommended on the first contact for ars
false
treatment for common cold
- analgesics, nasal saline irrigation, decongestants, selected herbal compounds
if failed after 10 days, add topical steroids
treatment for moderate (post viral) ars
- if symptoms persist after 10 d or increasing after 5 d
- tx: topical (intranasal) steroids for 7-14 d
- if no effect, refer
treatment for severe ars (+bacterial)
- if symptoms persist after 10 d or increasing after 5 d AND discolored discharge, fever, severe local pain, elevated crp/esr, double sickening
- tx: topical steroids and antibiotics
- no effect = refer
indications for immediate referral
- periorbital edema/ erythema
- displaced globe
- double vision
- ophthalmoplegia
- reduced vision acuity
- severe uni/bilateral frontal headache
- frontal swelling
- sx meningitis / neuro sx
empiric antibiotics for abrs
coamoxiclav 625 mg q8h or 1g q12h
amoxicillin 500 mg q8h or 1g q12h
allergic: doxycycline, levofloxacin, moxifloxacin
7-10 d
watchful waiting indicated for
temp less/= 38 C
no extra sinus complications
assurance of good follow up
indications for intranasal cs and topical nasal saline irrigation
cs: symptomatic relief
irrigation: to improve ciliary beat activity and mucociliary clearance
second line antibiotics
- for px with no response, or worsening symptoms after 5-7 d of first line
- sus amr
coamoxiclav 2g q12h, doxycyline, levofloxacin, moxifloxacin
definition of chronic rhinosinusitis
- > /= 12 wks for sinonasal symptoms
- endoscopic signs: nasal polyps, mucopurulent from middle, edema or obsturction in middle
- ct changes
predisposing factors to chronic rhinosinusitis
- allergy
- asthma
- nsaid exacerbated respiratory disease
- immune deficiencies
- microbiology
- fungal infection
- ciliary impairment
- smoking
- pollution
- osa, ms, obesity
how do nasid cause respiratory disease
- uninhibited 5 lipooxygenase resulting to increase leukotriene levels
- causes smooth muscle constriction resulting to airflow obstruction
- asthma + bronchiole constriction = bad
most common immunodeficiencies
common variable immunodeficiency
viruses that commonly cause exacerbations
coronavirus
parainfluenza
how do biofilms exacerbate disase
- adhere to surface, form mature biofilm, release more planktonic cells
- targets of macrolides: disrupts biofilm
what are superantigens
- stimulate all cells and can release chemokines = massive cytokine release
what is a fungal ball
- develops in immunocompetent individuals
- mucosa develops foreign body reaction
- tx: surgical removal
what is allergic fungal rhinosinusitis
- immune hypersensitivity
- florid ige response
- tx: surgery and long term intranasal cs
what is invasive fungal rs
- immunosuppressed
- tx: surgery and iv amphotericin b
t/f local exogenous factors can negatively modulate the ciliary dynamic response to stimuli
true, affects mucus blanket or ciliary beat
host, environment, and pathology facots in crs
environmental: local microbial community
host: mucosal inflammation and mucociliary dysfunction
disease: failure of mechanical and innate immune protection, activation of proinflammatory responses
mediators for type 1
defense against viruses
ilc, th1 cell, inf-gamma, tnf-alpha
mediators for type 2
ilc2, th2 cell, il4, il5, il13
il5 = eosinophils
what is type 2 crs
- defense against parasitic and allergic rxs
- crs with nasal polyps (caucasian)
- more ige and eosinophils
mediators for type 3
ilc3, th17, il17, il22
what is type 3 crs
- defense against bacteria and fungi
- crs with nasal polyps (asian)
- more non-eosinophilic (plasma cells, lymphocytes, neutrophils)
filipinos are more type __
3
localized vs diffuse crs
localized: unilateral, lower airway not involved, anatomically discrete sinus cavity
diffuse: bilateral, affects lower and upper airways, not limited by functional sinonasal units or spaces
examples of primary crs
localized, type 2: allergic fungal rhinosinusitis
localized, non-type 2: isolated sinusitis
diffuse type 2: crswnp, afrs, central compartment allergic disease
diffuse non type 2: non-eosinophilic crs
examples of isolated sinusitis
isolated maxillary sinusitis
frontal, sphenoid
what is central compartment allergic disease
- sinuses not that opacified or involved in ct, but secretions are concentrated in central compartment, sinuses not involved
examples of secondary crs
localized local: odontogenic, fungal ball, tumor
diffuse mechanical: primary ciliary dyskinesia
diffuse inflammatory: granulomatosis with polyangitis, eosinophilic gpa
diffuse immunity: selective immunodeficiency
first line for chronic rs
intranasal corticosteroids
- improve symptoms, decrease polyp size, prevent recurrent, improve nasal airflow and olfaction
- fluticasone, mometasone
proper spraying technique
- shake bottle
- look down and lean forward
- use right hand for left nostril
- squirt once or twice in different directions
- DO NOT SNIFF HARD
recommendation for topical nasal saline irrigation
- for symptom relief
- improves ciliary beat activity and mucociliary clearance
recommendation for short term oral steroids
- rapid transient symptom improvement and decrease in polyp size
- only adjunct
recommendation for long term low dose macrolides
- if poor response to incs
- moderate symptom improvement and decrease in polyp size
recommendation for short term doxycycline
- only adjunct
- if suspected staph superantigens
- moderate effects
recommendation for leukotriene receptor antagonists
if with concomitant allergic rhinitis, asthma, and aspirin-exacerbated respi disease
indications for endoscopic sinus surgery
- if unresponsive to medical treatment
- temporary relief of ostiomeatal complex blockage so steroids can penetrate
