Nose Flashcards
what is rhinitis?
inflammation of the nasal mucosa
etiologies of rhinitis
viral infection
allergic
acute bacteria infection
vasomotor
what is allergic rhinitis?
hay fever
seasonal allergic rhinitis is MOST common
Pathophysiology of allergic rhinitis
activation of humoral and cell mediated immune responses that lead to IgE mediated inflammatory response
allergic rhinitis nasal symptoms
rhinorrhea (clear)
sneezing
watery eyes
allergic shiners
Dennie’s lines (lines under eyes)
transverse nasal fold or “allergic salute”
throat discomfort
nasal congestion
hyposmia
malaise
allergic rhinitis eye symptoms
eye irritation
pruritus
conjunctival erythema
excessive tearing
what is the triad of allergic rhinitis?
nasal congestion, sneezing, clear rhinorrhea
what is associated with allergic rhinitis?
strong genetic component
asthma, nasal polyps, nasal speech, history of atopic dermatitis
testing for allergic rhinitis?
clinical diagnosis
nasal smear - elevated eosinophils
allergy skin tests or RAST tests often positive for specific allergens
treatment of allergic rhinitis
avoid allergens
corticosteroids - intranasal AND/OR oral or IM for severe cases
antihistamines
anticholinergic agents
antileukotrienes
immunotherapy for resistant cases
physical findings of allergic rhinitis
pale-bluish, edematous or boggy nasal mucosa
venous engorgement
AND
nasal polyps - yellow boggy masses of mucosa
associated with chronic allergic rhinitis
what are nasal polyps?
benign lesions that arise from nasal mucosa caused by chronic inflammation
associated with asthma, CF, aspirin tolerance, allergic rhinitis
what is viral rhinitis?
also known as the common cold, coryza
T/F: viral rhinitis most common adult infection
FALSE: most common pediatric infection
children < 5 years average 6-12 “colds” per year
testing for viral rhinitis?
diagnosis made by history
lab test unnecessary
complications may prolong illness (ear infection, pneumonia, pharyngitis, sinusitis)
*can trigger asthma attacks
viral rhinitis symptoms
rhinorrhea (clear to opaque)
nasal congestion, headache
hyposmia
sneezing
malaise
throat discomfort
post nasal drip –> cough
T/F: only 1 virus is responsible for the viral rhinitis
FALSE: multiple. rhinovirus (majority), adenovirus, coronavirus, enterovirus, influenza, influenza, parainfluenza, RSV
physical findings of viral rhinitis
erythematous, edematous, engorged nasal mucosa
watery discharge - intranasal purulent discharge suggest bacterial cause
viral rhinitis treatment
self-limiting - no effective anti-viral therapies
zinc acetate lozenges
nasal irrigation
decongestants
what is vasomotor rhinitis?
perennial non-allergic rhinitis associated with hyperactive nasal mucosa
Pathophysiology of vasomotor rhinitis
caused by increased sensitivity of the vidian nerve (passes through the pterygoid canal supplying the pterygopalatine ganglion)
T/F: vasomotor rhinitis etiology is unknown
TRUE
what is vasomotor rhinitis related to?
related to geriatric rhinitis and progressive degeneration of nasal mucosa
when and what is the onset of vasomotor rhinitis?
adults
presents with rapid onset of nasal congestion and postnasal drip
*No family history of allergies
physical exam of vasomotor rhinitis
clear rhinorrhea
triggers for vasomotor rhinitis
- cold temperature,
- inhaled irritants,
- strong odors,
- spicy foods,
- other nonallergenic environmental stimuli
what is rhinitis medicamentosa
- overuse of Decongestant nasal spray (limit use to <5 days)
- Swollen, red mucous membranes
what do the lab tests look like for vasomotor rhinitis
negative lab tests
treatment for vasomotor rhinitis
Inhaled decongestants or corticosteroids
Topical Ipratropium bromide (atrovent) - dries up drainage
Avoidance of triggers
how to differentiated between allergic, viral and vasomotor
-
Allergic Rhinitis – precipitated by allergen, nasal congestion, sneezing, clear rhinorrhea,
- PE: Watery Rhinorrhea, Pale, boggy nasal mucosa
-
Viral Rhinitis – precipitated by virus, inflammation of nasal mucosa, <10 days
- PE: erythematous mucosa, clear/yellow rhinorrhea
-
Vasomotor Rhinitis – precipitated by a trigger, hyperactive nasal mucosa, adults, no hx of allergies
- PE: clear, constant rhinorrhea
function of nose
- 80% Flavor of Food
- Recognize thousands of smells
- Smell affects our emotions
- Helps block bacteria from entering
function of sinuses
- Humidifying and warming inspired air
- Regulation of intranasal pressure
- Lightening the skull
- Resonance
- Absorbing shock
when is the frontal sinus present?
at significant size at 3-4 yrs. old, sphenoid at 8yrs
T/F: 3-4 liters of mucus produced per day
FALSE - One - Two Liters of mucus produced per day
common etiology of acute rhinosinusitis
VIRUS
how to manage acute rhinosinusitis
- Symptomatic management for comfort
- Does NOT decrease duration
- Helps with symptoms
- Self – limiting
- Usually lasts 7 – 10 days
viral rhinosinusitis
Inflammation and swelling of the mucous membranes of the nose
how long does viral rhinosinusitis lasts
<10 days, self-limited
symptoms of viral rhinosinusitis
- Clear/yellow rhinorrhea
More mucoid in appearance after day 2 - Erythematous Mucosa
- Congestion
- post-nasal drip
- Cough
- Low-grade fever
treatment acute viral rhinosinusitis
- Purpose: Relieve Nasal Obstruction and Rhinorrhea
- Antiviral drugs not effective / Abx. not effective
- Analgesic – Tylenol / Motrin
- Hypertonic saline nasal rinses
- Intranasal Glucocorticoids
- Nasal Decongestant Spray (use < 5 days)
- Antihistamines
- Drying affect – could lead to further
- Mucolytics (Guaifenesin)
bacterial rhinosinusitis
Precipitated by viral rhinosinusitis
how do you diagnose bacterial rhinosinusitis
Viral symptoms for > 10-14 days
Worsening of symptoms after 5-7 days
what is sinuses involved with bacterial rhinosinusitis
Maxillary and ethmoid sinuses
what are the cardinal signs of bacterial rhinosinusitis
Purlent Nasal discharge, nasal obstruction, facial pain
pathogens involved with acute sinusitis
0-1 months
Strep pneumococcus
H. influenza
Moraxella catarrhalis
pathogens involved with chronic sinusitis
> 3 months
Gram neg Staphylococcus
Staph aureus, including MRSA
Anaerobes
sinusitis symptoms
Facial pain/pressure
Facial congestion
Nasal obstruction
Purulent PND
Inability to smell
Fever, malaise
Headache
urgent sinusitis symptoms
Persistent Fevers > 102 F
Periorbital Edema / Erythema
Cranial Nerve Palsies
Proptosis
Visual Changes
Severe HA / AMS
Meningeal Signs
sinusitis exam
Edema
Hyperemia
Purulence
Polyps
Pain to palpation over sinus
Inability to transilluminate
+/- swelling or erythema over a sinus
+/- fever in severe cases
T/F: Plain radiography generally diagnostic
FALSE - NOT, Requires non-contrast CT Max/Face – use if complicating factors o/w not necessary
treatment of sinusitis
- Symptomatic treatment
- 80% of patients will improve within 10 -14 days
- Will Improve WITHOUT antibiotics
- This tx plan must include appropriate follow-up
- Antibiotics after trial with symptomatic tx. x 7 days with no improvement or presents with urgent symptoms.
when to treat sinusitis
Lack of adequate follow-up
Worsening Symptoms during symptomatic tx
No improvement after 7 days
Risk factors for a poor outcome sinusitis
Extremes of Age
Recent Hospitalization
Recent Abx use
Immunocompromised
Multiple Comorbidities
Severe Infection (Urgent Symptoms)
sinusitis complications
- Orbital cellulitis
- Osteitis of frontal bone
- Cheek cellulitis
- Brain abscess
- Osteomyelitis
- Meningitis
treatment of complications
surgical debridement and 4-6 weeks of ABO
signs and symptoms of foreign body
- Hx of FB insertion
- Mucopurulent Nasal Discharge
- Foul Odor
- Epistaxis
- Nasal Obstruction
- Mouth Breathing
are x-rays helpful for foreign bodies
NO, most FB are radiolucent
complications of FB
- Risk of Toxic Shock Syndrome
- Pressure risk - tissue necrosis
- Epistaxis
- Obstruction can lead to acute sinusitis
- Button Battery
- Paired Disc Magnets
when to refer FB
Posterior FB
Unable to Visualize
Impacted FB
Complications
Initial 1-2 attempts failed
techniques of FB
Positive Pressure (soft or smooth FB that occlude the ant. nasal cavity)
Instrumentation (non-occlusive FB)
what is epistaxis
Nose is a vascular organ with incredible heating/humidification requirements
Vasculature runs just under mucosa
anterior bleeding
Occurs in younger patients
Usually septal or anterior ethmoid
Usually not severe
posterior bleeding
Occurs in older patients
Usually from posterior ethmoid
Often severe
epistaxis etiology
- **Self-Induced
- HTN
- Coagulopathy
- Dessication (Dryness)
- Drug Use (Cocaine)
- Trauma – Facial Fractures
- Vascular malformations
- Infection/Inflammation
- Iatrogenic
- Neoplasm
- Foreign Bodies
- Post- op
coagulopathy causes
- Thrombocytopenia (Leukemia, TTP, HELLP)
- Platelet dysfunction (Systemic disease – Uremia and Drug-induced – Coumadin, Heparin, ASA)
- Clotting Factor Deficiencies (Hemophilia, VonWillebrand’s disease, Hepatic failure)
trauma causes
Nose picking
Nose blowing/sneezing
Nasal fracture
Nasal intubation
Trauma to sinuses, nose, orbits, middle ear, base of skull
neoplasm causes
Benign nasopharyngeal tumors
Squamous cell carcinoma
Adenocarcinoma
Melanoma
Lymphoma
desiccation (extreme dryness) causes
Temperature, Humidity
Nasal oxygen
Atrophic rhinitis
Septal perforation (Nasal sprays, cocaine)
epistaxis management
- Medical history/Medications
- Vital signs
non-surgical treatments of epistaxis
- If direct pressure ineffective, suction to remove clots
- Apply topical vasoconstrictors / anesthetic
- Cautery with AgNO3 (Silver Nitrate) or Bovie
NEVER both sides of septum
Less than 10 seconds - Gelfoam
- Surgicel
- Topical Thrombin
- Control hypertension
- Correct coagulopathies if indicated
anterior bleed treatment
Afrin+pressure
Cauterization
Gelfoam
Surgicel
Topical thrombin
posterior bleed treatment
call ENT
coagulopathy
surgery for epistaxis?
- Continued bleeding despite nasal packing
- Nasal anomaly precluding packing
- Patient refusal/intolerance of packing
- Failed medical mgmt after >72hrs
- Many times can’t tell anterior or posterior until pack and bleeding persists = POSTERIOR
septal perforation etiologies
- Overuse of nasal steroid
- Latrogenic
- Nasal cautery
- Post-operative complication
- Cocaine/Ketamine
nasal polyps
benign lesions that arise from nasal mucosa
what are nasal polyps caused by
chronic inflammation
nasal polyps are associated with
asthma, CF, aspirin intolerance, allergic rhinitis
samter’s triad
nasal polyps
asthma
hypersensitivity to aspirin
nasal polyps + asthma = no ASA
what is AERD
Aspirin Exacerbated Respiratory Disease
how to treat nasal polyps
nasal or oral steroids
how to diagnose nasal polyps
Diagnosed with nasal endoscopy CT/MRI
can you give aspirin to someone with nasal polyps
NOOOO
inverted papilloma
caused by HPV
treated with surgical resection
most common broken bone in the body
nose
high incidence of LeFort fractures
is imaging needed for nasal fractures?
- no unless….
- Septal hematoma
- Orbital or facial nerve involvement
- Tenderness is not limited to bridge of nose
- Patient cannot breathe through both nares
- Severe asymmetry suspecting comminuted fracture
nasal fracture
- Prior Injury?
- Edematous, Painful, Epistax.
- Eval for Hematoma
- +/- imaging
- Delayed repair
septal hematoma
- Septal cartilage lacks its own blood supply
- Untreated hematoma can lead to destruction of septum
- Must I&D (saddle or perf)
what is charge syndome?
- Coloboma – hole in one of the eye structures
- Heart disease
- Atresia of choanae - Posterior naris
- Retarded growth
- Genital hypoplasia
- Ear anomalies
choanal atersia
Congenital blockage of one or both nasal passages, usually by abnormal bony or soft tissue growth during fetal development
life threatening emergency
signs and symptoms of choanal atersia
cyanosis during feeding
continuous nasal drainage
how to diagnose choanal atresia
Inability to pass 6F catheter
CT sinus
treatment of choanal atresia
Surgical drilling and stent placement
Often need multiple surgeries through adolescent years and adulthood
lefort I
horizontal
edema, mobility of hard palate / teeth
lefort II
pyramidal
edema, subconj hemorrhage, mobility at nasofrontal suture, epistax., CSF rhinorrhea
lefort III
separation of all facial bones from cranium
massive edema, movement of all facial bones, epistaxis, CSF rhinorrhea
