Nose Flashcards
What are the different types of Rhinorrhea?
Allergic rhinitisnon-allergic rhinitisVasomotor rhinitis Acute and chronic rhinosinusitis (sinusitis)
What is allergic rhinitis?
Clear rhinorrhea, sneezing, tearing eye irritationAssociated symptoms: cough, bronchospasm, eczematous dermatitisEnvironmental allergen exposure with the presence of allergen specific IgE
How common in allergic rhinitis?
14-40% prevalence
What are the seasonal allergies for rhinitis?
Most common: shrub and tree pollens Spring: flowering shrub and tree pollens Summer: flowering plants and grasses Fall:ragweed and molds
Symptoms of allergic rhinitis?
History of atopysneezingwatery eyesseasonal predilectionprolonged symptomscongestion and pale mucosa with clear discharge (d/c)Afebrile
What facial features are associated with allergic rhinitis?
Allergic shinersAllergic salute (crease over nose) Pale boggy turbinates
What tests are used to diagnose allergic rhinitis?
CBCNasal smear for eosinophilsELISARASTskin prick test (affected by antihistamine or steroid use)
What are the components of a differential for allergic rhinitis?
Nonallergic rhinitis w/ eosinophilia syndrome (NARES)Vasomotor rhinitisChronic sinusitis Nasal polyps or tumorFBmedications-rebound effect from topical nasal decongestants septal/anatomic obstruction
Treatment for allergic rhinitis?
Avoidance1rst line: nasal steriods (nasonex/flonase)2nd line: antihistamines oral or intranasal decongestants Leukotriene receptor antagonist (singulair)Intranasal antihistamines (omnaris)cromolyn sodium”Allergy shots”
what are the side effects of nasal steroids?
Epistaxisperforated septum taste perversionoral candidiasis
What is Non-Allergic Rhinitis?
a common condition characterized by the chronic presence of one or more of the following: nasal congestion, rhinorrhea, postnasal drainage
How is NAR distinguished from AR?
onset is at a later ageabsence of nasal and ocular itching and prominent sneezingnasal congestion and postnasal drainage are prominent symptoms symptoms are perennial (year round)
what are the typical triggers for NAR?
Irritant odors and strong fragrances tobacco smoke diesel and car exhaustcleaning productsnewsprintchanges in temperaturealcoholic beverages
What is vasomotor rhinitis?
intermittent symptoms of congestion and or watery rhinorrhea and exaggerated reaction to nonspecific irritants such as air pollution, temp changes, exposure to cold or dry air
What id gustatory rhinitis?
Episodic condition with prominent watery rhinorrhea triggered by hot or spicy foodscased by the vagal-mediated reflex
what is Rhinitis Medicamentosa?
occurs when there is use of intranasal decongestants for greater than 5 days
How do you treat RM?
strop/weanintranasal steroidsPO steroidsnasal salineantihistaminesdecongestants
causes of vasomotor rhinorrhea?
Fumesodorstempatmospheric changes smoke other irritants
What are the drugs involved in drug-induced rhinitis?
ACE inhibitorsreserpineguanethidine phentolaminemethyldopabeta-blockerschlorpromazinegabapentinpenicillamineASA NSAIDS cocaineExogenous estrogensOCP
what is mixed rhinitis?
a combination of allergic and NARmost common form of rhinitis, affecting ~ 45%of the population
What is occupational rhinitis?
Airborne allergens or irritants in patients workplacesymptoms are more prominent at work and improve on days offunderlying mechanisms may be allergic or irritant
what are common examples occupational irritants?
proteins from urine or fur of lab animalsfood proteinsenzymatic proteins in detergent manufacturers organic dusts in wood workers
what is CSF rhinorrhea?
Straw colored leakage of CSFmay cause one or more nasal symptomsusually results in unilateral or bilateral clear nasal discharge without signs and symptoms of mucosal inflammation
what can CSF rhinorrea result from?
skull or nasal fracturesintracranial surgery inferior extension of sella turscia
what are the postural reflexes?
increased congestion with supine position and increased congestion in the lower nasal passage when lying on one sidenormal nasal cycle in the vertical position produces alternating congestion in the nostrils
what is crutch reflex?
increased congestion with pressure in the ipsilateral axilla
Hot and cold cutaneous temp reflexes
sneezing upon sudden exposure of the skin to dramatic temp extremes
Visible and infrared light reflexes
sneezing upon sudden exposure to bright light
Bronchonasal reflex
brochoconstriction in response to nasal stimulation (such as with cold air)
Ovulatory rhinitis
increased nasal congestion in the periovulatory period of the menstrual cycle in women
What is the definition of acute sinusitis?
symptomatic inflammation of 1 or more paranasal sinuses resulting from impaired drainage and retained secretions < 4 weeks duration
how long subacute sinusitis?
symptomatic for 4-12 weeks
How long is chronic sinusitis?
symptomatic for > 12 weeks
what is Rhinosinusitis?
the term given to rhinitis and sinusitis because they usually coexist
how many annual cases of sinusitis are there each year?
31 million with an annual cost of 5.8 billion
what us the 5th leading reason for prescribing antibiotics?
acute bacterial rhinosinusitis about 0.2-2% episodes of viral rhinosinusitis have bacterial superinfection
When is incidence of sinusitis the highest?
early fall through early spring because it is related to viral URI (adults have 2-3 URIs per year- 90% accompanied by rhinosinusitis)
what is pathophysiology of sinusitis?
inflammation and edema of the sinus mucosaobstruction of the sinus ostiaimpaired mucociliary clearancesecretions that are no cleared become hospitable to bacterial growth inflammatory response damages mucosal surfaces
what viruses cause sinusitis?
RhinovirusInfluenza A and Bparainfluenza virusrespiratory syncytailadeno/corona/enteroviruses
What cases bacterial sinusitis?
S. pnemoniae H. InfluenzaeM catarrhalisMore likely if symptoms are worse after 5-7 days or > 10 days complicates 0.2-2% of viral casesoften over diagnosed (leads ton increased antibiotic resistance)
when is fungal sinusitis seen?
in immunocompromised ( uncontrolled DM, neutropenia, or use of corticosteroids) As a nosocomial infection
Symptoms of bacterial sinusitis?
worsening symptoms 5-7 days after initial improvementpersistent symptoms more than 10 dayspersistent purulent nasal discharge unilateral upper tooth or facial painunilateral maxillary sinus tendernessfever
what are the risk factors for sinusitis?
viral URIAllergic rhinitisAsthmasmokingdental infections and procedurestonsillar and adenoid hypertrophyTurbinate hypertrophynasal polypsdeviated septumcleft palate HIVCystic fibrosis*no genetic factor
What are the PE findings for sinusitis?
FeverEdema and erythema of nasal mucosaPurulent dischargetenderness to palpation over sinusTransilllumination of the sinuses (only helpful for unilateral sinusitis)
What are some pediatric considerations for sinusitis?
Sinus are not fully developed until age 20maxillary and ethmoid sinuses present at birthchildren are at risk for developing sinusitis diagnosis can be harder because symptoms are more subtle
What are symptoms of sinusitis that need urgent attention?
Visual disturbances-DiplopiaPeriorbital swelling or erythemaaltered mental status
Are diagnostic tests used for sinusitis?
NOimaging techniques do not distinguish bacterial from viral
why would a coronal CT be used?
for recurrent infection or if medical treatment is not working
How are most cases of rhinosinusitis resolved?
supportive care by treating the pain and nasal symptoms antibiotics are used only when symptoms last more that 10 or get worse in 5-7 days
What medications are first line for sinusitis?
DecongestantsAnalgesicsAntibiotics
What are the first line antibiotics for sinusitis?
Amoxicillin: adults 80-90 mg/kg/dTrimethoprim-sulfamethoxazole (BACTRIM)Doxycycline 100 mg (adults only because it yellows children’s teeth)
What are the general treatments for sinusitis?
Hydrationsteam inhalation (20-30 min)Saline irrigationsleep with head of bed elevatedavoid smoke, fumes, caffeine, alcohol AnalgesicsNSAIDS
What are follow up recommendations for sinusitis?
return if there is no improvement in 72 hours or symptoms continue for more than 10 with antibioticsno follow up is symptoms resolve
What is the prognosis for sinusitis?
alleviation of symptoms in 72 hours and complete resolution within 10-14 days
What is nasal vestibulitis?
inflammation of nasal vestibule which may be from folliculitis of hairs lining the orifice
what is the leading nosocomial pathogen in the world?
Staph aureus 30% have of individual have no vestibulitis symptoms and are carriers
What is the tx for vestibulitis?
Antibiotics that cover S. aureus (dicloxacillin 250 mg PO QID 7-10 D)Topical mupirocin or bacitracin BID or TID
what is invasive fungal sinusitis?
it is similar to acute bacterial rhinosinusit but with more sever facial painclear nasal drainage *black eschar on middle turbinate
How is IFS spread?
spreads through the vascular systemvery rarelethal if not detected early
What are contributing factors for IFS?
DML-T corticosteroid useend stage renal disease
what are the features of epistaxis?
very commonmost case are <10 or 45-65most cases are uncomplicated
what is the source of anterior epistaxis?
Kiesselbach’s plexus
What is the source of posterior epistaxis?
Posterolateral branches of the sphenopalatine artery may also be from carotid arterycan result in significant hemorrhage
Causes of anterior epistaxis?
MC: manual mucus extraction via the digitus secunduc (digital trauma)low moisture in the air Mucosal hyperemia (allergic or viral)FB when there is blood and purulent dischargechronic excoriation leading to small septal perforation from internasal drug usefacial trauma
what are the causes of anterior and posterior epistaxis?
Anticoagulated patients ( on coumadin)familial blood dyscrasias ( VwF disorder) nasal neoplasmAlcoholLong standing HTN
How should epistaxis be evaluated?
Main focus is airway assessment and cardio stability predisposing conditionsTiming, frequency, and severityPresence of chronic medical conditions that could cause more blood loss or that could be related to dyspnea, CP, lightheadedness
what is the initial course of treatment for epistaxis?
- tamponade2. Pt blows nose to remove clots3. PA sprays nose with Afrin or cocaine4. patinet pinches nose againt septum for 5-10 minutes
What is the tx for anterior epistaxis?
Cautery:chemical via silver nitrate sticks or electrical use topical lidocaine
What is the tx for posterior epistaxis?
Nasal packing via nasal tampon made of merocelNasal ballon catheter (rapid rhino encased in carboxymethylated cellulose mesh)Gauze packing via ribbon gauze
what is a nasal obstruction?
something causing the sensation of insufficient airflow through the nosedivided into mucosal and structural causes
How do you diagnose NO in a PE?
Via an external examination: look at external nasal contour for body or cartilaginous deformities look for evidence of nasal traumacervical lymphadenopathy upon palpation also do an otoscopic exam
what can contribute to nasal obstruction in older patients?
deterioration or hypertrophy of the cartilage in the nasal tip
How do you treat a nasal obstruction?
it depends on the cause but usually alligator forceps or nasal sprays
What are nasal polyps?
sac-like growth of inflamed tissue lining the nose or sinuses
what are the risk factors for nasal polyps?
ASA sensitivityAsthmachronic sinus infectionscystic fibrosisAllergic rhinitis
What are the symptoms of nasal polyps?
Mouth breathingNose blockagedecreased sense of smell (hypoosmia)rhinorrhea
How do you diagnose nasal polyps?
they are visible upon exam as well as on CT scans
what is the treatment of nasal polyps?
Glucocorticosteriods1. nasal steroid sprays-fluticisone, budesnide, mometasone2. oral- only for severe cases Tx of the underlying allergiesdaily lavage with salinesurgery is usually temporary tx because they usually come back because they are allergy driven
what are the congenital anomalies of the nose?
Congenital nasal mass1. epidermal inclusion mass2. glioma3. meningocele or meningomyelocele
what is the common cause to septal deviation?
Impact trauma
what are the symptoms of septal deviation?
sinusitissleep apnea sneezingfacial painepistaxisdifficulty breathinghypoosmia
What is the tx for a deviated septum?
no tx if mildAntihistamines, nasal steroids, and decongestants helpif severe- septoplasty
what are juvenile nasopharyngeal adenomas (JNA)?
benign locally aggressive vascular tumor that grown in the posterior nasal cavity Tends to bleed Occurs in the nasopharynx of prepubertal and adolescent male
Who does JNA affect?
Males 7-19 years oldthere is a hormonal theory
What is JNA also know as?
juvenile nasopharyngeal angiofibrima or nasopharyngeal fibroma
How does JNA present?
one sided nasal obstruction with recurrent bleeding
symptoms of JNA?
Frequent epistaxisNasal obstruction and rhinorrheaconductive hearing loss from eustation tube disfunctionDiplopia (due to erosion into cranial cavity and pressure on optic chiasma) Rare: anosmia, recurrent otitis media and eye pain
How is JNA diagnosed?
PE- smooth submucosal mass in posterior nasal cavity ( this is very hard to see, PA has to be looking/ have a suspicion of it)CT scan
what is the third most common fracture?
Nasal bone fracture34%- from fights28%- from accidents23% from sports
How to diagnose a NBF?
Look for asymmetry upon xrayNasal patencyEpistaxis*refer to ENR w/i 3-5 days unless more cute referral is needed
TX for nasal bone fracture?
Manual realignment septoplasty if there is septal deviation
How does malignant nasopharyngeal and paranasal sinus tumors present?
Hx of chronic sinus congestion recurrent nasal obstructionNasal dischargeintermittent epistaxis unilateral symptoms
what are the symptoms of advanced lesions?
It depends on where the tumor has spread:1. widening of the bride of the nose2. Frontal headaches3. proptosis (eyes pushing out), diplopia or palpable orbital mass
what doeswidening of the bride of the nose indicate?
the lesion is invading the olfactory region
What do frontal headaches indicate?
extension through the cribriform plate or into the ethmoid sinuses
what doproptosis, diplopia or palpable orbital mass indicate?
Invasion of the medial orbit
