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EENT Exam 2 > Nose and Paranasal sinus disorders > Flashcards

Nose and Paranasal sinus disorders Flashcards

1
Q

T/F color of nasal discharge is not diagnostic in and of itself

A

T

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2
Q

Rhinosinusitis/sinusitis

A

▪ Rhinosinusitis is a more accurate term for sinusitis
▪ Inflammation of the nares and paranasal sinuses

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3
Q

Sinusitis without rhinitis is ____

A

rare

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4
Q

The most common acute
illness in the outpatient
setting

A

upper respiratory tract infection (URTI)

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5
Q

It is WNL to have up to ____ viral respiratory illnesses/year

A

8

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6
Q

Viral Causes (majority) of URI

A
  • Rhinoviruses (30-50%)
  • Coronaviruses
  • Adenoviruses
  • Enteroviruses
  • Coxsackieviruses
  • Orthomyxoviruses (influenza)
  • RSV
  • EBV
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7
Q

Bacterial causes of URI

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Staphylococcus aureus
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8
Q

Symptoms that begin to improve and then worsen should raise your suspicion for a _____

A

secondary bacterial infection

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9
Q

PE findings of URI

A
  • Redness and swelling of the nasal mucosa
  • Nasal Discharge
  • Foul breath
  • Fever
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10
Q

T/f Most URIs are self-diagnosed and
treated at home

A

T

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11
Q

Most common form of rhinitis

A

Allergic Rhinitis

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12
Q

Allergic Rhinitis

A

Inflammation of the nasal membranes triggered by an immunoglobulin E (IgE)–mediated response to allergens or irritants

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13
Q

T/F Allergic Rhinitis is Generally not life-threatening unless associated
with anaphylaxis or severe asthma

A

T

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14
Q

Allergic Rhinitis presentation

A

▪ Sneezing
▪ Itching
▪ Tearing
▪ Conjunctivitis
▪ Fatigue/malaise
Others
▪ Rhinorrhea
▪ Postnasal drip (PND)
▪ Congestion
▪ Decreased sense of smell
▪ Headache
▪ Otalgia

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15
Q

Exam findings for allergic rhinitis

A

▪ “Allergic shiners” - vasodilation causing dark circles
▪ Nasal mucosa boggy and pale
▪ Enlarged turbinates
▪ TM: Evaluate for air-fluid levels and retraction
▪ Oropharynx: “Cobblestoning”

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16
Q

Allergic Rhinitis Testing

A

▪ RAST
▪ Blood test
▪ The sensitivity and specificity are not always as accurate

▪ Skin testing
▪ Percutaneous or intradermal
▪ The extract of a suspected allergen is introduced
▪ An immediate wheal-and-flare reaction can be produced
within 15-20 minutes

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17
Q

How to Limit environmental exposure to allergens/irritants

A

▪ Keep windows closed as much as possible
▪ Don’t plant known allergens in close proximity
▪ HEPA filters
▪ Launder linens regularly
▪ Vacuum floors and household fabrics regularly
▪ Wear proper equipment/masks in industrial situations

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18
Q

Treatment for allergic rhinitis

A

▪ Second-generation oral antihistamines
▪ Third-generation oral antihistamines
▪ Leukotriene receptor antagonists
▪ Decongestants
▪ Opthalmic drops
▪ nasal corticosteroid sprays

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19
Q

Immunotherapy for allergic rhinitis

A

▪ “Allergy shots”
▪ Long-term process
▪ Results are not noticeable for 6-12 months
▪ Therapy is continued for several years
▪ Subcutaneous or sublingual
▪ Prescription tablet form for grasses and ragweed
approved in 2014
▪ Oralair, Grastek, Ragwitek
▪ Success rates as high as 80-90%

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20
Q

Vasomotor Rhinitis

A

A form of non-allergic rhinitis
Typically presents after age 20
Vasodilation of the nasal vessels
▪ Parasympathetic hyper-activity

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21
Q

Triggers of vasomotor rhinitis

A

▪ Spicy food
▪ Strong odors
▪ Cold air

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22
Q

Presentation of Vasomotor Rhinitis

A

▪ Nasal congestion
▪ Nasal discharge (clear, watery)
▪ Sneezing
▪ Patients may have noticed an association

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23
Q

Exam findings of vasomotor rhinitis

A

▪ Mucosal edema
▪ Turbinate hypertrophy
▪ Clear rhinorrhea

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24
Q

Labs in vasomotor rhinitis

A

▪ Consider allergy testing if diagnosis is not clear
▪ Beta2-transferrin

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25
Q

Treatment of vasomotor rhinitis

A

Patient education
▪ Manage expectations
▪ Avoid triggers
Nasal irrigation
Medications
▪ Ipratropium bromide (Atrovent)
▪ Azelastine (Astelin)
▪ Pseudoephedrine

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26
Q

Rhinitis Medicamentosa

A

Rebound rhinitis

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27
Q

Rhinitis Medicamentosa presentation

A

▪ Nasal congestion w/o rhinorrhea: Often severe
▪ Patients typically report a history of a
URI: Infectious symptoms resolved, nasal
congestion persisted
▪ Ask the patient if you can see the spray

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28
Q

Tx of Rhinitis Medicamentosa

A
  • Patient must completely discontinue the offending medication
  • Oral decongestants
  • Nasal steroid spray
  • Oral steroid
  • Patient education
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29
Q

Acute Bacterial Sinusitis

A

Acute inflammation of the lining of the
paranasal sinuses lasting < 4 weeks

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30
Q

Acute Bacterial Sinusitis presentation

A

▪ Facial pain or pressure (especially unilateral)
▪ Postnasal drip
▪ Dental pain
▪ Ear fullness/pressure
▪ Hyposmia/anosmia
▪ Nasal congestion, rhinorrhea
▪ Fever
▪ Cough
▪ Fatigue

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31
Q

Exam findings in acute bacterial sinusitis

A

▪ Purulent nasal secretions
▪ Purulent posterior pharyngeal secretions
▪ Mucosal erythema
▪ Periorbital edema
▪ Tenderness overlying sinuses

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32
Q

Acute Bacterial Sinusitis imaging

A

▪ Routine radiographs are not
recommended
▪ Noncontrast CT scan
▪ More cost-effective, rapid
▪ Consider MRI if malignancy,
intracranial extension, or
opportunistic infection are
suspected

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33
Q

Acute Bacterial Sinusitis Tx

A

▪ Aid drainage of the involved sinus (sudafed)
▪ NSAID
▪ Nasal steroid spray
▪ 40 to 69% of patients with acute bacterial
rhinosinusitis improve symptomatically within 2 weeks without antibiotic therapy

34
Q

When to refer an acute bacterial sinusitis to ENT

A

▪ Failure to resolve after an adequate course of oral antibiotics
▪ Nasal endoscopy and CT scan are indicated when symptoms persist longer than 4–12
weeks
▪ Concerning or unusual symptoms

35
Q

When to admit an acute bacterial sinusitis

A

▪ Facial swelling and erythema indicative of
facial cellulitis
▪ Proptosis
▪ Vision change or gaze abnormality
▪ Abscess or cavernous sinus involvement
▪ Mental status changes

36
Q

Chronic Sinusitis

A

Inflammatory disease process
that involves the paranasal
sinuses and persists for 12
weeks or longe

37
Q

Contributing factors for chronic sinusitis

A

▪ Nasal polyps
▪ Biofilms
▪ Seasonal allergies
▪ Fungi

38
Q

Diagnositic symptoms of Chronis sinusitis

A

12 weeks or longer of two or more of the following
symptoms:
▪ Mucopurulent drainage (anterior, posterior, or both)
▪ Nasal obstruction (congestion)
▪ Facial pain/pressure/fullness
▪ Decreased sense of smell
AND inflammation as seen by one of the following:
▪ Purulent mucus or edema in the middle meatus or ethmoid region
▪ Polyps in the nasal cavity or the middle meatus
▪ Radiographic imaging showing inflammation of the paranasal
sinuses

39
Q

Chronic Sinusitis Presentation

A

▪ Nasal obstruction
▪ Facial fullness
▪ Fetid breath
▪ Dental pain (upper teeth)

40
Q

A study by Mayo Clinic demonstrated ____ in
96% of patients with chronic sinus disease

A

fungal hyphae

41
Q

First line Imaging for chronic sinusitis

A

▪ Maxillofacial CT scan
▪ Consider MRI for complicated cases

42
Q

Treatment of choice for chronic fungal sinusitis

A

Surgery - Functional endoscopic sinus surgery

43
Q

Nasal Polyps

A

Abnormal lesions that originate from any
portion of the nasal mucosa or paranasal
sinuses

44
Q

Nasal Polyps Associated conditions

A

▪ Asthma
▪ Cystic fibrosis (CF)
▪ Allergic rhinitis
▪ Chronic rhinosinusitis
▪ Fungal sinusitis

45
Q

2 types of nasal polyps

A

▪ Antrochoanal: Arise from maxillary sinuses, single, unilateral, children
▪ Ethmoidal: Arise from ethmoid sinuses, bilateral, adults

46
Q

Presentation of nasal polyps

A

▪ Nasal obstruction
▪ Facial pressure
▪ PND
▪ Dull headaches
▪ Snoring
▪ Rhinorrhea
▪ Anosmic disturbances

47
Q

Most common location of nasal polyps

A

▪ The middle meatus if the most common location
▪ Pale, grape-like, “teardrops”

48
Q

Nasal Polyps Labs

A

▪ Sweat chloride test or genetic CF test in any child with multiple polyps
▪ RAST

49
Q

Tx of nasal polyps

A

▪ Oral and topical steroids
▪ Refer to ENT for surgical removal
▪ Nasal polyps tend to recur
▪ Immunologics

50
Q

Nasal Foreign Body (NFB)

A

Common in pediatric patients
▪ Median age is 3 years
Beads are the most common

51
Q

Remove all but the most anteriorly placed
nasal foreign bodies _____

A

under general anesthesia

52
Q

Most common locations of NFB

A

▪ Just anterior to the middle
turbinate
▪ Below the inferior
turbinate
▪ Unilateral foreign bodies
affect the right side about
twice as often as the left

53
Q

Presentation of NFB

A

▪ Unilateral nasal symptoms
▪ Discharge
▪ Odor
▪ Sneezing
▪ Snoring

54
Q

Intranasal exam in NFB

A

▪ Nasal speculum and headlamp are helpful
▪ May appear as a large conglomerate of mucous
▪ Evidence of trauma (bleeding, edema, etc.)

55
Q

___ of the nasal mucosa can facilitate removal of NFBs

A

Vasoconstriction

56
Q

Extraction tools for NFB

A

▪ For easily visualized, non-spherical, non-friable objects, most clinicians prefer direct instrumentation
▪ Bayonet forceps, alligator forceps, hemostats, right-angle hook
▪ Balloon catheter
▪ Suction
▪ Positive pressure
▪ “Parent’s kiss” or bag-valve mask
▪ Glue
▪ Magnet

57
Q

Indications for ENT referral for NFB

A

▪ Non-compliant patient
▪ Posterior location of NFB
▪ Cases of prior failed removal
▪ Damage to surrounding nasal
structures

58
Q

Risk factors for epistaxis

A

▪ Dry climate
▪ Winter months
▪ Allergic rhinitis
▪ Chronic sinusitis
▪ HTN
▪ Blood thinning medications
▪ Coagulopathy
▪ Migraine
▪ Hereditary hemorrhagic
telangiectasia (Osler-Weber-
Rendu syndrome)

59
Q

Causes of epistaxis

A

▪ Idiopathic
▪ Trauma (digital)
▪ Septal abnormality
▪ Foreign body
▪ Granulomatosis diseases
(Wegner)
▪ Tumors

60
Q

Anterior epistaxis

A

▪ 90% of bleeds occur anteriorly
▪ Capillary or venous bleeds
▪ Patients present with a
constant ooze or intermittent bleeding
that resolves quickly

61
Q

Posterior Epistaxis

A

▪ Often of arterial origin
▪ Arise posteriorly in the nasal
cavity
▪ Associated with
atherosclerotic disease and
hypertension
▪ Patients present with profuse
pumping of blood

62
Q

Consider the possibility of a posterior epistaxis bleed if:

A

▪ Anterior source cannot be visualized
▪ Hemorrhage from both nares
▪ Constant dripping of blood is seen in the posterior pharynx

63
Q

Treatment of anterior epistaxis

A

▪ Direct pressure on the site by compression of the nares continuously for 15 minutes, leaning slightly forward
▪ Topical 4% cocaine
▪ Silver nitrate
▪ Surgicel with a moisture barrier
▪ Refer to ENT if recurrent
▪ Those with ongoing bleeding beyond 15 minutes should be taken to the ER if the clinician is not prepared to manage

64
Q

Treatment of posterior epistaxis

A

▪ Refer to ER
▪ Cauterization and packing by ENT

65
Q
A
66
Q

Nasal Septal Perforation

A

Hole in the nasal septum

67
Q

Nasal Septal Perforation etiology

A

▪ Digital
▪ Iatrogenic
▪ Cocaine and/or heroin
▪ Inflammatory conditions
▪ Trauma
▪ Nasal steroid spray use

68
Q

Nasal Septal Perforation presentation

A

▪ Asymptomatic
▪ Whistling while breathing
▪ Recurrent bleeding
▪ Dry nasal membranes

69
Q

Nasal Septal Perforation tx

A

Nasal moisturization
▪ Polysporin ointment
Discontinue causative agent (if applicable)
▪ Nasal steroid spray
▪ Illicit drugs

70
Q

Silicone button prosthesis can be utilized with

A

Nasal Septal Perforation

71
Q

Nasal Fractures Presentation

A

▪ History of trauma
▪ Bruising
▪ Epistaxis
▪ Pain

72
Q

Nasal Fractures with nasal fractures

A

▪ Displacement of the septum
▪ Visualize the nasal septum and evaluate for a septal hematoma

73
Q

Septal hematoma

A

▪ Collection of blood in the space between in the cartilage and overlying perichondrium
▪ Septal cartilage has no blood supply of its own
▪ Receives nutrients and oxygen from perichondrium
▪ An un-evacuated septal hematoma may lead to destruction of the septum
▪ Immediate drainage necessary → ENT

74
Q

Nasal Fractures imaging

A

▪ Nearly 50% of nasal fractures
missed on plain film nasal
radiographs
▪ Consider CT scan: Preferred means of imaging facial trauma

75
Q

Nasal Fractures Tx

A

▪ Avoid contact sports for 2-4
weeks
▪ Patient education
▪ Referral to ENT

76
Q

Wegener’s Granulomatosis

A

Necrotizing granulomatous
inflammation and vasculitis in small-
and medium-sized blood vessels
- Rare, multisystem autoimmune
disease of unknown etiology

77
Q

Wegener’s Granulomatosis presentation

A

▪ Fevers, night sweats
▪ Fatigue, lethargy
▪ Loss of appetite
▪ Weight loss
▪ Chronic sinusitis
▪ Intranasal lesion
▪ Nasal deformity

78
Q

Wegener’s Granulomatosis Exam

A

▪ Rhinitis (22%)
▪ Epistaxis (11%)
▪ Bilateral nasal crusting with underlying friable mucosa
▪ Collapse of nasal support → saddle nose deformity
▪ Serous otitis media and hearing loss
▪ Strawberry gingival hyperplasia
▪ Stridor, possibly leading to respiratory compromise,
from tracheal or subglottic granulomatous masses
▪ Hearing loss

79
Q

saddle nose deformity is seen in

A

Wegener’s Granulomatosis

80
Q

Wegener’s Granulomatosis Labs

A

▪ Antineutrophil cytoplasmic antibodies (c-ANCA)
▪ PR3-ANCA (proteinase 3)
▪ CBC c diff
▪ CMP
▪ ESR
▪ CRP
▪ UA: Proteinuria, microscopic hematuria, and the presence of
red blood cell (RBC) casts

81
Q

Wegener’s Granulomatosis Imaging

A

▪ Chest radiograph: Bilateral nodules, approximately 50% are cavitated
▪ Consider CT scan

82
Q

Consider ENT referral for biopsy and
Rheumatology referral with Wegener’s Granulomatosis

A

Wegeners

EENT Exam 2 (5 decks)

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