Nose and Paranasal sinus disorders Flashcards
T/F color of nasal discharge is not diagnostic in and of itself
T
Rhinosinusitis/sinusitis
▪ Rhinosinusitis is a more accurate term for sinusitis
▪ Inflammation of the nares and paranasal sinuses
Sinusitis without rhinitis is ____
rare
The most common acute
illness in the outpatient
setting
upper respiratory tract infection (URTI)
It is WNL to have up to ____ viral respiratory illnesses/year
8
Viral Causes (majority) of URI
- Rhinoviruses (30-50%)
- Coronaviruses
- Adenoviruses
- Enteroviruses
- Coxsackieviruses
- Orthomyxoviruses (influenza)
- RSV
- EBV
Bacterial causes of URI
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- Staphylococcus aureus
Symptoms that begin to improve and then worsen should raise your suspicion for a _____
secondary bacterial infection
PE findings of URI
- Redness and swelling of the nasal mucosa
- Nasal Discharge
- Foul breath
- Fever
T/f Most URIs are self-diagnosed and
treated at home
T
Most common form of rhinitis
Allergic Rhinitis
Allergic Rhinitis
Inflammation of the nasal membranes triggered by an immunoglobulin E (IgE)–mediated response to allergens or irritants
T/F Allergic Rhinitis is Generally not life-threatening unless associated
with anaphylaxis or severe asthma
T
Allergic Rhinitis presentation
▪ Sneezing
▪ Itching
▪ Tearing
▪ Conjunctivitis
▪ Fatigue/malaise
Others
▪ Rhinorrhea
▪ Postnasal drip (PND)
▪ Congestion
▪ Decreased sense of smell
▪ Headache
▪ Otalgia
Exam findings for allergic rhinitis
▪ “Allergic shiners” - vasodilation causing dark circles
▪ Nasal mucosa boggy and pale
▪ Enlarged turbinates
▪ TM: Evaluate for air-fluid levels and retraction
▪ Oropharynx: “Cobblestoning”
Allergic Rhinitis Testing
▪ 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
How to Limit environmental exposure to allergens/irritants
▪ 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
Treatment for allergic rhinitis
▪ Second-generation oral antihistamines
▪ Third-generation oral antihistamines
▪ Leukotriene receptor antagonists
▪ Decongestants
▪ Opthalmic drops
▪ nasal corticosteroid sprays
Immunotherapy for allergic rhinitis
▪ “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%
Vasomotor Rhinitis
A form of non-allergic rhinitis
Typically presents after age 20
Vasodilation of the nasal vessels
▪ Parasympathetic hyper-activity
Triggers of vasomotor rhinitis
▪ Spicy food
▪ Strong odors
▪ Cold air
Presentation of Vasomotor Rhinitis
▪ Nasal congestion
▪ Nasal discharge (clear, watery)
▪ Sneezing
▪ Patients may have noticed an association
Exam findings of vasomotor rhinitis
▪ Mucosal edema
▪ Turbinate hypertrophy
▪ Clear rhinorrhea
Labs in vasomotor rhinitis
▪ Consider allergy testing if diagnosis is not clear
▪ Beta2-transferrin
Treatment of vasomotor rhinitis
Patient education
▪ Manage expectations
▪ Avoid triggers
Nasal irrigation
Medications
▪ Ipratropium bromide (Atrovent)
▪ Azelastine (Astelin)
▪ Pseudoephedrine
Rhinitis Medicamentosa
Rebound rhinitis
Rhinitis Medicamentosa presentation
▪ 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
Tx of Rhinitis Medicamentosa
- Patient must completely discontinue the offending medication
- Oral decongestants
- Nasal steroid spray
- Oral steroid
- Patient education
Acute Bacterial Sinusitis
Acute inflammation of the lining of the
paranasal sinuses lasting < 4 weeks
Acute Bacterial Sinusitis presentation
▪ Facial pain or pressure (especially unilateral)
▪ Postnasal drip
▪ Dental pain
▪ Ear fullness/pressure
▪ Hyposmia/anosmia
▪ Nasal congestion, rhinorrhea
▪ Fever
▪ Cough
▪ Fatigue
Exam findings in acute bacterial sinusitis
▪ Purulent nasal secretions
▪ Purulent posterior pharyngeal secretions
▪ Mucosal erythema
▪ Periorbital edema
▪ Tenderness overlying sinuses
Acute Bacterial Sinusitis imaging
▪ Routine radiographs are not
recommended
▪ Noncontrast CT scan
▪ More cost-effective, rapid
▪ Consider MRI if malignancy,
intracranial extension, or
opportunistic infection are
suspected
Acute Bacterial Sinusitis Tx
▪ 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
When to refer an acute bacterial sinusitis to ENT
▪ 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
When to admit an acute bacterial sinusitis
▪ Facial swelling and erythema indicative of
facial cellulitis
▪ Proptosis
▪ Vision change or gaze abnormality
▪ Abscess or cavernous sinus involvement
▪ Mental status changes
Chronic Sinusitis
Inflammatory disease process
that involves the paranasal
sinuses and persists for 12
weeks or longe
Contributing factors for chronic sinusitis
▪ Nasal polyps
▪ Biofilms
▪ Seasonal allergies
▪ Fungi
Diagnositic symptoms of Chronis sinusitis
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
Chronic Sinusitis Presentation
▪ Nasal obstruction
▪ Facial fullness
▪ Fetid breath
▪ Dental pain (upper teeth)
A study by Mayo Clinic demonstrated ____ in
96% of patients with chronic sinus disease
fungal hyphae
First line Imaging for chronic sinusitis
▪ Maxillofacial CT scan
▪ Consider MRI for complicated cases
Treatment of choice for chronic fungal sinusitis
Surgery - Functional endoscopic sinus surgery
Nasal Polyps
Abnormal lesions that originate from any
portion of the nasal mucosa or paranasal
sinuses
Nasal Polyps Associated conditions
▪ Asthma
▪ Cystic fibrosis (CF)
▪ Allergic rhinitis
▪ Chronic rhinosinusitis
▪ Fungal sinusitis
2 types of nasal polyps
▪ Antrochoanal: Arise from maxillary sinuses, single, unilateral, children
▪ Ethmoidal: Arise from ethmoid sinuses, bilateral, adults
Presentation of nasal polyps
▪ Nasal obstruction
▪ Facial pressure
▪ PND
▪ Dull headaches
▪ Snoring
▪ Rhinorrhea
▪ Anosmic disturbances
Most common location of nasal polyps
▪ The middle meatus if the most common location
▪ Pale, grape-like, “teardrops”
Nasal Polyps Labs
▪ Sweat chloride test or genetic CF test in any child with multiple polyps
▪ RAST
Tx of nasal polyps
▪ Oral and topical steroids
▪ Refer to ENT for surgical removal
▪ Nasal polyps tend to recur
▪ Immunologics
Nasal Foreign Body (NFB)
Common in pediatric patients
▪ Median age is 3 years
Beads are the most common
Remove all but the most anteriorly placed
nasal foreign bodies _____
under general anesthesia
Most common locations of NFB
▪ Just anterior to the middle
turbinate
▪ Below the inferior
turbinate
▪ Unilateral foreign bodies
affect the right side about
twice as often as the left
Presentation of NFB
▪ Unilateral nasal symptoms
▪ Discharge
▪ Odor
▪ Sneezing
▪ Snoring
Intranasal exam in NFB
▪ Nasal speculum and headlamp are helpful
▪ May appear as a large conglomerate of mucous
▪ Evidence of trauma (bleeding, edema, etc.)
___ of the nasal mucosa can facilitate removal of NFBs
Vasoconstriction
Extraction tools for NFB
▪ 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
Indications for ENT referral for NFB
▪ Non-compliant patient
▪ Posterior location of NFB
▪ Cases of prior failed removal
▪ Damage to surrounding nasal
structures
Risk factors for epistaxis
▪ Dry climate
▪ Winter months
▪ Allergic rhinitis
▪ Chronic sinusitis
▪ HTN
▪ Blood thinning medications
▪ Coagulopathy
▪ Migraine
▪ Hereditary hemorrhagic
telangiectasia (Osler-Weber-
Rendu syndrome)
Causes of epistaxis
▪ Idiopathic
▪ Trauma (digital)
▪ Septal abnormality
▪ Foreign body
▪ Granulomatosis diseases
(Wegner)
▪ Tumors
Anterior epistaxis
▪ 90% of bleeds occur anteriorly
▪ Capillary or venous bleeds
▪ Patients present with a
constant ooze or intermittent bleeding
that resolves quickly
Posterior Epistaxis
▪ Often of arterial origin
▪ Arise posteriorly in the nasal
cavity
▪ Associated with
atherosclerotic disease and
hypertension
▪ Patients present with profuse
pumping of blood
Consider the possibility of a posterior epistaxis bleed if:
▪ Anterior source cannot be visualized
▪ Hemorrhage from both nares
▪ Constant dripping of blood is seen in the posterior pharynx
Treatment of anterior epistaxis
▪ 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
Treatment of posterior epistaxis
▪ Refer to ER
▪ Cauterization and packing by ENT
Nasal Septal Perforation
Hole in the nasal septum
Nasal Septal Perforation etiology
▪ Digital
▪ Iatrogenic
▪ Cocaine and/or heroin
▪ Inflammatory conditions
▪ Trauma
▪ Nasal steroid spray use
Nasal Septal Perforation presentation
▪ Asymptomatic
▪ Whistling while breathing
▪ Recurrent bleeding
▪ Dry nasal membranes
Nasal Septal Perforation tx
Nasal moisturization
▪ Polysporin ointment
Discontinue causative agent (if applicable)
▪ Nasal steroid spray
▪ Illicit drugs
Silicone button prosthesis can be utilized with
Nasal Septal Perforation
Nasal Fractures Presentation
▪ History of trauma
▪ Bruising
▪ Epistaxis
▪ Pain
Nasal Fractures with nasal fractures
▪ Displacement of the septum
▪ Visualize the nasal septum and evaluate for a septal hematoma
Septal hematoma
▪ 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
Nasal Fractures imaging
▪ Nearly 50% of nasal fractures
missed on plain film nasal
radiographs
▪ Consider CT scan: Preferred means of imaging facial trauma
Nasal Fractures Tx
▪ Avoid contact sports for 2-4
weeks
▪ Patient education
▪ Referral to ENT
Wegener’s Granulomatosis
Necrotizing granulomatous
inflammation and vasculitis in small-
and medium-sized blood vessels
- Rare, multisystem autoimmune
disease of unknown etiology
Wegener’s Granulomatosis presentation
▪ Fevers, night sweats
▪ Fatigue, lethargy
▪ Loss of appetite
▪ Weight loss
▪ Chronic sinusitis
▪ Intranasal lesion
▪ Nasal deformity
Wegener’s Granulomatosis Exam
▪ 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
saddle nose deformity is seen in
Wegener’s Granulomatosis
Wegener’s Granulomatosis Labs
▪ 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
Wegener’s Granulomatosis Imaging
▪ Chest radiograph: Bilateral nodules, approximately 50% are cavitated
▪ Consider CT scan
Consider ENT referral for biopsy and
Rheumatology referral with Wegener’s Granulomatosis
Wegeners
