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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
Treatment of vasomotor rhinitis
Patient education ▪ Manage expectations ▪ Avoid triggers Nasal irrigation Medications ▪ Ipratropium bromide (Atrovent) ▪ Azelastine (Astelin) ▪ Pseudoephedrine
26
Rhinitis Medicamentosa
Rebound rhinitis
27
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
28
Tx of Rhinitis Medicamentosa
* Patient must completely discontinue the offending medication * Oral decongestants * Nasal steroid spray * Oral steroid * Patient education
29
Acute Bacterial Sinusitis
Acute inflammation of the lining of the paranasal sinuses lasting < 4 weeks
30
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
31
Exam findings in acute bacterial sinusitis
▪ Purulent nasal secretions ▪ Purulent posterior pharyngeal secretions ▪ Mucosal erythema ▪ Periorbital edema ▪ Tenderness overlying sinuses
32
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
33
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
34
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
35
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
36
Chronic Sinusitis
Inflammatory disease process that involves the paranasal sinuses and persists for 12 weeks or longe
37
Contributing factors for chronic sinusitis
▪ Nasal polyps ▪ Biofilms ▪ Seasonal allergies ▪ Fungi
38
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
39
Chronic Sinusitis Presentation
▪ Nasal obstruction ▪ Facial fullness ▪ Fetid breath ▪ Dental pain (upper teeth)
40
A study by Mayo Clinic demonstrated ____ in 96% of patients with chronic sinus disease
fungal hyphae
41
First line Imaging for chronic sinusitis
▪ Maxillofacial CT scan ▪ Consider MRI for complicated cases
42
Treatment of choice for chronic fungal sinusitis
Surgery - Functional endoscopic sinus surgery
43
Nasal Polyps
Abnormal lesions that originate from any portion of the nasal mucosa or paranasal sinuses
44
Nasal Polyps Associated conditions
▪ Asthma ▪ Cystic fibrosis (CF) ▪ Allergic rhinitis ▪ Chronic rhinosinusitis ▪ Fungal sinusitis
45
2 types of nasal polyps
▪ Antrochoanal: Arise from maxillary sinuses, single, unilateral, children ▪ Ethmoidal: Arise from ethmoid sinuses, bilateral, adults
46
Presentation of nasal polyps
▪ Nasal obstruction ▪ Facial pressure ▪ PND ▪ Dull headaches ▪ Snoring ▪ Rhinorrhea ▪ Anosmic disturbances
47
Most common location of nasal polyps
▪ The middle meatus if the most common location ▪ Pale, grape-like, “teardrops”
48
Nasal Polyps Labs
▪ Sweat chloride test or genetic CF test in any child with multiple polyps ▪ RAST
49
Tx of nasal polyps
▪ Oral and topical steroids ▪ Refer to ENT for surgical removal ▪ Nasal polyps tend to recur ▪ Immunologics
50
Nasal Foreign Body (NFB)
Common in pediatric patients ▪ Median age is 3 years Beads are the most common
51
Remove all but the most anteriorly placed nasal foreign bodies _____
under general anesthesia
52
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
53
Presentation of NFB
▪ Unilateral nasal symptoms ▪ Discharge ▪ Odor ▪ Sneezing ▪ Snoring
54
Intranasal exam in NFB
▪ Nasal speculum and headlamp are helpful ▪ May appear as a large conglomerate of mucous ▪ Evidence of trauma (bleeding, edema, etc.)
55
___ of the nasal mucosa can facilitate removal of NFBs
Vasoconstriction
56
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
57
Indications for ENT referral for NFB
▪ Non-compliant patient ▪ Posterior location of NFB ▪ Cases of prior failed removal ▪ Damage to surrounding nasal structures
58
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)
59
Causes of epistaxis
▪ Idiopathic ▪ Trauma (digital) ▪ Septal abnormality ▪ Foreign body ▪ Granulomatosis diseases (Wegner) ▪ Tumors
60
Anterior epistaxis
▪ 90% of bleeds occur anteriorly ▪ Capillary or venous bleeds ▪ Patients present with a constant ooze or intermittent bleeding that resolves quickly
61
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
62
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
63
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
64
Treatment of posterior epistaxis
▪ Refer to ER ▪ Cauterization and packing by ENT
65
66
Nasal Septal Perforation
Hole in the nasal septum
67
Nasal Septal Perforation etiology
▪ Digital ▪ Iatrogenic ▪ Cocaine and/or heroin ▪ Inflammatory conditions ▪ Trauma ▪ Nasal steroid spray use
68
Nasal Septal Perforation presentation
▪ Asymptomatic ▪ Whistling while breathing ▪ Recurrent bleeding ▪ Dry nasal membranes
69
Nasal Septal Perforation tx
Nasal moisturization ▪ Polysporin ointment Discontinue causative agent (if applicable) ▪ Nasal steroid spray ▪ Illicit drugs
70
Silicone button prosthesis can be utilized with
Nasal Septal Perforation
71
Nasal Fractures Presentation
▪ History of trauma ▪ Bruising ▪ Epistaxis ▪ Pain
72
Nasal Fractures with nasal fractures
▪ Displacement of the septum ▪ Visualize the nasal septum and evaluate for a septal hematoma
73
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
74
Nasal Fractures imaging
▪ Nearly 50% of nasal fractures missed on plain film nasal radiographs ▪ Consider CT scan: Preferred means of imaging facial trauma
75
Nasal Fractures Tx
▪ Avoid contact sports for 2-4 weeks ▪ Patient education ▪ Referral to ENT
76
Wegener’s Granulomatosis
Necrotizing granulomatous inflammation and vasculitis in small- and medium-sized blood vessels - Rare, multisystem autoimmune disease of unknown etiology
77
Wegener’s Granulomatosis presentation
▪ Fevers, night sweats ▪ Fatigue, lethargy ▪ Loss of appetite ▪ Weight loss ▪ Chronic sinusitis ▪ Intranasal lesion ▪ Nasal deformity
78
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
79
saddle nose deformity is seen in
Wegener’s Granulomatosis
80
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
81
Wegener’s Granulomatosis Imaging
▪ Chest radiograph: Bilateral nodules, approximately 50% are cavitated ▪ Consider CT scan
82
Consider ENT referral for biopsy and Rheumatology referral with Wegener’s Granulomatosis
Wegeners

EENT Exam 2 (5 decks)

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