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Nose and Paranasal Sinuses Flashcards

1
Q

Rhinorrhea

A

Runny nose

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2
Q

Coryza

A

Symptoms of a “cold,” describes the inflammation of the mucous membranes lining the nasal cavity, usually with nasal discharge

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3
Q

Rhinitis

A

Symptomatic disorder of the nose characterized by itching, nasal discharge, sneezing and nasal airway obstruction

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4
Q

Allergic rhinitis

A

Induction of rhinitis symptoms after allergen exposure by an IgE-mediated immune reaction; accompanied by inflammation of the nasal mucosa and nasal airway hyperreactivity

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5
Q

What would you check upon PE?

A 
HEENT exam (be sure to look up nose)
Lymph nodes
Respiratory
Heart
Abdominal
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6
Q

What else is an Upper Respiratory Tract Infection (URI) known as?

A

Common cold, acute viral rhinosinusitis

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7
Q

What kind of treatment does a URI require?

A

None, they are self limited

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8
Q

How many URIs does the average preschooler get per year?

A

5-7

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9
Q

How many URIs doe the average adult get per year?

A

2-3

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10
Q

What is the most common cause of a URI?

A

Rhinoviruses (30-50%)

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11
Q

What is the second most common cause of a URI?

A

Unknown (20-30%)

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12
Q

What is the third most common cause of a URI?

A

Coronaviruses (10-15%)

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13
Q

Which virus more commonly causes pharyngitis, fever and lower respiratory infections in military quarters and immunocompromised patients?

A

Adenovirus

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14
Q

Which type of virus frequently causes asymptomatic or an undifferentiated febrile illness?

A

Enteroviruses (echo and coxsackie)

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15
Q

Which viruses are more likely to be found causing illness in young children?

A

Parainfluenza and RSV

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16
Q

How are URIs transmitted from person to person?

A

Hand to hand contact
Droplets
Contaminated fomites (rhinovirus can survive for several hours)

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17
Q

When does viral shedding peak?

A

2nd or 3rd day of illness

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18
Q

How long can low levels of viral shedding persist?

A

Up to two weeks

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19
Q

What are common risk factors for contracting a URI?

A

Exposure to children in daycare settings
Psychological stress
Less sleep
Preexisting sleep disturbances

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20
Q

What can help decrease the risk of URI?

A

Moderate physical exercise

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21
Q

What are risk factors that can increase the severity of a URI?

A

Underlying chronic disease
Congenital immunodeficiency disorders
Malnutrition
Cigarette smoking

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22
Q

What are the most common symptoms of a URI?

A

Rhinitis

Nasal congestion

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23
Q

What other symptoms may also be present?

A 
Sneezing
Sore/scratchy throat
Cough
Malaise
Fever (uncommon in adults)
Conjunctivitis
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24
Q

What may you find upon physical exam?

A 
Nasal mucosal swelling
Nasal congestion
Pharyngeal erythema
Conjunctival injection
TMs may have fluid w/o signs of infection
Clear lung exam
Adenopathy (not prominent)
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25
Q

In what percentage of patients with a URI do complications occur?

A

0.5-2%

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26
Q

What are the possible complications?

A

Secondary bacterial infections
Rhinosinusitis
Otitis media
Pneumonia

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27
Q

How do you treat a URI?

A

NO ANTIBIOTICS!
Symptomatically
Saline nasal irrigation
Oral decongestants
Nasal decongestants (limited to a few days)
Can lead to rhinitis and medicomentosa
Zinc (helps to reduce the duration of illness)

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28
Q

Which sinuses are present at birth?

A

Maxillary and ethmoid

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29
Q

Which sinus develops after age 2?

A

Frontal

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30
Q

Which sinus develops after age 7?

A

Sphenoid

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31
Q

Which sinus is most commonly infected?

A

Maxillary

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32
Q

What are the causes of acute bacterial rhinosinusitis?

A

Viral URI is most common precursor
Allergic rhinitis (ostial obstruction by mucosal edema or polyps
NG tube (risk factor for nosocomial sinusitis)
Dental infections (maxillary sinusitis)
Barotrauma

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33
Q

What are some less-common causes of acute bacterial rhinosinusitis?

A 
Mucous abnormality (cystic fibrosis)
Chemical irritants
Foreign bodies
Tumors
Granulomatous diseases
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34
Q

What are the most typical pathogens of acute bacterial rhinosinusitis?

A 
Strep pneumo
Haemophilus influenzae
Moraxella catarrhalis
Other streptococcal species
Staph aureus
Anaerobes (dental infections)
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35
Q

What are the major symptoms of sinusitis?

A 
Purulent anterior nasal discharge
Purulent or discolored posterior nasal discharge
Nasal congestion or obstruction
Facial congestion or fullness
Hyposmia or anosmia
Fever (for acute sinusitis only)
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36
Q

What are the minor symptoms of sinusitis?

A 
HA
Ear pain/pressure/fullness
Halitosis
Dental pain
Fever (for subacute or chronic sinusitis)
Fatigue
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37
Q

How many major and minor symptoms must be present in order to make a diagnosis of sinusitis?

A

2 major
-or-
1 major and 2+ minor

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38
Q

What clinical findings will you have with acute bacterial rhinosinusitis?

A 
Localizes to involved sinus
   Maxillary - cheek or upper teeth
   Ethmoid - b/t eyes or retroorbital
   Frontal - above eyebrow
   Sphenoid - upper half of face or retroorbital with
                    radiation to occiput
Pain worse when bending over
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39
Q

How do you distinguish acute bacterial rhinosinusitis from viral rhinitis?

A

Persistance of symptoms >7 days
-and any of the following-
Purulent nasal discharge
Maxillary tooth or facial pain (especially unilateral)
Unilateral maxillary sinus tenderness
Worsening symptoms after initial improvement

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40
Q

How do you make the diagnosis of acute bacterial rhinosinusitis?

A

Clinically
CT or sinus radiography (plain xrays not helpful)
Not for routine cases
CT is study of choice

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41
Q

What are the typical pathogens of nosocomial sinusitis?

A 
Staph aureus
P. aeruginosa
Anaerobes
Serratia
Klebsiella
Enterobacter species
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42
Q

What are the clinical findings of nosocomial sinusitis?

A

Often critically ill patient

Suspect if risk factors and fever are present

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43
Q

How do you confirm nosocomial sinusitis (hospital acquired acute bacterial rhinosinusitis)?

A

CT scan

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44
Q

How do you treat acute bacterial rhinosinusitis

A 
Antibiotics if >10-14 days
Intranasal corticosteriods
NSAIDS for pain
Oral or nasal decongestants
Nasal saline lavage
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45
Q

How do you treat acute bacterial rhinosinusitis that is severe or has intracranial complications?

A

IV antibiotics

Surgery

46
Q

How do you treat nosocomial acute bacterial rhinosinusitis?

A

Sinus cultures
Broad spectrum IV antibiotics
Nafcillin and Ceftriazone

47
Q

What are the first-line therapies for acute bacterial rhinosinusitis?

A

Amoxicillin: 1000 mg 3x daily, 7-10 days
Trimeth-sulfameth: 160-800 mg 2x daily, 7-10 days
Doxycycline: 200 mg 1x, 100 mg 2x daily after that, 7-10 days
Amoxicillin-clavulanate: 1000/62.5 mg ER 2 tabs 2x daily, 10 days

48
Q

What are possible complications of acute bacterial rhinosinusitis?

A 
Orbital cellulitis and abscess - ethmoid sinus
Frontal subperiosteal abscess (Pott's puffy tumor) - frontal sinus
Intracranial:
   Epidural abscess
   Subdural empyema
   Meningitis
   Dural-vein thrombophlebitis
   Cavernous sinus thrombophlebitis
49
Q

Who is at risk for invasive fungal sinusitis?

Why is invasive fungal sinusitis so serious?

A

Immunocompromised patients

It is invasive and life-threatening

50
Q

What is included in invasive fungal sinusitis?

A

Rhinocerebral mucomycosis
Black eschar on middle turbinate
Other fungal infections
Aspergillus

51
Q

What are the clinical findings of invasive fungal sinusitis?

A 
Spread to orbits and cavernous sinus
   Orbital swelling and cellulitis
   Proptosis
   Ptosis
   Decreased EOM function
Nasopharyngeal ulcerations
CN V and VII involvement (more advanced cases)
Bony erosions
52
Q

How do you treat invasive fungal sinusitis?

A

Surgical debridement

IV amphotericin B

53
Q

When might you suspect chronic bacterial sinusitis?

A

Symptoms last longer than 12 weeks

Clinical cure difficult

54
Q

What is a potential cause of chronic bacterial sinusitis?

A

Anatomical variation in sinus structures

55
Q

What can result from chronic bacterial sinusitis?

A

Impaired mucociliary clearance
Constant sinus pressure
Nasal congestion

56
Q

How can you “confirm” the diagnosis of chronic bacterial sinusitis?

57
Q

How do you treat chronic bacterial sinusitis?

A 
Refer to ENT
Culture guided antibiotics
   Prolonged course of 3-4 weeks
Intranasal corticosteroids
Nasal saline irrigation
Sinus surgery
58
Q

what differentiates chronic fungal sinusitis from invasive fungal sinusitis?

A

Chronic is noninvasive and occurs in immunocompetent patients

59
Q

What can cause chronic fungal sinusitis?

A

Molds

Aspergillus species

60
Q

How would you diagnose mild/indolent disease?

A

Repeated failures of antibacterial therapy

Nonspecific mucosal changes on CT

61
Q

How do you cure mild/indolent chronic fungal sinusitis?

A

Endoscopic surgery

62
Q

How would you diagnose a mycetoma (fungus ball)?

A

Long-standing unilateral symptoms

Opacification of a single sinus

63
Q

How do you treat a mycetoma?

A

Surgery +/- antifungal therapy

64
Q

There is also an allergic form of chronic fungal sinusitis: How would you diagnose and treat it?

A

Hx of nasal polyposis and asthma
Multiple sinus suergeries
Thick, eosinophilic mucus

Treatment: surgery to remove impacted mucus

65
Q

Which patients are at risk for allergic rhinitis?

A

Atopic individuals w/family history of similar/related symptoms AND
Personal history of eczematous dermatitis, utricaria, and/or asthma

66
Q

What is the definition of allergic rhinitis?

A

Complex inflammatory disease of the upper airways, mediated by IgE

67
Q

When does allergic rhinitis first occur?

What does it imply if it appears later in life?

A

Childhood or adolescence

Probably is not allergic rhinitis

68
Q

What percentage of patients with allergic rhinitis also suffer from asthma?

69
Q

What percent of patients with asthma also suffer from allergic rhinitis?

70
Q

When do symptoms of allergic rhinitis typically occur?

A

Peak in childhood and adolescence
Before the fourth decade
Diminish gradually with aging

71
Q

What is the main contributor to allergic rhinitis?

A

Environment

72
Q

What are the main causes of seasonal allergic rhinitis in North America?

A

Trees pollinate between March and May
Grasses between June and July
Ragweed Between August and October
Molds (depend on climate)

73
Q

What are the main causes of perennial allergic rhinitis in North America?

A 
Animal dander
Cockroach-derived proteins
Mold spores
Dust/dust mites
Up to 50% has have no clear allergen identified
74
Q

What symptoms will you have with allergic rhinitis?

A

Episodic rhinorrhea
Sneezing
Obstruction of nasal passages with lacrimation
Pruritis of conjuntiva, nasal mucosa and oropharynx

75
Q

What clinical findings and signs are common with allergic rhinitis?

A

Pale/boggy nasal mucosa
Congested/edematous conjunctiva
Swelling of turbinates and mucous membranes
Obstruction of ostia -> sinus infection
Obstruction of eustachian tubes -> AOM
Nasal polyps
Allergic shiners (dark circles under eyes)
Allergis salute and crease (on nose)

76
Q

When do nasal polyps become threatening?

A

Only when they block air flow

77
Q

How do you make the diagnosis for allergic rhinitis?

A 
Accurate history
Nasal secretions contain eosinophils
Serum IgE elevated
Neutrophilia (indicates infection)
Skin testing
78
Q

What may be on your differential diagnosis for allergic rhinitis?

A

Vasomotor rhinitis (foods, cold weather etc.)
Resembles perennial rhinitis
Chronic symptoms can last up to 9 months
Negative test for specific allergen
Older age of onset than AR
Lack of atopic comorbidities
Occurs with nonspecific stimuli

79
Q

What else may be on your differential?

A 
Structural abnormality
Exposure to irritants
URI
Pregnancy
Medications
    (rhinitis medicamentosa, decongestant spray)
    B-blockers
    Estrogens
80
Q

How do you manage allergic rhinitis?

A

Correct diagnosis
Patient education
Pharmacotherapy
Immunotherapy

81
Q

Wheat is the be way to treat AR?

A

Allergen avoidance

82
Q

What are things you can educate your patient on about avoiding allergen exposure?

A 
Removal of pets
Air filtration devices
Travel to non-pollinating areas
Elimination of cockroaches
Plastic liners for mattresses and pillows
Wash bedding weekly
Dust frequently
Elimination of carpets and drapes
Avoid cigarette smoking
83
Q

What is the most potent and effective medical treatment for AR?

What is the most common mode of administration?

What are the potential side effects?

What are the most commonly used glucocorticoids for AR?

How should you dose them?

A

Glucocorticoids

Topical nasal sprays

Local irritation, epistaxis, nasal septum perforation, candida overgrowth

Fluticasone, Mometasone

Start high and titrate down

84
Q

What types of decongestants can you use to treat AR?

What are possible side effects of decongestants?

A

Oral (pseudoephedrine)
Topical (Phenylephrine, oxymetazoline)

Insomnia, tremor, tachycardia, hypertension

85
Q

Why is phenylephrine now substituted for pseudoephedrine in OTC preparations of antihistamine/decongestant combinations?

A

Abuse of pseudoephedrine

86
Q
  • What type of medication is cromolyn sodium?
  • What is its indication for use?
  • How often do you use it?
A
  • Topical nasal spray
  • Prophylaxis of allergic rhinitis
  • 3-4 times/day
87
Q
  • Which leukotriene antagonist is used in the treatment of asthma?
  • What types of complications manifest when combined with other asmtha meds?
  • What are the adverse effects?
A
  • Montelukast (Singulair)
  • None
  • Neuropsychiatric changes (abnormal dreams), insomnia, anxiety, depression, suicidal thinking
88
Q
  • What is the most effective medication for treating allergic rhinitis?
  • Why is it so difficult to get patients to use?
A
  • Anticholinergics

- Aversion to squirting liquid up nose

89
Q

What can be used as adjunctive therapy for allergic rhinitis?

A

Nasal saline irrigation

90
Q

When would you refer a patient for AR?

A

Prolonged or severe AR and any of the following: comorbidity; symptoms affecting quality of life; pharmacologic treat that is ineffective or that causes adverse reactions

91
Q
  • When is immunotherapy indicated?
  • How long does it take for immunotherapy to be effective?
  • When can you discontinue immunotherapy?
  • How long should you monitor your patient for adverse effects after in injection?
  • What are the contraindications for immunotherapy?
A
  • Severe allergic rhinitis
  • 3-5 years
  • After 2 consecutive seasons of minimal symptoms
  • 20 minutes
  • Significant CV disease, unstable asthma, caution if on beta-blockers
92
Q
  • What is epistaxis?
  • How can you differentiate between anterior and posterior epistaxis?
  • What is the most common site of origin for epistaxis?
A
  • Nose bleed
  • Posterior if: anterior source not visualized, bleeding from both nares, blood into posterior pharynx after anterior source controlled
  • Keisselbach’s plexus on anterior septum
93
Q

What are some predisposing factors to epistaxis?

A

Nasal trauma (FB, nose picking, forceful nose blowing), rhinitis, drying of nasal mucosa from low humidity, deviation of septum, alcohol use, medications, irritants, intranasal neoplasm or polyps

94
Q

How do you manage anterior epistaxis?

A

Direct pressure on site
Firmly compress for 10 minutes
Sitting, leaning forward
Short-acting topical nasal decongestants (vastoconstrictors) - phenylephrine

95
Q
  • If anterior bleeding is persistant, how else can you treat it?
  • If the bleeding point is identified, what else can be done to halt the bleeding?
  • If it still continues to bleed, what can be used?
A
  • Topical anesthetic - 4% topical cocaine solution -OR- 4% lidocaine and epinephrine
  • Thermal cauterization (for more agressive bleeding and done under anesthesia)
  • Nasal packing (sponge, balloon, absorbable material)
96
Q

How do you manage posterior epistaxis?

-Which arteries do you ligate for management of posterior epistaxis?

A

ENT consultation, Packing, Oxygen, Narcotic analgesics, Ligation of nasal arterial supply, Endovascular embolization fo the internal maxillary artery

-Internal maxillary and ethmoid arteries

97
Q
  • Which drugs do you use as antibiotic prophylaxis in cases of severe epistaxis?
  • When should follow-up occur?
A
  • Amoxicillin + clavulanic acid or Cephalexin

- 48-72 hours

98
Q

After controlling the epistaxis, what should be done to reduce the risk of recurrence during the next several days and long term?

A

Avoidance of vigorous exercise for several days, avoidance of hot/spice foods and tobacco, avoidance of nasal trauma, lubrication with petroleum jelly or bacitracin ointment, increase home humidity

99
Q
  • What is a nasal polyp?
  • When do you see them?
  • What are some negative side affects of nasal polyps?
  • Why should you avoid aspirin therapy in patients with nasal polyps and asthma?
  • Polyps in children is suggestive of which disease?
A
  • Pale, edematous, mucosally covered masses
  • AR
  • Chronic nasal obstruction and diminished sense of smell
  • Risk of sever bronchospasm
  • Cystic fibrosis
100
Q

How do you trat nasal polyps?

A

Topical nasal steroids for 1-3 months
Short course of oral steroids
Surgery if meds unsuccessful

101
Q
  • When should you suspect a nasal foreign body?

- How do you treat them?

A
  • Unilateral nasal obstruction; foul-smelling rhinorrhea; persistant unilateral epistaxis
  • Numb the affected side: forceps, suction catheter, hooked probes, ballon-tipped catheters, positive pressure in peds patients, ENT consult if unsuccessful
102
Q

-When treating a nasal fracture, what must you ALWAYS do?

A

-Consider the airway and exclude cervical spine injury

103
Q

What are the clinical features of nasal fractures?

-Why is a septal hematoma so dangerous?

A
  • Epistaxis, deformity, nasal airway obstruction, septal hematoma, periorbital swelling
  • It can cause necrosis of the cartilage
104
Q
  • What would you do upon physical exam for a nasal fracture?
  • What does a septal hematoma look like and how do you treat it?
  • Are septal hematoma usually uni- or bilateral?
A
  • Assess nasal airway patency; test ocular movement and function, test trigeminal nerve (CN V) sensation; check dental occlusion; examine for septal hematoma
  • Bluish, fluid-filled sacs on nasal septum; I&D with anterior nasal pack
  • Bi
105
Q

If there is no deformity, how would you manage a nasal fracture?

  • What is the danger with a fracture of the cribriform plate?
  • How would you treat a cribriform plate fracture?
A
  • Ice, analgesics, OTC decongestants; ENT referral
  • Violation of the subarachnoid space, may cause CSF rhinorrhea
  • CT and neurosurgical consultation; antibiotics
106
Q

If you discover a perforation on the nasal septum, what MUST you do?

A

Figure out the cause (cocaine, nose picking, corticosteroids)

107
Q
  • What are the pathologic hallmarks of granulomatosis with polyangiitis?
  • What is the mean age of onset of PGA?
A
  • Granulomatous inflammation, vasculitis, necrosis

- 50 years

108
Q

What clinical findings are associated with GPA?

A

Constitutional symptoms, fever, migratory arthralgias, malaise, anorexia, weight loss; saddle nose, upper airway/orbital masses

109
Q
  • Which imaging modality is preferred for evaluation of GPA?

- How do you make the diagnosis?

A
  • CT scan

- Tissue biopsy (pulmonary tissue has highest yield

110
Q

How do you treat granulomatosis with polyangiitis?

A

Refer to rheumatologist
Depends on severity
Severe: rituximab or cyclophosphamide and high-dose glucocorticoids; azathioprine or methotrexate for maintenance of remission
Less severe: Methotrexate and glucocorticoids

EENT (5 decks)

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