Nose and Paranasal Sinuses Flashcards
What is the most likely culprit of URI’s?
Rhinoviruses
Presentation:
Rhinitis, rhinorrhea, nasal congestion, ST, cough, laryngitis, lymphadenopathy, mild systemic sx, fever uncommon in adults but may be present in children - usually low grade
URI
PE findings:
may be normal
common findings: conjunctival injection, nasal mucosal swelling, pharyngeal erythema, exudates and cobblestoning, lungs usually clear
URI
treatment URI
symptomatic relief OTC medications
analgesics - tylenol, NSAIDS
decongestants - intranasal or oral
Antitussives - dextromethorphan or benzonatate
Cool moist humidifiers, saline nasal sprays
URI prognosis
usually lasts about 3-10 days, up to 2 weeks if smoking, other comorbidities
Rhinitis is
inflammation of nasal mucosa
Most common forms of rhinitis
allergic
vasomotor
rhinitis medicamentosa
Allergic Rhinitis happens when
climate changes resulting in increased amounts of pollen and season duration
spring - flowering shrub and tree pollens
summer - flowering plants and grasses
fall - ragweed and molds
Allergic Rhinitis is due to (immune-mediated)
Ige response to airborne antigens/ allergens
ie pollen mold dander dust
Symptoms of allergic rhinitis can develop at
any age, usually children or young adults
ssx:
nasal itching, watery rhinorrhea, nasal congestion, sneezing
itchy or watery eyes
dry cough
“allergic salute” in kids
Allergic Rhinitis
Allergic Rhinitis - treatment
antihistamines - immediate but temporary, can be used prn
Corticosteroids - intranasal, shrink nasal polyps and mucosa
Intranasal anticholinergics - ipratropium bromide spray
intranasal saline, neti pot
Vasomotor rhinitis is
increased secretion from nasal mucosa precipitated by temp or humidity, odors, light, alcohol or neurovascular imbalance
symptoms clear quickly
Treatment of vasomotor rhinitis
avoid irritant
Rhinitis medicamentosa is
rebound congestion from overuse of nasal decongestants - discontinue afrin
Acute sinusitis/ rhinosinusitis (ARS) is
inflammation in nasal cavity and para-nasal sinuses
most common etiology = viral infection
What makes mucus green?
breakdown of WBC
green means infection not either bacterial or viral
nasal/ear/facial pressure
low grade fever
sneezing, rhinitis, cough, ST
rhinorrhea may be discolored
duration 7 to 10 days
Viral acute sinusitis
Viral acute sinusitis treatment
symptomatic treatment
usually have preceding URI
nasal/ear/facial pressure, may be worse with bending forward, sinus tenderness
purulent discharge, nasal obstruction > 10 days after sx onset
fever fatigue malaise
duration > 10 days and worsening
facial/ eyelid swelling and/or erythema concerning for periorbital/ orbital cellulitis
Bacterial acute sinusitis
Acute bacterial sinusitis workup
clinical dx - transillumination may be positive but not necessary
imaging usually considered in chronic sinusitis (CT scan)
Acute bacterial sinusitis treatment
abx - augmentin (amoxicillin-clavulanate) for 10-14 days
if penicillin allergy - doxycycline or levaquin
include education on nasal hygiene
w/o abx pts will improve within 2 wks
Chronic sinusitis is when
a single infection lasts > 12 wks
sx of chronic sinusitis
persistent rhinorrhea, productive cough, foul breath, low grade fever, malaise, HA, facial or dental pain
Complicated acute bacterial sinusitis
high persistent fever > 102
periorbital edema, inflammation or erythema
cranial nerve palsies
severe HA, altered mental status or meningeal signs
Complicated acute bacterial sinusitis treatment
urgent referral to otolaryngologist for evaluation and dx
image of choice - CT scan with contrast
Nasal Obstruction - turbinate hypertrophy
inflammation of turbinates resulting in increased congestion and drainage
URI, allergic rhinitis, vasomotor rhinitis, drugs
Nasal Obstruction - turbinate hypertrophy treatment
treat the underlying condition
surgery is last resort - clean out airway
Deviated Septum - Etiology
Trauma
connective tissue disease
drugs - cocaine
Postsurgical changes
Deviated Septum - Treatment
nasal endoscopy
surgery
implants
Adenoid Hypertrophy is the most common cause of
nasal obstruction in a child
Adenoid Hypertrophy symptoms
mouth breathing, mucopurulent discharge, snoring, sleep apnea
Adenoid Hypertrophy - etiology
chronic inflammation, allergies, chronic sinus sx
Adenoid Hypertrophy - prolonged mouth breathing due to adenoid hypertrophy affects
facial and dental growth and development
“adenoid facies” - open mouth, flattening and elongation of midface, retraction of upper lip, narrowing of hard palate resulting in crowing of maxillary teeth
Adenoid Hypertrophy dx
clinical suspicion, endoscopic visualization
Adenoid Hypertrophy treatment
adenoidectomy
Nasal Polyps is the most common
tumor of the nasal cavity
Etiology of Nasal Polyps
long-standing inflammation, aspirin sensitivity, environmental allergies, Cystic fibrosis
Sx of Nasal polyps
mouth, breathing, sneezing, rhinorrhea, reduced smell and taste, frequent sinusitis
PE findings of nasal polyps
nasal obstruction, pale mucosa, fleshy mass with superficial vessels
Nasal Polyp treatment
steroids (PO, topical, intra-polyp injections), avoid aspirin, surgical excision for larger polyps, test and treat for allergies
Foreign body - nasal locations
floor of nasal passage just under the inferior turbinate
or
superiorly in nasal cavity in front of the middle turbinate
FB ssx
nasal discharge
foul odor
epistaxis
nasal obstruction
mouth breathing
FB = button batteries warning!
may result in septal perforation in ~ 4 hours
FB treatment
fogarty catheter
Katz extractor
forvents (if you can visualize object)
irrigation
Epistaxis is
nose bleeds!
Epistaxis can be due to
trauma vs spontaneous
anterior (kiesselbach plexus) vs posterior
anticoagulation
ETOH
90% of bleeds are
anterior
Posterior is most commonly from
posterolateral branches of sphenopalatine artery, can be from the carotid artery
1 cause of epistaxis
nose picking
Other causes of epistaxis
dryness
allergic or viral rhinitis
FB
Chronic intranasal drug use
Blunt trauma
Epistaxis treatment - anterior bleed
clear clots
topical medications (afrin drops, boyette’s solution)
topical tranexamic acid (TXA)
direct pressure for ~ 15 mins on the bulb of the nostrils
identify source of bleed - check back of throat
cauterize - silver nitrate sticks
nasal packing as needed
After cautery there should be no
blowing of nose, sneezing, coughing, bearing down
sleep in a humidified environment
topical abx ointment
Treatment of posterior bleed
balloon catheters: tamponade posterior bleeding
arterial ligation
angiographic embolization
Trigeminal Neuralgia is a
paroxysmal attack of usually intense, sharp, superficial or stabbing pain in distribution of one or more branches of fifth cranial nerve
pain usually lasts from one to several seconds but may occur repetitively
Treatment of trigeminal neuralgia
Carbamazepine (used for seizures as well)
