Nose and Paranasal Sinuses - Exam 4 Flashcards
______ forms the medial wall the nasal cavity
______ forms the lateral wall
septum
turbinates
______ Runny nose
_____ Symptoms of a “cold”; describes the inflammation of the mucous membranes lining the nasal cavity, usually with nasal discharge
______ Symptomatic disorder of the nose characterized by itching, nasal discharge, sneezing, and nasal airway obstruction
Rhinorrhea
coryza
rhinitis
______ Symptomatic inflammation of the nasal cavity and paranasal sinuses
______ Induction of rhinitis symptoms after allergen exposure by an IgE-mediated immune reaction; accompanied by inflammation of the nasal mucosa and nasal airway hyperreactivity
Rhinosinusitis
Allergic Rhinitis
What is the correct term for an URI? What is the tx? How common is it?
Acute viral rhinosinusitis
self-limiting aka no tx
most frequent acute illness
How is an URI transmitted? How is it NOT transmitted? How long does it last? When are you most contanigous?
hand contract
droplet
contaminated fomites aka surfaces
NOT transmitted via saliva
10-14 days, 21 days in kids
Peak viral shedding occurs on the 2nd and 3rd day of illness
What risk factors can increase severity of URI s/s?
Underlying chronic diseases
Congenital immunodeficiency disorders
Malnutrition
Cigarette smoking
Rhinitis
Nasal congestion
Runny nose
Sneezing
Sore or scratchy throat
Cough
Malaise
Headache
Fever - less common in adults
Conjunctivitis
Lung examination is clear
TMs may have fluid but no infection
What am I? What are the 3 highlighted ones?
What are the 2 important PE findings?
URI: Upper respiratory tract infection
S/S:
Rhinitis
Nasal congestion
Runny nose
PE:
Lung examination is clear
TMs may have fluid but no sign of infection
What is the tx for URI?
treatment aimed at the s/s:
NSAIDS/Acetaminophen
Fluids
Nasal saline irrigation
Oral decongestants
Nasal decongestants - limited to a few days
NO ABX!!!!!
When you are born you have ____ and _____ sinuses.
maxillary and ethmoid
Around age 2-5 you start developing the ____ sinus
Around age 12 start developing the ____ sinus
What age are your sinuses fully developed?
sphenoid
so total sinuses include: maxillary, ethmoid and sphenoid
frontal
so now have all 4: maxillary, ethmoid, sphenoid and frontal
fully developed at 20
What is the MC sinus infected? ____ is the most common precursor
maxillary
viral URI
Cystic fibrosis pts tend to develop ______
nasal polyps
What are the top 3 pathogens for acute bacterial rhinosinusitis? ____ is the most cause of dental infections
Strep pneumon
H. influ
M. catarrhalis
anaerobes
What is the pathophys behind acute bacterial sinusitis?
Impaired mucociliary clearance
Inflammation of the nasal mucosa
Obstruction of the ostiomeatal complex (aka sinus pore)
This results in accumulation of mucus in the sinus cavity that gets secondarily infected by bacteria
What sinus cavity? Unilateral facial fullness, pressure, tenderness over cheek,
Referred pain to upper incisor and or canine teeth
maxillary
What sinus cavity? Pain or pressure on high lateral wall of nose, often referred to orbits. aka pain between the eyes
ethmoid
What sinus cavity? Points to pain on vertex of head. aka top of the head
sphenoid sinus
What sinus cavity? Pain and tenderness on forehead: pain elicited by palpation of orbital roof just below medial end of eyebrow aka forehead, above the eyebrows
frontal
Point on your face to where the following sinus cavities are located. Frontal, ethmoid, maxillary, sphenoid.
Nasal congestion and obstruction
Purulent nasal discharge
Tooth pain
Facial pain or pressure, worse with bending over
Fever
Fatigue
Cough
Hyposmia or anosmia: decreased/absent smell/taste
Ear pressure or fullness
Headache
Halitosis: bad breath
**What am I?
**What is the criteria?
acute bacterial rhinosinusitis
s/s of acute rhinitis lasting more than 10 DAYS!
or
severe s/s with FEVER/purulent nasal discharge/facial pain for 3-4 days
or
viral URI s/s that improve but then worsen to severe s/s after 5-6 days
How do you dx acute bacterial rhinosinusitis? What is the imaging of choice? What is the tx?
CT scan is TOC but not routinely used
can transilluminate sinuses!!
careful observation!!
can give tx based on s/s:
NSAIDS, nasal saline sprays and intranasal decongestants have shown to help with symptom reduction
Oxymetazoline 1-2 sprays q6-8h for 3 days (Afrin)
What 3 pathogens are common in nosocomial sinusitits?
S. aureus
P. aeruginosa
Anaerobes
What is considered a complicated case of acute bacterial rhinosinusitis? What is the tx? What is they have an allergy?
symptoms last more than 7-10 days
or
symptoms including fever, facial pain, or swelling are severe
or
Immunodeficiency, complicated (spreading to other places/tissues)
no risk factors: Augmentin
risk factors: high dose: Augmentin 2 grams BID
mild PCN allergy: clindamycin plus cefixime
severe PCN: doxy, levo, moxi, Zithromaz
What are some risk factors for resistance with acute sinusitis
What is the complete management for complicated acute bacterial rhinosinusitis
Antibiotics for 7 - 10 days: based on allergy
Intranasal corticosteroids
NSAIDS for pain
Nasal saline lavage
What are some common complications from bacterial rhinosinusitis
orbital cellulitis
Pott’s Puffy Tumor
intracranial complications
What is a Pott’s Puffy tumor? How does it present? What is the tx?
frontal bone osteomyelitis
Tender, doughy swelling over forehead
Drainage of abscess and frontal sinus
IV antibiotics for 6 weeks - culture sensitive
Immunocompromised patients
opportunistic infection of sinuses, nasal passages, oral cavity, and brain caused by saprophytic fungi
spreads rapidly through vascular channels
Severe facial pain
Nasal drainage clear / straw colored
Black eschar on middle turbinate
Orbital swelling and cellulitis
Proptosis, ptosis, decreased EOM
Retro orbital or periorbital pain
Nasopharyngeal ulcerations
CN V and VII involvement - more advanced
Bony erosions
What am I?
What are some common organisms?
How do you dx?
What is the tx?
invasive fungal sinusitis
Rhinocerebral mucormycosis (molds)
Aspergillus
nasal endoscopy with bx
sx and IV Amphotericin B, can switch to oral Itraconazole 3-6 months after improvement
What is chronic sinusitis define as? What is the dx TOC? What is the tx?
Symptoms > 12 weeks
Impaired mucociliary clearance due to repeated infections
Constant sinus pressure, nasal congestion
dx: CT scan
tx: Refer to ENT!!
abx
intranasal steroids
saline irrigation
if everything else fails: sinus sx
Non-invasive
Older patients, only mildly immunocompromised (DM II and low dose steroid therapy)
Molds, Aspergillus species
Patients often endure symptoms for months before development of a complication
White escar
What am I?
How do you dx?
What is the tx?
chronic fungal sinusitis
nasal endoscopy with bx, CT to determine the extent of the dz
tx: difficult to cure
IV Amphotericin B then Switch to Itraconazole for at least 3-6 months, some possibly lifelong
History of nasal polyposis and asthma
Multiple sinus surgeries
Thick, eosinophilic mucous and fungal debris
High levels of IgE found in blood
IgE-mediated allergy to fungus by skin testing or immunoassay
What am I?
What is the tx?
Allergic Fungal Sinusitis
tx: Endoscopic sinus surgery to remove mucin and debris, created drainage
Post-op systemic steroids mainstay
**_____ inflammation of the blood vessels of the ears, nose, throat, lungs and kidneys. What is another name for it? **What are some s/s?
Wegener’s Granulomatosis
Granulomatosis with Polyangiitis
Symptoms may include sinus pain, cough, fever, joint aches, blood in urine, and hearing loss
Blood flow is reduced to nose, resulting in:
Nasal crusting
Sinus pain
Chronic rhinosinusitis
Nasal obstruction
Smell disturbances
Purulent /bloody discharge
Can also get erosion and perforation of nasal septum, resulting in ______
What am I?
**Saddle-Nose Deformity: due to septal erosion
Wegener’s Granulomatosis
How do you dx Wegener’s Granulomatosis? What is the tx?
Rheumatologic lab work
PFT (pulmonary function testing)
Imaging of sinus tract (CT), lungs (radiographs)
Biopsy
tx:
Steroids
Immunosuppressants (for maintenance as well)
What immunoglobin is allergic rhinitis mediated by? What dz is it closely associated with? When do symptoms usually occur?
Immunoglobulin E (IgE)
In patients with allergic rhinitis, asthma prevalence is > 20%
In patients with asthma, allergic rhinitis prevalence is > 80%
Peak in childhood and adolescence
Before 4th decade
Diminish gradually with aging
Uncommon under the age of 2
What are some risk factors for allergic rhinitis?
Family history of atopy
Male sex
Birth during pollen season
First born status
Early use of antibiotics
Maternal smoking in the first year of life
Exposure to indoor allergens, such as dust mite allergens
Presence of allergen specific IgE
“Hay Fever”
Episodic rhinorrhea
Sneezing
Nasal obstruction
Nasal itching
Post nasal drip
Cough
Irritability
Fatigue
Pruritus of conjunctiva, nasal mucosa, and oropharynx
Some will have bronchospasm with asthma
“shiners”
“salute and crease”
allergic faces
What am I?
What are the 3 components to allergic faces?
allergic rhinitis
Highly arched palate
Mouth breathing
Dental malocclusion
What is the allergic “salute and crease”? What are the accentuated lines of the eyes called? What is it called when it looks like the child has a black eye?
Horizontal crease across lower half of nasal bridge
Dennie-Morgan lines
allergic shiner
What can happen to the kids jaw as a result of allergic rhinitis?
open mouth with recessed lower jaw
Nasal mucosa pale, bluish hue and boggy d/t venous engorgement
cobblestoning of the pharynx
swelling of the turbinates and mucous membranes
nasal polyps
What am I?
What are the highlighted s/s?
allergic rhinitis
boggy nasal mucosa
cobblestoning of the pharynx
nasal polyps
In allergic rhinitis serum ____ will be elevated. What is considered a positive allergy test? What consideration must be made before allergy testing is done?
IgE
Wheal 5 mm or larger
Must be off antihistamines for at least 5 days prior to testing
In ____ you do NOT need to be off antihistamines. How does it compare to skin allergy testing?
Allergen specific serum IgE testing
equal to skin allergy testing
Name some prevention strategies for allergic rhinitis
Removal of pets
Air filtration devices
Travel to non-pollinating areas
Elimination of cockroaches
Plastic-lined covers for mattresses, pillows
Wash bedding weekly
Dust frequently
Elimination of carpets and drapes
Avoid cigarette smoking
**Describe the allergic rhinitis classifications.
What is the tx for allergic rhinitis? What is the dosing schedule? What is the important pt education?
**intranasal glucocorticoids
-Fluticasone, mometasone, beclomethasone (1-2 sprays QD or BID)
Start with maximum dose for age and then step down at one week intervals once symptoms controlled. May take up to 2 weeks for full benefit
Tilt head forward, point bottle to ipsilateral ear (away from septum) NOT A PRN MEDICATION
What are the SE of topical nasal sprays?
local irritation, epistaxis, nasal septum perforation, Candida overgrowth (rare)
make sure to immediately report any increasing or bothersome bleeding or crusting
______ little effect on congestion–first line for mild symptoms, intermittent. What are some SE?
Antihistamines
1st: SEDATING, dry mouth, weight gain
2nd: dry mouth, antihistamine tolerance
What are the first generation antihistamines? 2nd generation? Which one is preferred? Why?
1st: Diphenhydramine (Benadryl), Hydroxyzine (Atarax, Vistaril), Chlorpheniramine, Brompheniramine
2nd: Cetirizine (Zyrtec), Loratadine (Claritin), Fexofenadine (Allegra), Desloratadine (Clarinex), Levocetirizine (Xyzal)
2nd generation is preferred due to less sedating effects
which 2nd generation antihistamine is sedating in 10% of pts?
Cetirizine
______ are nasal antihistamine that has rapid onset that can improve nasal congestion
Azelastine (Astelin), Olopatadine (Patanase)
What are some topical and oral decongestants that are helpful in allergic rhinitis?
oral: Pseudoephedrine (Sudafed)
topical: Phenylephrine (Sudafed), Oxymetazoline (Zicam/Afrin))
____ and ____ are non-sedating antihistamines combined with Pseudoephedrine. Phenylephrine substituted now in OTC preparation due to substance abuse of pseudoephedrine but are not as effective.
Allegra D / Claritin D
______ is a mast cell stabilizer that is used in allergic rhinitis tx
Cromolyn sodium (NasalCrom):
less potent but very few SE
_____ inflammatory mediators produced by mast cells, basophils, and eosinophils, that are accompanied by the production of histamines and prostaglandins. What do they trigger? What is the major medication?
Leukotrienes
smooth muscle contraction
Montelukast (Singulair)
dreams, insomnia, anxiety, depression, suicidal thinking are all SE of _____
Montelukast (Singulair)
Insomnia, tremor, tachycardia, hypertension, rebound vasodilation, rhinitis medicamentosa are all SE of ______
Phenylephrine (Sudafed), Oxymetazoline (Zicam/Afrin)
_____ is Useful for post nasal drip, rhinorrhea, perennial symptoms, and often combined with intranasal steroids. Useful in vasomotor rhinitis.
topical anticholinergics
Ipratropium bromide
When are allergy shots indicated? Describe the procedure. When are the CI?
Severe allergic rhinitis
Each shot contains a tiny amount of specific substance(s) that trigger your allergic reactions. Just enough to stimulate immune system, but not enough to cause full blown reaction
Over time, the dose of allergens increases, which helps your body get used to the allergens (desensitization), building up a tolerance
CI: Significant CVD, uncontrolled asthma
Caution if on Beta Blockers
Sneezing, rhinorrhea, nasal congestion, post-nasal drip
Absence of a specific etiology-theory includes increased sensitivity of vidian nerve
Usually later onset with age, specifically elderly
Worse with weather change or respiratory irritants, odors, etc.
No other allergy symptoms
What am I?
What is the tx?
Vasomotor Rhinitis
Intranasal steroid or antihistamine
Ipratropium
Daily nasal saline lavage
______ is a subtype of non-allergic rhinitis that includes watery rhinorrhea in response to eating. What is the tx?
Gustatory Rhinitis
antihistamines and avoid foods that cause it
_____ is chronic nasal obstruction due to overuse of nasal decongestants. What is the treatment? **What is the max length you can use afrin?
Rhinitis Medicamentosa
Discontinue use of nasal decongestant
Start intranasal corticosteroids
**Use for 3 days MAX!!!
What are the 2 different types of epistaxis? which one is MC? Where specifically?
Anterior and posterior
**MC-Anterior
**Kiesselbach’s plexus on anterior septum: 90%
What are some s/s that indicate it is a posterior bleed?
Anterior source not visualized
Bleeding from both nares
Blood into posterior pharynx after anterior source controlled
What are some predisposing factors for epistaxis?
Nasal trauma - picking, foreign body, forceful nose blowing
Rhinitis
Dryness of nasal mucosa from low humidity
Deviation of septum
Alcohol use
Medications
Irritants
Intranasal neoplasms or polyps
What is the tx for mild anterior epistaxis?
Pressure on site
Firmly compress for 15 minutes
Sit, leaning forward
Short acting topical nasal decongestants
Vasoconstrictors - phenylephrine
What is the tx for a persistent anterior epistaxis?
-Topical anesthetic vasoconstrictor :
4% topical cocaine solution OR
4% lidocaine and epinephrine (1:10,000)
or
- chemical cauterization with silver nitrate stick
or
- nasal packing: Sponge (Merocel) or Balloon (Rapid Rhino) OR
Absorbable material - oxidized cellulose (Surgicel), gelatin foam (Gelfoam), gelatin and thrombin combination (FloSeal)
Posterior epistaxis is commonly associated with ____ and _____. What do you need to do?
hypertension and atherosclerotic disease
refer to ENT!! they will most likely do:
Packing
Narcotic analgesics
Ligation of nasal arterial supply (internal maxillary artery and ethmoid arteries)
Endovascular embolization of the internal maxillary artery
What is the management for epistaxis? Trying to avoid ____ with nose packing
abx prophylaxis: Augmentin, clindamycin, or Keflex
avoid toxic shock syndrome
After control of the nose bleed has been established, what other things do you need to do?
Avoidance of vigorous exercises for several days
Avoidance of hot or spicy foods and tobacco
Avoid nasal trauma
Lubrication with petrolatum or Bacitracin ointment
Increase home humidity
_____ are pale, edematous, mucosally covered masses that cause nasal obstruction and diminished sense of smell. Commonly seen in _____ and ______.
Nasal Polyps
allergic rhinitis d/t prolonged irritation
Polyps in children - may suggest Cystic Fibrosis
What is the tx for nasal polyps?
Topical nasal steroids for 1 - 3 months
Short course of oral steroids
Surgical removal
If medication unsuccessful
Unilateral nasal obstruction
Foul-smelling, sometimes copious rhinorrhea unilateral
Persistent unilateral epistaxis
What am I?
What is the tx?
nasal foreign body
Suction catheters, Forceps, Hooked probes, Balloon-tipped catheters, alligator forceps
Pediatric patients - positive pressure
ENT consultation if unsuccessful
**If you suspect a nasal fracture what two things do you always need to keep in mind?
Consider the airway
Exclude cervical spine injuries
Epistaxis
Deformity
Nasal airway obstruction
Septal hematoma
Periorbital swelling and ecchymosis
What am I?
What do you need to check?
nasal fracture
Assess nasal airway patency
Test ocular movement and function
Test CN V sensation
Check dental occlusion
Appears as widening of anterior septum
Bluish, fluid filled sacs on the nasal septum
What am I?
What is the tx?
What can it lead to?
septal hematoma
I&D with anterior nasal packing
antistaph oral abx
left untreated: abscess or necrosis of the septum
What is the tx for a nasal fracture without deformity? with deformity?
w/o:
Ice, analgesics, OTC decongestants
Maintain long-term airway patency and cosmesis
with:
ENT referral
No clear recommendation exists regarding type of surgery or timing (open vs. closed, acute vs. waiting)
If the fracture involves the _____ it may violate the subarachnoid space and cause ______. Then what do you do?
cribriform plate
CSF rhinorrhea
CT and neurosurgical consultation
Antibiotics
