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HEENT > Nose and Paranasal Sinuses - Exam 4 > Flashcards

Nose and Paranasal Sinuses - Exam 4 Flashcards

1
Q

______ forms the medial wall the nasal cavity

______ forms the lateral wall

A

septum

turbinates

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1
Q

______ 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

A

Rhinorrhea

coryza

rhinitis

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2
Q

______ 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

A

Rhinosinusitis

Allergic Rhinitis

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3
Q

What is the correct term for an URI? What is the tx? How common is it?

A

Acute viral rhinosinusitis

self-limiting aka no tx

most frequent acute illness

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4
Q

How is an URI transmitted? How is it NOT transmitted? How long does it last? When are you most contanigous?

A

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

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5
Q

What risk factors can increase severity of URI s/s?

A

Underlying chronic diseases
Congenital immunodeficiency disorders
Malnutrition
Cigarette smoking

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6
Q

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?

A

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

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7
Q

What is the tx for URI?

A

treatment aimed at the s/s:
NSAIDS/Acetaminophen
Fluids
Nasal saline irrigation
Oral decongestants
Nasal decongestants - limited to a few days

NO ABX!!!!!

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8
Q

When you are born you have ____ and _____ sinuses.

A

maxillary and ethmoid

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9
Q

Around age 2-5 you start developing the ____ sinus

Around age 12 start developing the ____ sinus

What age are your sinuses fully developed?

A

sphenoid

so total sinuses include: maxillary, ethmoid and sphenoid

frontal

so now have all 4: maxillary, ethmoid, sphenoid and frontal

fully developed at 20

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10
Q

What is the MC sinus infected? ____ is the most common precursor

A

maxillary

viral URI

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11
Q

Cystic fibrosis pts tend to develop ______

A

nasal polyps

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12
Q

What are the top 3 pathogens for acute bacterial rhinosinusitis? ____ is the most cause of dental infections

A

Strep pneumon
H. influ
M. catarrhalis

anaerobes

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13
Q

What is the pathophys behind acute bacterial sinusitis?

A

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

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14
Q

What sinus cavity? Unilateral facial fullness, pressure, tenderness over cheek,
Referred pain to upper incisor and or canine teeth

A

maxillary

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15
Q

What sinus cavity? Pain or pressure on high lateral wall of nose, often referred to orbits. aka pain between the eyes

A

ethmoid

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16
Q

What sinus cavity? Points to pain on vertex of head. aka top of the head

A

sphenoid sinus

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17
Q

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

A

frontal

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18
Q

Point on your face to where the following sinus cavities are located. Frontal, ethmoid, maxillary, sphenoid.

A
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19
Q

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?

A

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

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20
Q

How do you dx acute bacterial rhinosinusitis? What is the imaging of choice? What is the tx?

A

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)

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21
Q

What 3 pathogens are common in nosocomial sinusitits?

A

S. aureus
P. aeruginosa
Anaerobes

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22
Q

What is considered a complicated case of acute bacterial rhinosinusitis? What is the tx? What is they have an allergy?

A

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

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23
Q

What are some risk factors for resistance with acute sinusitis

A
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24
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
25
What are some common complications from bacterial rhinosinusitis
orbital cellulitis Pott's Puffy Tumor intracranial complications
26
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
27
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
28
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
29
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
30
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
31
**_____ 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
32
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
33
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)
34
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
35
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
36
“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
37
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
38
What can happen to the kids jaw as a result of allergic rhinitis?
open mouth with recessed lower jaw
39
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
40
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
41
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
42
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
43
**Describe the allergic rhinitis classifications.
44
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**
45
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
46
______ 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
47
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
48
which 2nd generation antihistamine is sedating in 10% of pts?
Cetirizine
49
______ are nasal antihistamine that has rapid onset that can improve nasal congestion
Azelastine (Astelin), Olopatadine (Patanase)
50
What are some topical and oral decongestants that are helpful in allergic rhinitis?
oral: Pseudoephedrine (Sudafed) topical: Phenylephrine (Sudafed), Oxymetazoline (Zicam/Afrin))
51
____ 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
52
______ is a mast cell stabilizer that is used in allergic rhinitis tx
Cromolyn sodium (NasalCrom): less potent but very few SE
53
_____ 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)
54
dreams, insomnia, anxiety, depression, suicidal thinking are all SE of _____
Montelukast (Singulair)
55
Insomnia, tremor, tachycardia, hypertension, rebound vasodilation, rhinitis medicamentosa are all SE of ______
Phenylephrine (Sudafed), Oxymetazoline (Zicam/Afrin)
56
_____ is Useful for post nasal drip, rhinorrhea, perennial symptoms, and often combined with intranasal steroids. Useful in vasomotor rhinitis.
topical anticholinergics Ipratropium bromide
57
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
58
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
59
______ 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
60
_____ 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!!!
61
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%
62
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
63
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
64
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
65
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)
66
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
67
What is the management for epistaxis? Trying to avoid ____ with nose packing
abx prophylaxis: Augmentin, clindamycin, or Keflex avoid toxic shock syndrome
68
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
69
_____ 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
70
What is the tx for nasal polyps?
Topical nasal steroids for 1 - 3 months Short course of oral steroids Surgical removal If medication unsuccessful
71
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
72
**If you suspect a nasal fracture what two things do you always need to keep in mind?
Consider the airway Exclude cervical spine injuries
73
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
74
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
75
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)
76
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
77

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