Nose and Sinus Flashcards
Acoustic neuromaAKA Vestibular schwannomas
Etiology
benign
arise from the vestibular portion of the eighth cranial nerve and account for ~9% of primary brain tumors
Most are unilateral, but about 5% are associated with the hereditary syndrome neurofibromatosis type 2, in which bilateral eighth nerve tumors may be accompanied by meningiomas and other intracranial and spinal tumors.
Acoustic neuromaAKA Vestibular schwannomas
S/Sx
Symptoms
The hearing loss of acoustic neuroma is unilateral and asymmetric
deterioration of speech discrimination
slowly progressive unilateral sensorineural hearing loss, tinnitus and some dizziness
Usually have continuous disequilibrium rather than episodic vertigo
Acoustic neuroma
PE
vestibular examination will show a deficient response to the head impulse test when the head is rotated toward the affected side, but nystagmus will not be prominent.
Acoustic neuroma
Dx
enhanced MRI (with contrast)
Acoustic neuroma
Tx
Observation
microsurgical excision
stereotactic radiotherapy
All depend on such factors as patient age, underlying health, and size of the tumor.
Bevacizumab (vascular endothelial growth factor blocker) has shown promise for treatment of tumors in neurofibromatosis type 2.
Acoustic neuroma
fun fact
frequently involve the facial nerve by local compression
Vertebrobasilar Insufficiency
Etiology
Triggers
Poor blood flow to the brain from vertebral arteries to posterior portion of brain
Usually in elderly population with atherosclerosis
Usually triggered by change in posture or neck motion
Vertebrobasilar Insufficiency
S/Sx & PE
Intermittent vertigo
Can sometimes reproduce symptoms with head and neck motion
Signs of atherosclerosis in other parts of the body
Vertebrobasilar Insufficiency
Dx
MRA (magnetic resonance angiography)
Vertebrobasilar Insufficiency
Tx
Vasodilators
Aspirin to prevent clotting
Vertebrobasilar Insufficiency
Should be considered when
Probably have issues in other parts of the body
Consider this part of the ddx for vertigo/ dizziness in patients with known blockages elsewhere
Nasal Cavity, Paranasal Sinuses
Functions
Breathing
Humidification
Warming
Smell
Voice modulation
Reduction of skull weight
Nasal Cavity, Paranasal Sinuses
Common Sx
Nasal obstruction
Nasal drainage
Sneezing
Itching
Hyposmia/Anosmia
Nasal/facial pain
Nasal bleeding
I.T.
Inferior turbinate
M.T.
Middle turbinate
N.S.
Nasal septum
Deviated Nasal Septum
General/Tx/Referral
Very common
Usually post-traumatic
No treatment necessary if asymptomatic
Treatment
Intranasal steroids
Intranasal antihistamines
Refer
If no improvement after 1 month, or
If symptoms and exam severe
Septal Deviation / Adhesion
Shown because it’s a common finding. On the right is a severe DNS, left is an adhesion, likely from prior trauma or surgery.
Septum Deviation – Adhesion
The slide on the left side shows a septum deviation with almost total obstruction of the nasal airway.
The slide on the left side shows an adhesion of the middle turbinate to the septum. These adhesions are usually of iatrogenic origin after endonasal surgery or nasal packing in the treatment of epistaxis. These adhesions induce respiratory obstruction and may promote crusting.
Nasal obstruction
causes
Allergic rhinitis
Non-allergic rhinitis
Anatomic obstruction
Rhinosinusitis
Adverse drug reaction
Neoplasm
Foreign body
Pregnancy
Rhinitis
general and Sx
“Inflammation of the nasal mucous membranes”
Symptoms
Nasal congestion
Rhinorrhea
Sneezing
Nasal itching
Nonallergic rhinitis
causes
Vasomotor
Gustatory
Drug-induced
Infectious
Hormonal
Occupational
NARES= nonallergic rhinitis with esosinophilia syndrome
Allergic rhinitis
general
Affects over 50 million Americans yearly
Most common chronic disease of childhood
Decreased quality of life
$2 to $5 billion US economic impact
Direct costs
Millions of lost work and school days annually
Decreased work/school productivity
Allergic rhinitis
etiology
Adverse clinical reaction to an environmental agent (antigen/allergen) caused by an immunological reaction
Host sensitization
IgE production by host
Mast cell sensitization
Further exposure provokes symptoms
Early & late phase reactions
End-organ response
Allergic Rhinitis
Dx
History most important
classic symptoms
Seasonal vs perennial
Exam often consistent
Testing
Allergic rhinitis
Inferior turbinate
Pale/purple
Edematous
Cobblestone
Allergic rhinitis
Dennie’s lines
Allergic rhinitis
Allergic shiners
https://i4.photobucket.com/albums/y144/tooloflife/IMG_7986.jpg
Allergic rhinitis
Treatment options 3
Treatment options
Medicines
Avoidance & environmental control
Immunotherapy (desensitization)
Allergic rhinitis
Tx - Avoidance & environmental control
Dust mite encasements
HEPA filters
Windows up in car & house during high pollen counts
Masks for known high exposure
Sinus irrigation & shower after high exposure
Avoid indoor animals and plants, wet areas
Allergic rhinitis
immunotherapy Tx
SCIT and SLIT
Subcutaneous IT (SCIT)- “allergy shots”
Sublingual IT (SLIT)- “allergy drops”
70-80% effective if given 3-5 years with average duration of benefit after stopping 12 years, only option with chance of cure
allergic rhinitis
Tx - Medicines (4)
Oral antihistamines
Cetirizine, fexofenadine, loratadine
Intranasal steroid sprays (INS)
Fluticasone rx, it and others OTC
Intranasal antihistamine sprays (INAH)
Leukotriene modifiers
Singulair (montelukast)
Allergic Disorders/ Hypersensitivity Reactions
4 types
I: IgE antibody mediated reaction
II: IgG or IgM antibody mediated cytotoxic reaction
III: immune complex mediated reaction
IV: cellular response mediated delayed reaction
Allergic Disorders/ Hypersensitivity Reactions
general
Common allergens: food, venom (things that bite and things that sting), drugs/ medications, latex
Anaphylaxis: allergen exposure followed by acute illness involving skin changes, respiratory compromise, hypotension, GI symptoms &/or mucosal tissue problems
Allergic Disorders/ Hypersensitivity Reactions
Testing
nothing during the reaction but perform allergy testing after patient’s reaction subsides
Anaphylaxis
Tx and supportive measures
IM epinephrine (epipen) ASAP;
supportive measures like oxygen, IV fluid, possibly airway mgmt.; adjunct tx with antihistamines, bronchodilators and corticosteroids
Allergy Testing
general
Should have moderate to severe reactions before putting patients through this
Typically involves placing a small amount of common allergens on the skin and then scratching or pricking the skin to barely introduce it beneath skin; wait 15-20 minutes; observe response
Performed by allergist; must avoid antihistamines and steroids prior to testing
Pseudo-allergic Reactions
general
Caused by?
Similar to “allergic reactions” but not IgE mediated
Caused by direct mast cell activation (ex.: contrast dye for imaging, opioids and Red Man Syndrome)
Pseudo-allergic Reactions
Red Man Syndrome
caused by infusing vancomycin or opioids too quickly
Pseudo-allergic Reactions
Dye rxn prevention (3)
Dye: prevent with use of low-osmolality contrast preparations AND giving prednisone and diphenhydramine before dye
Pseudo-allergic Reactions
Red man rxn Tx
Prevention(2)
administer antihistamine (usually diphenhydramine) and slow down the infusion rate of offending medication to less than half of previous rate for current reaction;
prevention is done with preadministration of diphenhydramine AND cimetidine
Olfactory Dysfunction (no smell AKA hyposmia or anosmia)
Etiology
Usually due to blockage of nasal passage (swelling, polyps, mucus, foreign bodies, etc)
20% is idiopathic but often follows viral illness
Common symptom of COVID (not as common with omicron)
Can be caused by nerve damage to olfactory bulb(s), CN I, or olfactory cortex of the brain (tumors or trauma)
Olfactory Dysfunction (no smell AKA hyposmia or anosmia)
Sx & PE
Trouble with sense of smell and sometimes taste
Often can see nasal blockage
Other signs of illness (other cold, COVID symptoms)
University of Penn Smell Identification test (UPSIT)- scratch and sniff
Olfactory Dysfunction
Dx
Consider CT?
UPSIT
Consider CT or MRI if there is no sign of blockage/ structural abnormality or recent viral infection
Olfactory Dysfunction
Tx
Fix the blockage/ structural problem
Wait out the virus
Refer to ENT
Mild hyposmia has better outcome than severe hyposmia or anosmia
Olfactory Dysfunction
Pt education
Counsel patients to be mindful of salt use (don’t oversalt just to get taste; might cause other health problems)
Patients need to be sure smoke detectors work and need to consider not using gas appliances
Vasomotor rhinitis
general and triggers
Treatment
Too much parasympathetic input?
Triggers:
Cold air, strong odors, stress, irritants
Symptoms very similar to AR, but allergy test negative
Treatment
Intranasal anticholinergic (ipratropium) spray
INS (intranasal steroid), INAH (intranasal antihistamine)
Drug-induced rhinitis/Rhinitis medicamentosa
Causes
Many drugs can cause nasal mucosal edema
ACE inhibitors, beta-blockers, oral contraceptives, NSAIDs, aspirin, others
Rhinitis medicamentosa distinct etiology
Prolonged use of nasal sympathomimetics (topical decongestant sprays):
Oxymetazoline
Phenylephrine
Rhinitis medicamentosa
general
Alpha receptors desensitized
Loss of adrenergic tone leads to chronic congestion & rhinorrhea
Rhinitis medicamentosa
Tx
INS, INAH
Systemic steroids
Wean one nostril at a time
acute rhinosinusitis
Acute viral rhinosinusitis
Acute bacterial rhinosinusitis
Going to discuss both simultaneously as “acute rhinosinusitis”, because they are near impossible to clinically differentiate.
Acute rhinosinusitis
general
Inflammation of lining of paranasal sinuses
Almost always concurrent with rhinitis
“Rhinosinusitis”
Affects 35 million people annually in US
16 million office visits annually
Vast majority are viral
Acute rhinosinusitis
S/Sx
Symptoms
Facial pain: cheeks, forehead, maxillary teeth
Nasal drainage: rhinorrhea and/or PND
Nasal congestion
Hyposmia
Cough
Ear fullness/pressure
Less common: fever, fatigue
General Signs/Symptoms of Sinusitis
Acute viral rhinosinusitis
general
Most common virus
Rhinovirus most common
Also: coronavirus, flu A & B, paraflu, RSV, adenovirus, enterovirus
Viral URI biggest risk factor for acute bacterial rhinosinusitis
90% of viral URI patients have sinus involvement
Only 5-10% develop bacterial infection
Acute rhinosinusitis
Viral vs bacterial
Think bacterial if
Symptoms beyond 10 days
Worsening within 10 days after initial improvement
Less reliable:
Severity of symptoms
Color of nasal drainage
Acute bacterial rhinosinusitis
S/Sx
Symptoms
Nasal congestion
Nasal drainage
Facial pain/pressure
And all others of viral rhinosinusitis, except:
> 7-14 days symptoms
Acute bacterial rhinosinusitis
Most Common Pathogens
Streptococcus pneumonia
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Anaerobes
Fungal
Normal / Acute Sinusitis
CT Scan of the Sinus (Normal)
The picture shows coronal view of the sinuses. The scan shows normal ethmoid structures and patent osteomeatal ducts, along with a DNS to the right.
Orbital abscess from ethmoid sinusitis
Ethmoiditis Radiologic Findings
The slide on the right side shows an ethmoiditis with the presence of an intraorbital abscess seen as a capsulated air/fluid level inducing displacement of the intra-orbital contents. The picture on the left shows an ethmoiditis with the presence of intraorbital subperiosteal abscess and cellulites.
(Orbital cullulitis)
Cavernous Sinus Thrombosis
general
50% mortality rate even today.
Cavernous Sinus Thrombosis
Cavernous sinus thrombosis is usually found subsequent to ethmoiditis and/or sphenoiditis. The disease is potentially fatal and requires immediate and adequate treatment.
The small picture in the lower left shows proptosis and chemosis. The slide on the right side demonstrates a transverse MRI view at the level of the sphenoid sinus and the cavernous sinus. There is evidence of right-sided sphenoiditis. At the same time there is diffuse opacification of the cavernous sinus as demonstrated around the lower portion of the white lines (circles). On the left side of the picture in the upper part we can see pre-septal and post-septal edema manifested by eyelid edema and proptosis. In the same picture small skin ulcerative lesions are seen in the nasal pyramid. These lesions were disturbed by the patient causing skin cellulitis and subsequent cavernous sinus thrombosis.
Cavernous sinus thrombosis
Classical signs (5)
Classical signs of cavernous sinus thrombosis include proptosis, chemosis and ophthalmoplegia, fever, and general toxicity.
Cavernous sinus thrombosis
Tx (3)
The treatment includes antibiotics, surgical drainage of the affected sinus, and anticoagulants.
Acute bacterial rhinosinusitis
Tx
when to refer?
Treatment
Antibiotics: amoxicillin, cefdinir, Augmentin, etc
Systemic steroids
INS, INAH
Mucinex
Saline irrigation
Topical and systemic decongestants
Refer, if no improvement after 1 month
Classifying Sinusitis - Duration
Acute: <= 4 weeks
Subacute: 5-12 weeks
Chronic: > 12 weeks
Recurrent Acute - > 4 episodes of acute sinusitis per year each lasting 7-10 days with symptom resolution between
Chronic rhinosinusitis
general
Multifactorial inflammatory process of nose and paranasal sinuses
Symptoms persist 3 months or longer
Most cases are due to acute sinusitis that is either:
Untreated, or
Unresponsive to treatment
Chronic rhinosinusitis (CRS)
Etiology
Sinus ostial obstruction
Allergies
Less common
Polyps
Immunodeficiency
Dental disease
Smoking a risk factor
Chronic rhinosinusitis (CRS)
S/Sx
Major factors
Facial pain/pressure
Nasal obstruction
Nasal discharge
Hyp/anosmia
Minor factors
Headache
Fever
Halitosis
Fatigue
Dental pain
Cough
Ear pain/fullness
Chronic rhinosinusitis (CRS)
Dx criteria
Diagnostic criteria
2 or more major factors, or
1 major factor plus 2 minor factors
Plus confirmatory:
Nasal endoscopy, or
Radiographic findings (CT sinus)
Rhinosinusitis
Rhinosinusitis (Maxillary-Ethmoid)
In acute maxillary rhinosinusitis bulging of the middle meatus and hypertrophy of the bulla ethmoidalis are frequently seen due to increased intramaxillary pressure after obstruction of the osteomeatal complex.
The picture on the right side shows a bulging middle meatus; the picture on the left is a coronal CAT scan view of an acute maxillary rhinosinusitis with deforming bulging of the middle meatus.
Rhinosinusitis (Maxillary-Ethmoid)
The picture shows two coronal CAT scans of the sinuses.
The CAT scan on the right side shows a rhinosinusitis of the right maxillary sinus with obstruction of the osteomeatal complex. In the left maxillary sinus there is mucoperiosteal thickening as well as obstruction of the osteomeatal complex. There is also thickening of the mucosa of the ethmoid sinuses. Bilateral bullous middle turbinates can be seen.
The CAT scan on the left demonstrates mucoperiosteal thickening of the left ethmoid cells as seen in chronic and acute ethmoiditis.
Rhinosinusitis (Sphenoid)
This coronal CAT scan shows an opacified left sphenoid sinus.
Sinusitis
Tx
Nasal Sprays
Flonase
Afrin/ Decongestant (3 days max)
Pain Relief:
Tylenol
Motrin
Sinus Rinse:
NeilMed
NetiPot
Navage
Treatment
Antibiotics
Systemic steroids
INS, INAH
Mucinex, sinus irrigation
3-4 weeks
Surgery if no better
Initially Similar to acute rhinosinusitis….just longer
Sinusitis
Bacterial Treatment
Amoxicillin - more helpful in children
Augmentin (Amoxicillin-Clavulanate) - 1st line treatment
Penicillin Allergic patients:
Doxycycline
Fluoroquinolones
Less commonly used but sometimes helpful
Azithromycin, Clarithromycin
Bactrim
Keflex
Steroids?
Helps decrease inflammation to facilitate drainage
Especially useful with polyposis patients
Side effects, use sparingly
Sinusitis
Surgery Tx
Restore sinus ventilation, Balloon open osteomeatal complex
Restructure obstructing anatomy - Septoplasty, Turbinate Reduction
Debulking refractory polyps
Repair bony erosion or extension of disease beyond the sinus cavities
