Nose and Sinus Flashcards
Most frequent acute illness in the U.S.?
URI
How often do children/adults get URIs?
Preschool children: 5-7 x per year
Adults: 2-3 x per year
Most common cause of common cold
Rhinovirus (30-50%)
Coronavirus (10-15%) Influenza virus (5-15%)
Who are risk factors for the common cold?
Who is at risk for more severe complications?
daycare
at home parents
psychological stress
poor sleep
more severe: chronic dz immunodeficiency malnutrition cigarette smoking
Explain the normal course of the common cold and duration. (incubation, what symptoms normally present when?)
incubation: 2-3 days
Day 1 of sx: sore throat
day 2-3: nasal congestion, rhinitis
day 4-5: cough
duration: 3-10 days
Common sx with common cold
rhinitis nasal congestion sore throat cough sneezing malaise \+/- fever \+/- conjunctivitis watery eyes HA- mild myalgias- mild
PE findings in common cold
- nasal mucosal edema
- nasal congestion
- pharyngeal erythema
- +/- adenopathy
- clear lungs
- +/- conjunctival injection
How do you dx common cold?
H&P!- aka clinical diagnosis
Tx of common cold
Supportive care
- zinc, >75 mg
- hypertonic nasal saline irrigation
- nasal decongestant sprays
- oral decongestants
- intranasal ipratropium bromide (atrovent)
- intranasal cromoly sodium
- antitussives: dextromethorphan; codeine
- expectorants: guaifenesin
- analgesics: NSAIDS, acetaminophen
Pt education
- expected duration
- discuss abx
when should you use abx in common cold?
Only when you think pt will have complications like secondary bacterial infection
Acute Rhinosinusitis:
how many get it yearly?
men vs women?
age?
1 in 7-8 yearly
women> men
45-74 yo
Common cause of acute rhinosinisitis
Viral: rhinovirus, influenza, parainfluenza
bacterial- 0.5-2%
risk factors for Acute Rhinosinisitis
- older age
- smoking
- air travel
- changes in atmospheric pressure
- swimming
- asthma
- allergies
- dental dz
- immunodeficiency
explain the process of acute rhinosinisitis
normal sterile environment
decreased drainage of thick secretions
mucosal edema and sinus inflammation
obstruction of sinus ostia
entrapment of bacteria- leading to infection
Most important sx of acute rhinosinisitis
- nasal congestion/obstruction
- purulent nasal discharge
- facial pain or pressure
others (not highlighted): tooth discomfort fever fatigue cough ear pressure HA
Clinical signs of acute rhinosinisitis
- erythema or edema of cheekbone or periorbital
- cheek tenderness
- percussion tenderness of upper teeth
- purulent dischage in nose or pharynx
- sinus pain w/ percussion
- opacity of sinuses w/ transillumination
- diffuse nasal mucosal edema, turbinate hypertrophy
What are some red flags to watch for in acute rhinosinusitis?
- Fever > 102 w/ severe HA
- Abnormal vision (diplopia, blindness)
- change in mental status
- periorbital edema
- cranial nerve palsies
How do you diagnose Acute rhinosinusitis?
If suspected complicated ABRS?
Recurrent resistent sinusitis?
clinically!
ABRS: CT w/ contrast
recurrent: Non contrast CT
Indications of bacterial rhinosinusitis
- lasting 10 or more days w/o improvement
- fever > 102, purulent nasal discharge, facial pain
- onset of worsening sx after initially improving (double-worsneing)
from days 1-9, how do you treat acute Rhinosinusitis?
Supportive care
- analgesics
- saline irrigation
- oral decongestants
- intranasal glucocorticoids
If bacterial acute Rhinosinusitis, how do you treat? How long?
w/ Penicillin allergy?
Amoxicillin-clavulanate (aka Augmentin) 500-875 mg BID; 5-7 days
-If penicillin allergy: doxycycline
What do you NOT treat bacterial acute Rhinosinusitis with?
probs don’t need to know
macrolides
trimethoprim-sulfamethoxazole
cephalosporins
Potential complications of acute Rhinosinusitis
periorbital/orbital cellulitis
meningitis
osteomyelitis of sinus bone
intracranial abscess
How long does a pt need to have sx before saying it is chronic rhinosinusitis?
more than 12 weeks
Possible sx that might indicate a pt has chronic rhinosinusitis
- anterior/posterior nasal mucopurulent drainage
- nasal obstruction/congestion
- facial pain/pressure
- reduction of smell
- purulent mucus or edema in the middle meatus
- polyps in nasal cavity
- radiographic imaging showing mucosal thickening
How do you treat chronic rhinosinusitis?
- nasal irrigation
- intranasal glucocorticoids
- topical antimicrobials
- oral antimicrobials
Name some risk factors for allergic rhinitis?
how common is it?
- fam hx
- male
- birth during pollen season
- first born
- early use of abx
affects 10-30% of the population and is increasing!
How do you classify what kind of allergic rhinitis a pt has?
- Intermediate: <4 days/week of less than 4 weeks
- perisistant: >4 days/weel or more than 4 weeks
Mild: none of mod-severe criteria met Mod-severe: 1 or more- -sleep disturbance -impaired work -impaired daily activities -troublesome sx
What are some sx the pt might complain of if they have allergic rhinitis?
sneezing rhinorrhea nasal congestion cough postnasal drip irritability fatigue eye itching
Physical exam findings that indication allergic rhinitis?
- “allergic shiners”
- “allergic salute”
- pale bluish or pallor nasal mucosa
- clear rhinorrhea
- hyperplastic lymohoid tissue in posterior phargyn “cobblestoning”
- TM retraction or serous fluff behind TM
What is the most common allergy skin test?
Prick skin test
What are some treatments options for allergic rhinitis?
- Glucocorticoid nasal spray
- Oral antihistamines
- Nasal spray antihistamines
- Mast cell stabilizer (ex= going to a person’s house w/ a cat)
What are some possible triggers of nonallergic rhinitis?
- temp changes
- eating (ex= spicy food)
- exposure to odors
- alcohol use
What differences in sx would you see in nonallergic rhinitis vs allergic rhinitis?
Would not see sneezing/itchiness as in allergic rhinitis
Nasal turbinates would be boggy, edematous, and more erythematous
In allergic rhinitis they are bluish
Most common location for epistaxis? Most common causes?
Anterior! 95%
-Nasal trauma (aka nose picking)
What are treatments of epistaxis?
1st- Conservative:
- occlusion
- lean forward to prevent swallowing of blood
- cold compress to nasal bridge
2nd- Cautery
-silver nitrate or electrical
3rd- Nasal packing
- nasal tampon
- gauze packing
- nasal baloon
What is a bigger deal, anterior or posterior epistaxis bleed?
What is likely to be done?
Posterior!
Emergency, likely admit
What are conditions a/w nasal polys?
If a child has nasal polyps, what do you think about?
allergic rhinitis, asthma, cystic fibrosis
children- think about cystic fibrosis
What is Samter’s triad?
Nasal polyps + asthma = avoid aspirin!
immunologic salicylate sensitivity causes severe episode of bronchospasm
How do you treat nasal polyps?
- topical intranasal corticosteroids
- surgical excision
What are the 2 possible malignant neoplasms of the nose/sinuses?
Risk factors of malignant neoplasms
squamous cell carcinoma
adenocarcinoma
tobacco smoke
HPV
