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Foundations II Exam 1 > Nose and Sinus > Flashcards

Nose and Sinus Flashcards

1
Q

Common cold

  • MC etiology
  • Transmission
  • Risk factors
  • Clinical presentation
  • Incubation period
  • Physical exam
  • Differential diagnosis
  • Diagnosis
  • Complications
  • Treatment
  • Medications
A

Common cold

  • MC etiology: Rhinovirus
  • MC in children: RSV and parainfluenza
  • Transmission: droplets

Risk factors

  • Daycare
  • At home parents
  • Psychological stress
  • Poor sleep

Risk factors for getting more severe infection

  • Chronic dz
  • Immunodeficiency
  • Malnutrition
  • Cigarette smoking

Clinical presentation

  • Rhinitis
  • Nasal congestion
  • Sore throat, cough, sneezing
  • Malaise, possible fever
  • Headache, myalgia

Incubation period

  • Time from exposure to symptomatic: 24-72 hours
  • Day 1: sore throat
  • Day 2-3: runny nose
  • Day 4-5: cough
  • Typical duration: 3-10 days

Physical exam

  • Nasal mucosal edema
  • Nasal congestion
  • Pharyngeal erythema
  • Lungs clear
  • Possible adenopathy
  • Possible conjunctival injection

Differential diagnosis

  • Allergic Rhinitis
  • Bacterial pharyngitis / tonsillitis
  • Acute bacterial rhinosinusitis
  • Influenza
  • Acute bronchitis
  • Asthma exacerbation
  • Pneumonia
  • Infectious mono
  • Pertussis

Diagnosis

  • H & P (this is all you really need to make a dx)
  • Further testing to r/o other things
    • CXR (pneumonia)
    • Sinus imaging (chronic sinusitis)
    • Viral cultures (flu)

Complications (secondary infections)

  • Viral sinusitis (MC in adults)
  • Bacterial sinusitis
  • Lower respiratory disease
  • Acute asthma exacerbation
  • Acute otitis media (MC in children)
  • Eustachian tube dysfunction / transient middle ear effusion

Treatment

  • Supportive care
  • Patient education

Medications (to tx sxs)

  • Zinc, > 75 mg/day (Zicam)
  • Hypertonic nasal saline irrigation
  • Nasal decongestant sprays (Afrin, but do not use for more than 3 days)
  • Oral decongestants: pseudoephedrine, phenylephrin
  • Antihistamines: diphenhydramine; chlorpheniramine
  • Intranasal ipratropium bromide (Atrovent)
  • Intranasal cromolyn sodium
  • Antitussives: dextromethorphan; codeine
  • Expectorants: guafenesin
  • Analgesics: NSAIDS, acetaminophen
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2
Q

Acute rhinosinusitis

  • Epidemiology
  • Etiology
  • Risk factors
  • Clinical presentation
  • Physical exam
  • Red flags
  • Differential diagnosis
  • Diagnosis
  • 3 features of bacterial cause
  • Treatment
A

Acute rhinosinusitis

Epidemiology

  • 1 in 7-8 people annually
  • Women > men
  • 45-74 year old

Etiology

  • VIRAL
    • _​_Rhinovirus
    • Influenza
    • Parainfluenza
  • Bacterial

Risk factors

  • Old age
  • Smoking
  • Air travel
  • Changes in atmospheric pressure (deep sea diving)
  • Swimming
  • Asthma
  • Allergies
  • Dental dz
  • Immunodeficiency

Pathophysiology

  1. Normal sterile environment
  2. Mucosal edema and sinus inflammation
  3. Decreased drainage of thick secretions
  4. Obstruction of sinus ostia
  5. Entrapment of bacteria leads to infection

Clinical presentation

  • Nasal congestion / obstruction
  • Purulent nasal discharge
  • Facial pain or pressure
  • Maxillary tooth discomfort
  • Fever
  • Fatigue
  • Cough
  • Hyposmia or anosmia
  • Ear pressure or fullness
  • Headache
  • Halitosis

Physical exam

  • Erythema or edema of cheekbone or periorbital
  • Cheek tenderness
  • Percussion of upper teeth tenderness
  • Purulent drainage in nose or pharynx
  • Sinus pain with percussion
  • Opacity of sinuses with transillumination
  • Diffuse nasal mucosal edema, turbinate hypertrophy

Red flags

  • Fever > 102 with severe headache
  • Abnormal vision (diplopia, blindness); abnormal EOMs; proptosis; opthalmoplegia; papilledema - think orbital cellulitis
  • Change in mental status
  • Periorbital edema or erythema
  • Cranial nerve palsies
  • Altered mental status
  • Neck stiffness or other meningeal signs

Differential diagnosis

  • Viral URI
  • Allergic/nonallergic rhinitis
  • Neuralgias
  • TMJ disorder
  • Headaches
  • Migraines, tension h/a, cluster h/a
  • Dental pain

Diagnosis

  • Based on clinical impression
  • Radiologic studies
    • Indicated if suspect complicated ABRS (CT with contrast)
    • Recurrent or treatment resistant sinusitis (CT w/o contrast)

Features of bacterial cause

  1. Persistent sxs lasting more than 10 days with no improvement
  2. Onset of severe sxs (fever, purulent nasal discharge, facial pain) lasting at least 3 days at beginning of illness
  3. Onset with worsening sxs following a viral URI that lasted 5-6 days and was initally improving (“double worsening”)

Treatment

  • Days 1-9, supportive care
  • Bacterial management
    • Amoxicillin-clavulante
    • PCN allergy, use doxycyline or 3rd generation cephalosporin with or w/o clindamycin
    • Alternatively, use a respiratory fluoroquinolone
    • NOT RECOMMENDED
      • Macrolides
      • Trimethoprim-sulfamethoxazole
    • Duration of tx is 5-7 days

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3
Q

Chronic rhinosinusitis

  • Symptoms lasting longer than
  • Risk factors
  • Clinical presentation
  • Differential diagnosis
  • Treatment
A

Chronic rhinosinusitis

  • Symptoms longer than 12 weeks

Risk factors

  • Allergic rhinitis
  • Chronic exposure to environmental irritants or ciliostatic substances
  • Immunodeficiency
  • Defects in mucociliary clearance
  • Recurrent viral URIs
  • Anatomic abnormalities predisposing to sinus obstruction
  • Latrogenic (complications from repeated sinus surgery)

Physical exam

  • Anterior and/or posterior nasal mucopurulent drainage
  • Nasal obstruction/nasal blockage/congestion
  • Facial pain, pressure, and/or fullness
  • Reduction or loss of sense of smell
  • Purulent mucus or edema in the middle meatus or ethmoid regions
  • Polyps in the nasal cavity or the middle meatus
  • Radiographic imaging demonstrating mucosal thickening, or partial or complete opacification of the paranasal sinuses

Differential diagnosis

  • Recurrent, acute rhinosinusitis
  • Allergic rhinitis, nonallergic rhinitis, vasomotor rhinitis
  • Migraines, cluster headaches, tension headaches, vascular headaches
  • Trigeminal neuralgia

Treatment

  • Nasal irrigation
  • Intranasal glucocorticoids
  • Topical antimicrobials
  • Oral antimicrobials
  • Oral glucocorticoids
  • Antileukotriene agents
  • Endoscopic sinus surgery
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4
Q

Allergic rhinits

  • Epidemiology
  • Risk factors
  • Etiology
  • Pathophysiology
  • Classification
  • Clinical presentation
  • Physical exam
  • Diagnosis
  • Treatment
  • Patient education
A

Allergic rhinits

Epidemiology

  • 10-30% of people in US
  • Prevalence is increasing

Risk factors

  • Family history atopy (triad: eczema, allergies, and asthma)
  • Male
  • Birth during pollen season
  • First born
  • Early use of antibiotics
  • Maternal smoking in first year of life
  • Indoor allergen exposure
  • Serum IgE > 100 IU/mL before age 6
  • Presence of allergen-specific IgE

Etiology

  • Exposure to an airborne allergen in a predisposed person
  • Activation of B-cell (humoral) and T-cell (cytotoxic) immune system responses
  • Allergen-specific IgE responses cause release of inflammatory mediators

Pathophysiology

  • Abnormal immune response to an environmental protein

Classification

  • Intermittent
  • Persistent
  • Mild, moderate, or severe
  • Seasonal
  • Perennial (year round, thought to be related to indoor than outdoor allergens)

Related disorders

  • Allergic conjunctivitis
  • Sinusitis
  • Asthma
  • Atopic dermatitis
  • ETD (serous and AOM)

Clinical presentation

  • Sneezing
  • Rhinorrhea
  • Nasal obstruction/congestion
  • Nasal itching (also palate & inner ear)
  • Postnasal drip
  • Cough
  • Irritability
  • Fatigue
  • Eye itching, tearing, burning

Physical exam

  • Infraorbital edema/darkening “allergic shiners” (dark bags under eyes)
  • Transverse nasal crease “allergic salute”
  • Nasal mucosa pale bluish color or pallor & turbinate edema
  • Clear rhinorrhea (nose or posterior pharynx)
  • Hyperplastic lymphoid tissue in posterior pharynx “cobblestoning”
  • TM retraction or serous fluid behind TM

Diagnosis

  • Clinical dx with H&P
  • Labs are often normal
  • Allergy skin testing
  • Serum IgE

Treatment

  • Glucocorticoid nasal sprays
  • Oral antihistamines (if there are other sxs outside of nasal sxs)
  • Antihistamine nasal sprays (bad taste)
  • Combo glucocorticoid and antihistamine nasal spray
  • Mast cell stabilizer
  • Leukotriene receptor antagonist (Singulair)
  • Ipratropium bromide nasal
  • Nasal decongestant sprays (not more than 3 days)
  • Systemic glucocorticoids (old school tx that was used, older patients may want this)

Patient education

  • Use nasal saline spray
  • Allergen avoidance
    • Pillows, mattresses, carpets, drapes, bedspreads
    • Air purifiers
    • Dust filters
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5
Q

Nonallergic rhinitis

  • Etiology
  • Triggers
  • Clinical presentation
  • Diagnosis
  • Treatment
A

Nonallergic rhinitis

Etiology

  • Abnormal autonomic regulation of innervation of nose
  • Nasal eosinophili without allergen sensitivity

Triggers

  • Temperature changes
  • Eating
  • Exposure to odors / chemicals
  • Alcohol use

Clinical presentation

  • Nasal congestion
  • Postnasal drainage
  • Boggy, edematous nasal turbinates – more erythematous

Diagnosis

  • Dx of exclusion
  • No test to test positive
  • Absence of evidence for clincial allergy

Treatment

  • Topical intranasal glucocorticoids
  • Topical antihistamine (azelastine)
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6
Q

Epistaxis

  • 2 types
  • Etiology
  • Examination
  • Diagnostics
  • Treatment
  • After control of bleeding
A

Epistaxis

  • Anterior bleed 95% - Kiesselbach’s plexus
  • Posterior bleed 5% - much more serious

Etiology

  • Nasal trauma
  • Mucosal dryness/irritation
  • Mucosal hyperemia
  • FB / neoplasm
  • Intranasal drug use
  • Alcohol
  • Anticoagulation therapy
  • Blood disorders
  • Atherosclerotic disease
  • Hereditary hemorrhagic telangiectasia
  • Hypertension (possibly)

Examination

  • Vitals, mental status, airway
  • Nose: may need to pre tx with anesthetic (lidocaine) or vasoconstrictor (Afrin), try to identify source

Diagnostics

  • PT/INR - only for anticoagulated patients
  • Hematocrit - type and crossmatch

Treatment

  • Conservative measures
    • Occlusion, continuous x 10-15 minutes
    • Lean forward to prevent swallowing blood
    • Cold compress to bridge of nose
  • Cautery (if you can find the source of the bleed)
    • Silver nitrate
    • Electrical
  • Nasal packing
    • Nasal tampon
    • Gauze packing
    • Nasal balloon catheter

Persistent bleeding tx

  • Pack both sides
  • ENT consult
  • Posterior bleed is an emergency

After control of bleeding

  • Avoid straining or vigorous exercise
  • Apply nasal saline to packing
  • Avoid hot or spicy food, tobacco (vasodilation)
  • Avoid nasal trauma
  • Lubrication (petroleum jelly or bacitracin ointment)
  • Increase home humidity
  • Possible antibiotics for TSS prophylaxis
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7
Q

Nasal polyps

  • Etiology
  • Associated with
  • When to avoid ASA
  • Think about what dz for children
  • Clinical presentation
  • Treatment
A

Nasal polyps

  • Unclear etiology
  • Associated with
    • Allergic rhinitis
    • Asthma
    • Cystic fibrosis
  • Nasal polyps + asthma = avoid ASA
    • Samter triad: immunologic salicylate sensitivity causes severe episode of bronchospasm
    • Worry that they may have this triad
  • In children, think about cystic fibrosis

Clinical presentation

  • Nasal obstruction
  • Anosmia
  • Rhinorrhea
  • Post nasal drip
  • Pale, edematous, mucus covered mass

Treatment

  • Topical intranasal corticosteroids
  • Sx excision (high recurrence though)
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8
Q

Malignant neoplasms

  • Epidemiology
  • Risk factors
  • Clinical presentation
  • Diagnositcs
  • Diagnosis
  • Treatment
A

Malignant neoplasms

  • Squamous cell and adenocarcinoma
  • Rare
  • Male > female
  • Usually over 50 years old

Risk factors

  • Tobacco smoke
  • Exposure to wood dust, glue, adhesives
  • HPV

Clinical presentation

  • Obstruction & epistaxis
  • Advanced: facial swelling/pain, proptosis, diplopia, cranial nerve dysfunction, seizure, nodal masses

Diagnostics

  • CT
  • MRI

Diagnosis

  • Biopsy

Treatment

  • Head/neck surgeon
  • Neurosurgeon
  • Radiation oncology
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Foundations II Exam 1 (6 decks)

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