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FA17 HEENT > Nose and Sinus Disease > Flashcards

Nose and Sinus Disease Flashcards

1
Q

hollow cavities in the skull

A

sinuses

drain unidirectionally into nose (via ostia) and mucosa of nose and sinuses (contiguous)

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2
Q

turbinates

A

make air flow more turbulent to assists in humidifying and filtering particulates from the air

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3
Q

cilia location

A

concentrated near and beat towards natural sinus ostia

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4
Q

sinus drainage depends on:

A

ciliary action

mucus viscosity

size of sinus ostia

stasis of mucous flow

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5
Q

what might cause abnormal ciliary action ?

A

infection/large inoculation of bacteria

systemic disease (causing ciliary disfunction)

local hypoxia

environmental factors

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6
Q

what might cause mucus viscosity to increase?

A

infection

autoimmune disorders

dehydration

systemic inflammatory

medications (diuretics, pseudofedarin, narcotics)

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7
Q

what can cause Ostium obstruction infection?

A

mc common cause, SWELLING

respiratory viruses, chemical irritants, physical obstruction, allergic reaction, trauma

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8
Q

inflammation of lining of sinuses

A

rhinosinusitis

classified by timing and etiology

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9
Q

epidemiology of infectious sinusitis

A

1 of 7 adults

more common from early fall to spring

more common in women

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10
Q

etiologies of infectious rhinosinusitis

A

vast majority are caused by viral infection

viral URI can also cause acute bacterial rhinosinusitis

fungal rhinosinusitis

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11
Q

Viral rhinosinusitis agents

A

mostly caused by rhinovirus (can be flu, RSV, etc)

treatment is supportive

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12
Q

bacterial sinusitis agents

A

mc cause of community rhinosinusitis are normal flora (h. influenza, strep pneumonia, M. catarrhalis, S. aureus)

nosocomial sinusitis - gram - but also poly microbial

dental disease, chronic sinusitis - anaerobes

caused by eventual colonization via sneezing, coughing, or invasion

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13
Q

acute rhinosinusitis

A

clinically diagnosed (no labs)

patient will have s/s of common cold (sneezing, congestion, runny nose)

patient appears to recover then gets worse (around day 7)

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14
Q

bacterial sinusitis s/s

A

viral URI history

facial pain over cheek (radiating to frontal region or teeth)

tenderness or pressure

purulent nasal or post nasal discharge

sinus tenderness

hyposmia

fever is RARE

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15
Q

classification of rhinosinusitis (diagnosed if)

A

these symptoms for up to 4 weeks:

  • purulent nasal discharge: cloudy, colored
  • nasal obstruction: congestion, blockage, stuffiness
  • facial pain-pressure-fullness: anterior face, headache that is diffuse

facial pressure must be accompanied w/other 2

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16
Q

acute rhinosinusitis is divided into

A

actue viral rhinosinusitis

actue bacterial rhinosinusitis

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17
Q

actue viral rhinosinusitis

A

s/s present less than 10 days and symptoms are not worsening

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18
Q

acute bacterial rhinosinusitis

A

s/s of acute rhinosinusitis fail to improve in 10 days or more beyond the onset of URI symptoms

OR s/s acute rhinosinusitis worsen within 10 days after an initial improvement

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19
Q

recurrent acute rhinosinusitis

A

4+ episodes of acute bacterial rhinosinusitis per year with sinus mucosa completely normalizing between attacks

GET BETTER between attacks

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20
Q

chronic sinusitis

A

persistence of insidious symptomatology >12 weeks, with or without exacerbations

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21
Q

chronic sinusitis symptoms

A

must HAVE 2

mucopurulent drainage
nasal congestion
facial pain/pressure/fullness
decreased sense of smell

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22
Q

chronic sinusitis signs/images

A

must have 1

purulent mucous or edema of meatus or ethmoid region

polyps in nasal vanity or middle meatus

inflammation of paranasal sinuses on radiograph

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23
Q

ENT level work up for chronic sinusitis

A

more serious diagnosis

nasal cytology
paranasal sinus biopsy
fiberoptic sinus endoscopy

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24
Q

treatment of acute rhinosinusitis

A

two fold - drain sinuses and give antimicrobial treatment

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25
Q

drainage of sinuses (mechanisms)

A
  1. saline lavage (can be used in patients w/o comorbidities)
  2. Intranasal steroids (shortens duration in patients with allergic rhinitis, decreases inflammation of lining (2-3 weeks) )
  3. mucolytics (theoretically helpful)
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26
Q

OTC remedies for rhinosinusitis

A

topical (nasal spray) - CI’d bc can cause rebound congestion

oral medications (OTC cold and flu remedy) can cause increased BP and tachycardia

antihistamines - not used bc it thickens mucus

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27
Q

first line ABX treatment of acute rhinosinusitis

A

community adult patients with uncomplicated acute bacterial sinusitis

  1. Amoxicillin (500 mg po/8hrs)
  2. Doxy 100 mg PO bid
  3. respiratory flouroquinalone
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28
Q

special situations in acute rhinosinusitis treatment

A

dental caries and foul discharge - ANAEROBIC coverage - metronidazole (500mg/8 hrs)
-clindamycin (300mg/6-8 hrs)

ICU patients - GP and GN and anaerobes - consider surgical drainage and culture

  • zosyn (3.75gm IV/6hrs)
  • Ceftriaxone (2gm IV/12 hrs)
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29
Q

how long after starting ABX should patient see improvement

A

2-3 days following start

most of them resolve spontaneously

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30
Q

complications of rhinosinusitis

local

A

Mucoceles

Osteomyelitis

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31
Q

mucoceles

A

chronic epithelial cysts in sinuses

may expand concentrically causing bony erosion and extension beyond the sinus

some are benign (maxillary) or severe (frontoethmoidal, etc)

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32
Q

osteomyelitis

A

infection of bone adjacent to sinus

presents with few symptoms and may cause extensive bony destruction prior to detection

mc affected is frontal sinus

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33
Q

complication of rhinosinusitis

orbital (5)

A

orbital complications are most common

preseptal cellulitis 
orbital cellulitis 
subperiosteal abscess 
orbital abscess 
cavernous sinus thrombosis
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34
Q

s/s of orbital complication

A

visual acuity loss
muscle eye movement loss
erythema
eyelid (tosis)

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35
Q

management of orbital complications

A

consult
CT scan of facial bone with IV contrast to evaluate orbital abscess

IV ABX and surgical drainage

36
Q

intracranial sinusitis complication

2 ways

A
  1. direct extension of the infection thru posterior frontal sinus wall to CNS
  2. retrograde thromophlebitis of ophthalmic veins
37
Q

s/s of intracranial complication

A

altered mental status
meningitis s/s (stiff neck, light sensitivity)
focal deficit

visual change
ataxic gait
pupillary reflex

38
Q

mc intracranial sinusitis complication

A

subdural abscess

can cause seizure and coma

managed surgically with drainage, long IV ABX

39
Q

chronic sinusitis

A

sinus inflammation lasting >12 weeks

most cases are caused by unresolved bacterial sinusitis

40
Q

risk factors for chronic sinusitis

A 
anatomical blockages (polyps, deviated septum) 
rhinitis 
nasotrachial or naogastric intimation
41
Q

chronic rhinosinusitis results from

A
  1. obstruction of ostia
  2. stagnation of mucus
  3. chronic inflammation

these all lead to lower oxygen tension and lower pH within the sinus

MC cause of anaerobes caused

42
Q

chronic rhinosinusitis pathophysiology

A

infection by anaerobes and further damages ciliary action

polymicrobial infection with GP, GN, anaerobes, and fungi

43
Q

chronic rhinosinusitis s/s

A

SUBTLE presentation

nasal stuffiness 
nasal discharge 
postnasal drip 
facial fullness, discomfort and headache 
chronic unproductive cough
sore throat
44
Q

chronic rhinosinusitis work up

A

CT of sinuses with IV contrast

have to image this bc the presentation is subtle

45
Q

chronic rhinosinusitis treatment

A

reduce mucosal edema, promote sinus drainage and eradicate infections

topical or oral glucocorticoids + abx and nasal irrigation

46
Q

fungal sinusitis

A

invaded or non invasive disease but more likely to infuse in DM or immunocompromised

47
Q

pathogens that cause fungal sinusitis

A

Apergillus and mucor species

48
Q

spectrum of fungal disease (4)

A

allergic fungal sinusitis

sinus mycetoma

actue invasive fungal sinusitis

chronic invasive fungal sinusitis

49
Q

allergic fungal sinusitis

A

occurs secondary to asthma and allergic rhinitis

development of allergic reaction to inhaled fungus

overproduction of mucin and develop nasal polyps

treatment is with sinus surgery to clear mucin and restore flow

50
Q

sinus mycetoma

A

immunocompetent patients - ball of fungi blocks drainage of sinus

less likely atopic disease

mucupurulent/cheesy and clay like material is found at time of surgery

51
Q

acute invasive fungal sinusitis

A

immunocompromised

rapid hematogenous spread of fungi from sinus to CNS

patients look toxic with fever cough, HA, congestion, AMS, and necrotic tissues of the septum

52
Q

chronic invasive fungal sinusitis

A

invasive, slowly progressive, occurring in diabetics

patients do not look acutely ill s/s of chronic

fever, AMS, are ABSENT

53
Q

fungal sinusitis dx

A

CT scan with IV contrast of sinus (poorly drained ostia, polyps, edema)

MRI to asses spread

tremens of all fungal sinusitis is surgical

54
Q

allergic rhinitis

pathophysiology

A

IgE mediated inflammatory response to extrinsic protein within mucous membranes

55
Q

allergic rhinitis s/s

A

paroxysms of sneezing

itching (nose, eyes, ears, palate)

rhinorrhea (thin snot)

56
Q

allergic rhinitis

associated diseases

A

often associated with other igE mediated inflammatory disorders (asthma, atopic dermatitis, nasal polyps)

57
Q

allergic rhinitis

exam findings

A

allergic shiners
allergic salute
pale, boddy blys nasal mucosa

thin and copious nasal discharge

58
Q

allergic rhinitis

diagnostic workup

A

allergic rhinitis is diagnosed clinically (no lab testing)

control of allergic rhinitis will improve other allergic comorbidities

59
Q

treatment of allergic rhinitis

A
  1. avoidance of triggers
  2. symptomatic treatment
  3. immunotherapy
60
Q

avoidance of triggers

allergic rhinitis

A

keep windows closed, AC

bar animals from bedroom and wash them frequently

dehumidify

air pollution exacerbates allergies

61
Q

glucocorticoid nasal spray lists (6)

A

Omaris

Nasonex

Flonase

Veramyst

Rhinocort

Nasacort

62
Q

MOA glucocorticoid nasal spray

A

most effective maintenance therapy for allergic rhinitis + cover for nasal symptoms

  1. down regulate inflammatory response of mucosal cells to allergens
  2. turn on anti-inflammatory protein production in nasal mucosal cells
  3. suppress local release of cytokines
63
Q

glucocorticoid nasal spray safety concerns

A

concern for suppression of growth and adrenal axis

they are altered to protect them

can have some negative effects and lowest dose for shortest amount of time

64
Q

glucocorticoid nasal spray ADRs

A

local nasal irritation

aqueous preparations are less likely to have this effect

trace blood in mucous or epistaxis can occur

65
Q

glucocorticoid nasal spray

directions for Aq formulation

A

spray and snif

chin tucked (head forward)

66
Q

glucocorticoid nasal spray

directions for dry formulation

A

head should be tilted back

no blowing nose for 15 minutes

67
Q

2nd gen oral antihistamines drug name/list (5)

A

Fexofenadine (Allegra)

Cetrizine (Zyrtec)

Levocetirizine (Xytal)

Loratidine (Claritin)

Desoloratidine (Clarinex)

68
Q

1st gen oral antihistamine

drug name/list (2)

A

Diphenhydramine (Benadryl)

Hydroxysine (Vistaril)

69
Q

initial allergic rhinitis therapy

A

chronic daily symptoms are best managed with an intranasal steroid, +/- oral antihistamine

drugs must take medication for several days before noting improvement

70
Q

side effects of first generation antihistamines

A

cause significant sedation (cross BBB) and have powerful anticholinergic effects (dry mucous membranes, urinary retention, dilated pupils)

71
Q

who is CI’d in first generation antihistamines

A

preschool children – causes paradoxical agitation

can impair school performance in school age children

no role in therapy for allergic rhinitis

72
Q

role of oral antihistamines in allergic rhinitis

A

decrease itching, sneezing and rhinorrhea with less impact on nasal congestion

73
Q

oral antihistamines

MOA

A

decrease inflammation on multiple levels

decrease release of mast cells, down regulate inflammatory response, and inhibition IL-4 IL-3

74
Q

antihistamine nasal sprays

A

Azelastine (Astelin)
Olopatadine (patanase)

administration on demand

75
Q

rhinitis medicamentosa pathophysiology

A

rebound rhinitis characterized by nasal congestion without rhinorrhea or sneezing

triggered by topical OTC but process is not clear

they rebound congestion when try to stop nasal spray

76
Q

what might predispose patients to suffer from rhinitis medicamentosa

A

rhinitis of pregnancy and CPAP machine

77
Q

rhinitis medicamentosa treatment

A

discontinuation of nasal spray ASAP

start intranasal steroids and wean OTC nasal spray as they take effect

78
Q

anterior epistaxis

A

occur > 90% of time

typically the source of these bleeds Kisselbach’s Plexus

79
Q

posterior epistaxis

A

usually more profuse

arterial pattern

greater risk of airway compromise, aspiration of blood, greater difficulty controlling bleeding

80
Q

epistaxis etiologies

A 
local trauma 
environmental factors 
Coagulopathies 
drugs 
others
81
Q

epistaxis local trauma causes

A

picking, foreign body, facial trauma, nasal surgery

82
Q

epistaxis workup

A

most are self limiting are not brought to medical attention

evaluate source of bleeding, CBC, PT/INR, chemistries

83
Q

epistaxis treatment

A

may be prevented with light application of petroleum jelly

direct pressure 5-30 minutes

pledges soaked in lidocaine or cocaine to produce vasoconstriction

cauterization or packing

84
Q

population most affected by epistaxis

A

children 2-5

typically in right nare

85
Q

where are foreign objects most commonly found in nose

A

below inferior turbinate or immediately anterior to middle terbinate

86
Q

foreign objects diagnosis

A

physical exam

foul smelling discharge, epistaxis and pain

87
Q

foreign object treatment

A

typically can be removed if patient is calm

can consult ENT

FA17 HEENT (8 decks)

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