Nose and Sinus Disease Flashcards
hollow cavities in the skull
sinuses
drain unidirectionally into nose (via ostia) and mucosa of nose and sinuses (contiguous)
turbinates
make air flow more turbulent to assists in humidifying and filtering particulates from the air
cilia location
concentrated near and beat towards natural sinus ostia
sinus drainage depends on:
ciliary action
mucus viscosity
size of sinus ostia
stasis of mucous flow
what might cause abnormal ciliary action ?
infection/large inoculation of bacteria
systemic disease (causing ciliary disfunction)
local hypoxia
environmental factors
what might cause mucus viscosity to increase?
infection
autoimmune disorders
dehydration
systemic inflammatory
medications (diuretics, pseudofedarin, narcotics)
what can cause Ostium obstruction infection?
mc common cause, SWELLING
respiratory viruses, chemical irritants, physical obstruction, allergic reaction, trauma
inflammation of lining of sinuses
rhinosinusitis
classified by timing and etiology
epidemiology of infectious sinusitis
1 of 7 adults
more common from early fall to spring
more common in women
etiologies of infectious rhinosinusitis
vast majority are caused by viral infection
viral URI can also cause acute bacterial rhinosinusitis
fungal rhinosinusitis
Viral rhinosinusitis agents
mostly caused by rhinovirus (can be flu, RSV, etc)
treatment is supportive
bacterial sinusitis agents
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
acute rhinosinusitis
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)
bacterial sinusitis s/s
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
classification of rhinosinusitis (diagnosed if)
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
acute rhinosinusitis is divided into
actue viral rhinosinusitis
actue bacterial rhinosinusitis
actue viral rhinosinusitis
s/s present less than 10 days and symptoms are not worsening
acute bacterial rhinosinusitis
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
recurrent acute rhinosinusitis
4+ episodes of acute bacterial rhinosinusitis per year with sinus mucosa completely normalizing between attacks
GET BETTER between attacks
chronic sinusitis
persistence of insidious symptomatology >12 weeks, with or without exacerbations
chronic sinusitis symptoms
must HAVE 2
mucopurulent drainage
nasal congestion
facial pain/pressure/fullness
decreased sense of smell
chronic sinusitis signs/images
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
ENT level work up for chronic sinusitis
more serious diagnosis
nasal cytology
paranasal sinus biopsy
fiberoptic sinus endoscopy
treatment of acute rhinosinusitis
two fold - drain sinuses and give antimicrobial treatment
drainage of sinuses (mechanisms)
- saline lavage (can be used in patients w/o comorbidities)
- Intranasal steroids (shortens duration in patients with allergic rhinitis, decreases inflammation of lining (2-3 weeks) )
- mucolytics (theoretically helpful)
OTC remedies for rhinosinusitis
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
first line ABX treatment of acute rhinosinusitis
community adult patients with uncomplicated acute bacterial sinusitis
- Amoxicillin (500 mg po/8hrs)
- Doxy 100 mg PO bid
- respiratory flouroquinalone
special situations in acute rhinosinusitis treatment
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)
how long after starting ABX should patient see improvement
2-3 days following start
most of them resolve spontaneously
complications of rhinosinusitis
local
Mucoceles
Osteomyelitis
mucoceles
chronic epithelial cysts in sinuses
may expand concentrically causing bony erosion and extension beyond the sinus
some are benign (maxillary) or severe (frontoethmoidal, etc)
osteomyelitis
infection of bone adjacent to sinus
presents with few symptoms and may cause extensive bony destruction prior to detection
mc affected is frontal sinus
complication of rhinosinusitis
orbital (5)
orbital complications are most common
preseptal cellulitis orbital cellulitis subperiosteal abscess orbital abscess cavernous sinus thrombosis
s/s of orbital complication
visual acuity loss
muscle eye movement loss
erythema
eyelid (tosis)
management of orbital complications
consult
CT scan of facial bone with IV contrast to evaluate orbital abscess
IV ABX and surgical drainage
intracranial sinusitis complication
2 ways
- direct extension of the infection thru posterior frontal sinus wall to CNS
- retrograde thromophlebitis of ophthalmic veins
s/s of intracranial complication
altered mental status
meningitis s/s (stiff neck, light sensitivity)
focal deficit
visual change
ataxic gait
pupillary reflex
mc intracranial sinusitis complication
subdural abscess
can cause seizure and coma
managed surgically with drainage, long IV ABX
chronic sinusitis
sinus inflammation lasting >12 weeks
most cases are caused by unresolved bacterial sinusitis
risk factors for chronic sinusitis
anatomical blockages (polyps, deviated septum) rhinitis nasotrachial or naogastric intimation
chronic rhinosinusitis results from
- obstruction of ostia
- stagnation of mucus
- chronic inflammation
these all lead to lower oxygen tension and lower pH within the sinus
MC cause of anaerobes caused
chronic rhinosinusitis pathophysiology
infection by anaerobes and further damages ciliary action
polymicrobial infection with GP, GN, anaerobes, and fungi
chronic rhinosinusitis s/s
SUBTLE presentation
nasal stuffiness nasal discharge postnasal drip facial fullness, discomfort and headache chronic unproductive cough sore throat
chronic rhinosinusitis work up
CT of sinuses with IV contrast
have to image this bc the presentation is subtle
chronic rhinosinusitis treatment
reduce mucosal edema, promote sinus drainage and eradicate infections
topical or oral glucocorticoids + abx and nasal irrigation
fungal sinusitis
invaded or non invasive disease but more likely to infuse in DM or immunocompromised
pathogens that cause fungal sinusitis
Apergillus and mucor species
spectrum of fungal disease (4)
allergic fungal sinusitis
sinus mycetoma
actue invasive fungal sinusitis
chronic invasive fungal sinusitis
allergic fungal sinusitis
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
sinus mycetoma
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
acute invasive fungal sinusitis
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
chronic invasive fungal sinusitis
invasive, slowly progressive, occurring in diabetics
patients do not look acutely ill s/s of chronic
fever, AMS, are ABSENT
fungal sinusitis dx
CT scan with IV contrast of sinus (poorly drained ostia, polyps, edema)
MRI to asses spread
tremens of all fungal sinusitis is surgical
allergic rhinitis
pathophysiology
IgE mediated inflammatory response to extrinsic protein within mucous membranes
allergic rhinitis s/s
paroxysms of sneezing
itching (nose, eyes, ears, palate)
rhinorrhea (thin snot)
allergic rhinitis
associated diseases
often associated with other igE mediated inflammatory disorders (asthma, atopic dermatitis, nasal polyps)
allergic rhinitis
exam findings
allergic shiners
allergic salute
pale, boddy blys nasal mucosa
thin and copious nasal discharge
allergic rhinitis
diagnostic workup
allergic rhinitis is diagnosed clinically (no lab testing)
control of allergic rhinitis will improve other allergic comorbidities
treatment of allergic rhinitis
- avoidance of triggers
- symptomatic treatment
- immunotherapy
avoidance of triggers
allergic rhinitis
keep windows closed, AC
bar animals from bedroom and wash them frequently
dehumidify
air pollution exacerbates allergies
glucocorticoid nasal spray lists (6)
Omaris
Nasonex
Flonase
Veramyst
Rhinocort
Nasacort
MOA glucocorticoid nasal spray
most effective maintenance therapy for allergic rhinitis + cover for nasal symptoms
- down regulate inflammatory response of mucosal cells to allergens
- turn on anti-inflammatory protein production in nasal mucosal cells
- suppress local release of cytokines
glucocorticoid nasal spray safety concerns
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
glucocorticoid nasal spray ADRs
local nasal irritation
aqueous preparations are less likely to have this effect
trace blood in mucous or epistaxis can occur
glucocorticoid nasal spray
directions for Aq formulation
spray and snif
chin tucked (head forward)
glucocorticoid nasal spray
directions for dry formulation
head should be tilted back
no blowing nose for 15 minutes
2nd gen oral antihistamines drug name/list (5)
Fexofenadine (Allegra)
Cetrizine (Zyrtec)
Levocetirizine (Xytal)
Loratidine (Claritin)
Desoloratidine (Clarinex)
1st gen oral antihistamine
drug name/list (2)
Diphenhydramine (Benadryl)
Hydroxysine (Vistaril)
initial allergic rhinitis therapy
chronic daily symptoms are best managed with an intranasal steroid, +/- oral antihistamine
drugs must take medication for several days before noting improvement
side effects of first generation antihistamines
cause significant sedation (cross BBB) and have powerful anticholinergic effects (dry mucous membranes, urinary retention, dilated pupils)
who is CI’d in first generation antihistamines
preschool children – causes paradoxical agitation
can impair school performance in school age children
no role in therapy for allergic rhinitis
role of oral antihistamines in allergic rhinitis
decrease itching, sneezing and rhinorrhea with less impact on nasal congestion
oral antihistamines
MOA
decrease inflammation on multiple levels
decrease release of mast cells, down regulate inflammatory response, and inhibition IL-4 IL-3
antihistamine nasal sprays
Azelastine (Astelin)
Olopatadine (patanase)
administration on demand
rhinitis medicamentosa pathophysiology
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
what might predispose patients to suffer from rhinitis medicamentosa
rhinitis of pregnancy and CPAP machine
rhinitis medicamentosa treatment
discontinuation of nasal spray ASAP
start intranasal steroids and wean OTC nasal spray as they take effect
anterior epistaxis
occur > 90% of time
typically the source of these bleeds Kisselbach’s Plexus
posterior epistaxis
usually more profuse
arterial pattern
greater risk of airway compromise, aspiration of blood, greater difficulty controlling bleeding
epistaxis etiologies
local trauma environmental factors Coagulopathies drugs others
epistaxis local trauma causes
picking, foreign body, facial trauma, nasal surgery
epistaxis workup
most are self limiting are not brought to medical attention
evaluate source of bleeding, CBC, PT/INR, chemistries
epistaxis treatment
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
population most affected by epistaxis
children 2-5
typically in right nare
where are foreign objects most commonly found in nose
below inferior turbinate or immediately anterior to middle terbinate
foreign objects diagnosis
physical exam
foul smelling discharge, epistaxis and pain
foreign object treatment
typically can be removed if patient is calm
can consult ENT
