Otolaryngology

Question 1

intranasal glucocorticoids

Answer 1

first line for AR

beclomethasone, flunisolide, budesonide, fluticasone, propionate, mometasone furoate

Question 2

1st gen antihistamines

Answer 2

use after steriods and 2nd/3rd Gen for AR

diphenhydramine, chlorpheniramine, hydroxyzine

Question 3

2nd gen antihistamine

Answer 3

loratadine, cetirizine, azelastine, olopatadine

Question 4

3rd gen antihistamines

Answer 4

metabolistes of 2nd gen - fexofenadine, desloratadine, levocetirizine

Question 5

antihistamine nasal sprays

Answer 5

azelastine, olopatadine

Question 6

antihistamine+ decongestant

Answer 6

loratadine or cetirizine/pseudophedrine

decongestant - incr. in BP and insomnia

Question 7

cromolyn sodium

Answer 7

mast cell stabilizer, not 1st line for AR, nasal spray

Question 8

montelukast

Answer 8

pts with AR and asthma

Question 9

ipratropium bromide

Answer 9

anticholinergic, rhinorrhea, nasal spray (usually COPD)

Question 10

nasal decongestant sprays

Answer 10

vasoconstrictor decongestants - phenylephrine, oxymetazoline, xylometazoline
chronic use - rhinitis medica mucosa (rebound)

Question 11

systemic glucocorticoids

Answer 11

used with severe s&s short-term for AR, adverse side effects risk

Question 12

Management of AR in mild cases over 2 yrs old

Answer 12

1. 2nd gen oral/topical antihistamine, regularly or prn
2. intranasal steriod regularly or prn (most cost effective)
3. intranasal antihistamine - azelastine (5-12 yo), olopatadine (12+ yo)
4. intranasal cromlyn, regularly or prn for pts w/asthma

Question 13

rhinitis medicamentosa

Answer 13

rebound nasal congestion due to overuse of intranasal alpha-adrenergic decongestants or cocaine
must stop using offending agent while useing topical or oral corticosteriods to tx s&s

Question 14

vasomotor rhinitis

Answer 14

chronic, (most common)nonallergenic rhinitis not associated with nasal eosinophilia
avoid irritants and use intranasal corticosteriod or antihistamines

Question 15

samter triad

Answer 15

nasal polyps, bronchial asthma, aspirin sensitivity that can be dangerous in some cases

Question 16

nasal polyps

Answer 16

inflammatory conditions of nasal and sinus mucosa, may be in conjunction (not causative) with chronic rhinitis or sinusitis
40+ yo
Hx - rhinorrhea, nasal congestion, anosmia
PE - pale, edematous, mucousally covered masses
Tx - intranasal steroids, severe - oral prednisone, surgical resection in rare cases

Question 17

acute bacterial rhinosinusitis dx

Answer 17

1. onset with persistent s&s w/o clinical improvement over 10+ days
2. onset of severe symptoms of a. >102F AND b. purulent nasal discharge or facial pain for 3-4 consecutive days at beginning of illness
3. onset of worsening s&s after initially improving with new onset of fever, headache or increase in discharge

Question 18

acute bacterial rhinosinusitis tx

Answer 18

first line - amoxicillin + clavulanate for 5-7 days
- 500 mg / 125 orally TID or 875 / 125 mg BID
high dose - 2mg BID when in geographic region of high endemic rate of PNS OR severe infection OR pt > 65 yo OR pt has recent hospitalization/ antibiotic use in past month
penicillin allergy - doxycycline or respiratory fluoroquinolone
adjunctive - hydration, analgesics, saline irrigation and intranasal glucocorticoids if also AR

Question 19

refer ABRS

Answer 19

early - severe infection, suspected fungal or granulomatous disease, nosocomial infection
less-urgent - >4 cases annually, chronic rhinosinusitis with recurrent exacerbation with ABRS, immunotherapy candidates that have concurrent AR
also - anatomic defects causing obstruction, immunocompromised or resistnt pathogens, fail second-line tx

Question 20

chronic rhinosinusitis (CRS) Dx

Answer 20

12+ wks of 2+
- mucopurulent drainage
- nasal obstruction/congestion
- facial pain, pressure, fullness
- dysnosmia or anosmia
AND 1+ doccumentation of
- purulent mucus or edema in middle meatus or ethmoid region
- polyps
- CT image showing inflammation of paranasal sinuses

Question 21

CRS tx

Answer 21

ENT consultation
tx inflammation and infection
- long term antibiotics, topic or oral glucocorticoids, nasal saline lavage
- surgery if indicated