Paranasal Sinus

Question 1

Pathophysiology

Answer 1

-Normal function depends on patent ostia, ciliary function, & quality of mucous
-Obstruction of natural ostia -> hypo-oxygenation -> ciliary dysfunction and poor mucous quality -> retention of secretions
-Local factors can impair ciliary function
-Cold air “stuns” the epithelium -> retained secretions
-Dry air desiccates the blanket
-Anatomical factors- polyps, tumors, foreign bodies and rhinitis, block the ostia
-Kartagener’s Syndrome (immotile cilia syndrome)

Question 2

Kartagener’s Syndrome (immotile cilia syndrome)

Answer 2

-Situs inversus- rare disease when organs on the right side are on left (vice versa)
-chronic sinusitis
-bronchiectasis- destroyed architecture of bronchi - widened and tram like + mucus
-defect in the formation of cilia -> particles will get past and infect
-Autosomal recessive pattern
-result from defective cilia motility
-Immotile cilia and immotile spermatozoa

Question 3

upper respiratory infection (URI)

Answer 3

-Common Cold, acute infective rhinitis,acute rhinopharyngitis/nasopharyngitis,acute coryza, andacute nasal catarrh
-Nasal congestion, clear rhinorrhea, and hyposmia
-malaise, headache, and cough
-Erythematous- engorged nasal mucosa without intranasal purulence (differs from allergic rhinitis)
-self-limited (goes away without treatment)
- < 4 weeks and typically < 10 days
-Numerous serologic types of rhinoviruses, adenoviruses, and other viruses -> this is why you catch it frequently
-can develop into viral sinus infection

Question 4

3 types of rhinosinusitis

Answer 4

-1. acute rhinosinusitis (ARS)- acute viral rhinosinusitis & acute bacterial rhinosinusitis (ABRS)
-2. subacute rhinosinusitis- 4-12 weeks
-3. chronic rhinosinusitis (CRS)
-classified by length of time

Question 5

classification of sinus infection

Answer 5

-symptomatic inflammation of paranasal sinuses and nasal cavity
-divided into Acute rhinosinusitis (ARS) & Chronic rhinosinusitis (CRS).
-ARS- < 4 weeks
-CRS- > 12 weeks, with or without acute exacerbations
-ARS -> acute bacterial rhinosinusitis (ABRS) or viral rhinosinusitis (VRS)
-Treatment depends on classification
-Recurrent-ARS - 4+ annual episodes of rhinosinusitis, without symptoms between.
-Uncomplicated rhinosinusitis- no extension of inflammation outside the paranasal sinuses and nasal cavity at time of dx -> no neurologic, ophthalmologic, or soft tissue involvement -> dont necessarily need antibiotics

Question 6

VRS and ARBS diagnosis

Answer 6

-primarily clinical- use duration and pattern
-radiographs- used rarely- must be a complication
-transillumination- not reliable

Question 7

acute viral rhinosinusitis (VRS)

Answer 7

-numerous serologic types of rhinoviruses, adenoviruses, and other
-recurrent
-3-4 weeks
-subacute- 4-12 weeks (not a separate entity)
-benign and self limited
-high loss of productivity, cost, overuse of antibiotics
-predisposing factors- URTI, allergic rhinitis, nasal polyps, immunodeficiency, environmental factors (smog, smoking)
-when acute viral rhinosinusitis is longer than 10 days or double worsening you suspect acute bacterial rhinosinusitis

Question 8

VRS symptoms and signs

Answer 8

-nasal congestion
-initial watery discharge
-AVR- must have purulent discharge
-hyposmia
-associated symptoms- cough, postnasal drip, toothache, headache, facial pressure pain, sneezing, irritated throat, general malaise
-tenderness over sinus cavities
-increased posterior pharyngeal secretions
-purulent (Infected, colored, oozing) secretions (middle meatal region)
-reddened, edematous mucosa
-dark circles beneath eyes
-absence of transillumination

Question 9

VRS differential diagnosis

Answer 9

-acute bacterial rhinosinusitis (ARBS)
-COVID-19
-URTI
-nasal polyposis
-orbital cellulitis
-headache differentials
-wegener’s granulomatosis
-immotile cilia syndrome
-neoplasms- rare

Question 10

management of acute viral rhinosinusitis

Answer 10

-generally self-limited process
-Supportive; symptom relief
-NSAIDs; Acetaminophen
-Mechanical irrigation
-Intranasal corticosteroids; decongestants -> max 3 days
-? Antihistamines - efficacy
-? Mucolytics – thin secretions
-? high dose Zinc lozenges

Question 11

COVID-19 and URI

Answer 11

-Predominantly lower respiratory
-Viral prodromal S&S
-Fever, nasal inflammation, rhinorrhea, cough, myalgias, fatigue
-*Hyposmia and anosmia - ? Pathognomonic
-If suspicious –> test immediately
-Can be transient or permanent

Question 12

Complications of AVR

Answer 12

-Acute bacterial rhinosinusitis
-Chronic rhinosinusitis
-Eustachian tube dysfunction
-Middle ear effusion
-Precursor to more serious conditions:
-S pneumoniae, other streptococci, H influenzae, S aureus, and Moraxella catarrhalis
-Acute otitis media, asthma, and cystic fibrosis exacerbation, and bronchitis

Question 13

complication of treatment AVR

Answer 13

-Rhinitis medicamentosa
-cannot use more than 3 days
-decongestants-> oxymetazoline or phenylephrine - rapidly effective BUT!!!
-> Chronic use of vasoconstrictor nasal sprays or intranasal cocaine abuse -> Beefy red nasal membranes
-Management:
-Stop offending drug
-Severe nasal congestion
-Topical intranasal corticosteroids
-Oral prednisone (5 days)

Question 14

presentation of AVR in children vs adult

Answer 14

-children -> increased irritability and vomiting as result of gagging on mucus and prolonged cough
-Both adults & children- less frequent symptoms include fever, nausea, malaise, fatigue, halitosis, and sore throat (fever is more common in children than in adults)

Question 14

acute bacterial rhinosinusitis (ABRS)

Answer 14

-DIAGNOSE WHEN:
-symptoms or signs of acute rhinosinusitis (AVR) are present 10 days or more beyond the onset of URS
OR
-symptoms or signs of acute rhinosinusitis (AVR) worsen within 10 days after initial improvement (double worsening)
-additional symptoms/signs: fever, cough, fatigue, malaise, reduced sense of smell (Hyposomnia), lack of smell (anosmia), maxillary dental pain, ear fullness or pressure

Question 15

acute bacterial etiology

Answer 15

-streptococcus pneumoniae
-haemophilus influenzae
-moraxella catarrhalis

Question 16

chronic sinusitis etiology

Answer 16

-pseudeomonas aeruginosa
-group A streptococcus
-staphylococcus aureus
-anaerobes: bacteriodes spp. and fusobacterium spp.
-more serious pathogens

Question 17

management of ABRS

Answer 17

-symptom relief
-drainage with topical decongestants and sometimes antihistamines
-watchful waiting
-observation without use of antibiotics is an option for adults with uncomplicated ABRS with mild illness (mild pain, temperature < 101 and assurance of follow up)

Question 18

ABRS treatment

Answer 18

-1st episode- no recent antibiotic use
-symptoms relief- saline irrigation, pseudoephedrine (sudafed), guafenesin (Tussin, muscinex), oxymetazoline (afrin), fluticasone
-cornerstone - drainage and antibiotics -> especially pts with recurrent or chronic attacks
-choice of antibiotic depends on suspected pathogen and antimicrobial susceptibility of the pathogen, cost of drug, side effects
-first line, second line
-may need to be extend to 12 weeks of use

Question 19

first line antibiotics

Answer 19

• amoxicillin+Clavulanate (Augmentin)
  -500 mg/125 mg orally 3x daily OR
  -875 mg/125 mg orally 2x daily for 5–7 days*
  -Higher risks:
  -High dose Amoxicillin/Clavulanate- 2000 mg/125 mg extended-release orally 2x daily for 7–10 days
  -PCN allergy – clindamycin

Question 20

second line antibiotics

Answer 20

-Clindamycin Or Trimethoprim and sulfamethaxazole
-Or Levofloxacin Or Azithromycin
-Dupilumab- monoclonal antibody
-no improvement after 5-7 days -> appropriate, broad-spectrum, potent antibiotic
-no response within 3-4 weeks -> metronidazole or clindamycin may be added -> gives anaerobic coverage
-Hospital patients

Question 21

surgical drainage: other treatment

Answer 21

-maxillary - Antral lavage, inferior or middle meatal windows- cannula inserted into maxillary sinus for drainage and irrigation
-Frontal sinuses - trephination, and a drain is left in place and irrigated
-Ethmoidectomy- removes infected tissue and bone in the ethmoid sinuses that blocks natural drainage

Question 22

chronic sinusitis

Answer 22

-Acute sinusitis- often imposed on chronic disease
-Note any facial edema, tenderness, mucosal edema, septal perforations and deviations
- > 12 weeks with abnormal findings on Nasal Endoscopy, CT or MRI
-Mucopurulent discharge
-Fever -usually not present

Question 23

investigations

Answer 23

-Paranasal sinus biopsy / Nasal Endoscopy
-Sweat Chloride test
-Ciliary function studies
-tests for immunodeficiency

Question 24

paranasal sinus biopsy/nasal endoscopy

Answer 24

-detects underlying allergic rhinitis, nonallergic rhinitis with eosinophilia syndrome, nasal polyposis -diagnoses chronic sinusitis -R/O if a lesion is neoplastic -confirms presence of suspected fungal disease -assesses the possibility of granulomatous disease

Question 25

imaging investigation

Answer 25

-Plain films are generally obsolete; limited value -Exceptions : confirmation of air fluid levels in acute sinusitis; evaluating size and integrity of sinuses -CT- for recurrent/chronic sinusitis or if diagnosis is uncertain -MRI- For fungal sinusitis and tumors

Question 26

referral

Answer 26

-otolaryngologist -Failure of acute bacterial rhinosinusitis to resolve after antibiotics -suspected extension of disease outside the sinuses -> urgent -> orbital cellulitis, cranial nerve involvement, or central nervous system involvement -for Imaging and testing: -Endoscopic cultures may direct further treatment choices. -Nasal endoscopy and CT scan- when symptoms > 4–12 weeks -unusual opportunistic infections -Suspected structural abnormalities with recurrent sinusitis -Suspected underlying allergic or immunologic response -things that complicate assessment -> asthma, nasal polyps, immunodeficiency Otitis media, asthma, or fungal sinusitis

Question 27

when to admit

Answer 27

-Facial swelling and erythema indicative of facial cellulitis. -Proptosis- orbital cellulitis especially posterior - eyes are being pushed out -Vision change or gaze abnormality indicative of orbital cellulitis. -Abscess or cavernous sinus involvement. -Mental status changes suggestive of intracranial extension. -Immunocompromised status. -Failure to respond to appropriate first-line treatment for acute bacterial rhinosinusitis -symptoms > 4 weeks

Question 28

complications: orbital involvement

Answer 28

-Orbit separated from ethmoids by thin lamina papyracea -First indication - inflammatory edema of eyelids -> progresses to cellulitis, proptosis, chemosis (collection of fluid in the eye) and ophthalmoplegia (paralysis of eye) -Osteomyelitis - infection spread to the bone- Seen in frontal sinusitis bc floor of the sinus is thin-> Pott’s puffy tumor -Treatment: IV antibiotics with or without sinus drainage -Abscesses -> surgical drainage and IV antibiotics -Indications: progressive orbital cellulitis, symptoms which do not resolve, abscess, loss of visual acuity

Question 29

pre septal orbital cellulitis

Answer 29

-Lid edema and redness -spreading into the eye -Tenderness -Absence of proptosis -Absence of extraocular muscle restriction -Absence of fever

Question 30

post septal cellulitis

Answer 30

-becomes emergency when its post -Results from infection traversing the orbital septum -Requires emergency immediate hospitalization -Urgent ophthalmologic examination -Treatment with IV antibiotic therapy -May require surgery

Question 31

nasal polyps

Answer 31

-often associated with allergic rhinitis -samter's triad- asthma, nasal polyps, acute hypersensitivity reactions to aspirin NSAIDs)

Question 32

fungal sinusitis

Answer 32

-uncommon -aspergillosis most common- high index of suspicion -> farmers -dx by biopsy and culture -soil, fruits, vegetables, grains, birds, mammals -suspect if dark, greasy material seen

Question 33

HIV and AIDS

Answer 33

-incididence of sinusitis ranges from 30-68% -sinusitis is common in aids -direct association between CD4+ T cell deficiency and sinusitis may exist

Question 34

cystic fibrosis (CF) and sinusitis

Answer 34

-chronic sinusitis- significant cause of morbidity -common pathogens- pseudomonas aeruginosa, E coli, S aureus -nasal polyps

Question 35

mucormycoses

Answer 35

-dust and soil -enters through respiratory tract -invades vascular channels -causes hemorrhagic ischemia and necrosis -fungal -frequently fatal -90% mortality in immuno-compromised -diabetes complication- ketoacidosis predisposes to mucormycoses -> thrives in acidic environment -engorgement of turbinate's -> followed by ischemia and necrosis of the turbinate's and adjacent nose -loss of vision -treated with: -radical surgical debridement (drainage) -amphotericin B -correction of underlying immunosuppression

Question 36

cavernous sinus thrombosis complications

Answer 36

-High mortality rate -cavernous sinus infection -Usually from retrograde transmission through valveless veins leading to the cavernous sinus -Heralded by bilateral orbital involvement -progressive chemosis- Temp: 105F -Treat with drainage, IV antibiotics -Heparin is controversial

Question 37

intracranial sinus infection complications

Answer 37

-subdural abscess, intracranial abscess, meningitis -meningitis is common in children -1/3 to 2/3 of all subdural abscesses believed due to sinusitis -nuchal rigidity is first symptom -neurosurgery consult to manage ICP -> surgical drainage

Question 38

antibiotics

Answer 38

-dont want to use antibiotics if they had just taken some -especially the same antibiotic

Question 39

QUIZ QUESTION: Normal vitals, college student, symptoms for 13 days, rhinitis, facial pain, bilateral congestion, moderate maxillary tenderness

Answer 39

-bacterial sinusitis -facial pain and maxillary tenderness -> 13 days