Rhinitis and Rhinosinusitis Dr. Burchette EXAM I

Question 1

Typical patient presentation of Allergic Rhinitis

Answer 1

-Watery nose
-sneezing
-itching

Question 2

Which immunoglobulin is most likely to be involved in allergic responses?

Answer 2

-IgE
-causes Histamine release

Question 3

What does “atopic” mean?

Answer 3

-predisposition (more likely) to have an allergic response to something - when a first-degree relative has allergic tendencies

Question 4

Which respiratory condition can be triggered by allergic responses?

Answer 4

-asthma, eczema (dermatitis, inflammation of the skin)
-people with tendencies to allergic reactions may be more likely to have asthma

Question 5

Other medical conditions that are associated with Allergic Rhinitis?

Answer 5

-asthma
-chronic sinusitis
-nasal polyps
-otitis media

Question 6

Physical findings indicating allergic rhinitis

Answer 6

-The “allergic salute”: wiping away the discharge due to runny nose
-allergic crease: line on the nose from lifting the nose
-allergic shiners: dark rings around the eyes

Question 7

Clinical patient presentation of Allergic Rhinitis

Answer 7

-Watery nose: clear discharge
-sneezing
-Itchy eyes, ears, nose, soft palate
-Nasal congestion
-Postnasal drip
-Mouth breathing, especially at night

Question 8

First-line pharmacotherapy for Allergic Rhinitis

Answer 8

-Oral antihistamines - PREFERRED

-Intranasal antihistamines - not preferred bc of taste and dripping into the throat

Question 9

What are the symptoms that are appropriate to treat with Antihistamines?

!!!!

Answer 9

-sneezing, itching, and watery nose

-caused by Histamines

Question 10

Antihistamines are good for prevention and not as effective once the action has occurred
T or F

Answer 10

True

Question 11

What are the anticholinergic side effects of Antihistamines?

Answer 11

Drying effects: dry the runny nose
-dry mouth
-dry nose -> nose bleeding
-urinary retention
-eyes dry, pupils dilated
-constipation
-tachycardia, increased BP (caution older patients)
-stimulates appetite

Question 12

Which agents are most likely to have Anticholinergic side effects?

Answer 12

-(also common with Intranasal steroids: Flonase)
Ethanolamines:
Clemastine
Diphenhydramine

-Promethazine

-they also have sedative side effects

Question 13

Which ‘nasal’ Antihistamine has low sedative and low anticholinergic side effects?

Answer 13

Azelastine
(nasal is less preferred)

Question 14

Which Antihistamines are associated with low sedative and anticholinergic side effects?

Answer 14

-Azelastine (nasal)
-Cetirizine (Levo) (Zyrtec)* associated with drowsiness
-Loratadine (Claritine)
-Desloratadine (Clarinex)
-Fexofenadine (Allegra)

Question 15

What are the directions for Antihistamines?

Answer 15

-Avoid with other CNS depressants, like alcohol
-take with a glass of water, and food (helps with N/V)
-Caution with other OTC preps that may have antihistamines
included
-Most effective if taken 1 – 2 hours prior to allergen exposure

Question 16

Patients may take Antihistamines every day, which is fine.
T or F

Answer 16

True

Question 17

How do Decongestants work?

Answer 17

-Vasoconstriction of blood vessels in the nasal cavity to reduce the swelling
-works best with antihistamines when decongestion is present

-Long-term use causes rebound vasodilation

Question 18

Side effects for topical Decongestants

Answer 18

-Topical AEs include burning, stinging, sneezing and dryness

-rebound congestion

Question 19

Side effects for oral (systemic) Decongestants

Answer 19

-HTN, cardiovascular diseases
-Caution with those at risk for strokes

Question 20

What are common Decongestant agents?

Answer 20

-oxymetazoline (Afrin) !! - higher risk for rebound congestion
-phenylephrine
-naphazoline

Question 21

What is the maximum duration for topical decongestion?

Answer 21

3-5 days
-less is better
-caution for oxymetazoline (Afrin)

Question 22

What to look out for in Combo products?

Answer 22

-ask patients if they take combi products
-they contain acetaminophen, phenylephrine, antihistamine

-overmedication of decongestants (they should be taken for short-term treatment)

Question 23

What is Intranasal steroids appropriate for?

Answer 23

Allergic rhinitis
-best for yearly allergies
-MOA: change gene transcription in immune cells

Question 24

Side effects of Intranasal steroids

Answer 24

-sneezing
-burning
-stinging
-headache
-nosebleeds

Question 25

What to counsel on patients who might need fast relief

Answer 25

-it gets better after 1-2 days
-may take weeks to get full effect (2 – 3 weeks) -> works on the transcriptional level
-take it constantly - it takes time to see the full effect

-consider antihistamines instead

Question 26

Counseling points

Answer 26

-May take weeks to get full effect (2 – 3 weeks)
-Avoid blowing nose or sneezing for 10 min post admin
-Avoid with nasal ulcers or nasal trauma
-Clear blocked nasal passages prior to admin to ensure adequate penetration into the nasal mucosa

Question 27

EXAM QUESTION
How to take Flonase

Question 28

When are Leukotrienes appropriate?

Answer 28

-not appropriate for allergic rhinitis alone
-only with concomitant asthma!

-patients with allergies and asthma may take leukotriene agents (leukotriene antagonists) to help with asthma attacks triggered by allergens

-Example: Montelukast (Singulair)

Question 29

What is Rhinosinusitis?

Answer 29

-Infected and inflamed membranes of the sinuses
-need antibiotics
-often secondary to a VIRAL rhinosinusitis (feeling worse than before - double sickening)

Question 30

What are signs that point to bacterial versus viral infection?

Answer 30

-Persistent symptoms for 10 or more days without
signs of improvement
-Onset with severe symptoms (high fever, purulent nasal discharge, or facial pain) for 3-4 consecutive days

-double-sickening: feeling better, than worse than before -> the virus caused inflammation -> warm environment for bacteria to grow

Question 31

What are the most common bacterial pathogens associated with Rhinosinusitis?

Answer 31

-Strep. pneumoniae
-Haemophilus influenzae
-Moraxella catarrhalis

Question 32

Signs and Symptoms

Answer 32

-purulent discharge
-Nasal congestion or obstruction
-Facial pain or pressure, dental pain
-Fever, fatigue
-Headache
-Ear pain/pressure/fullness
-Cough

Question 33

First-line treatment for Rhinosinusitis

Answer 33

Amox/Clav (Augmentin)
-children or adults

Question 34

Why might Augmentin be a good choice to treat Rhinosinusitis?

Answer 34

-the target pathogens are Strep. pneumo. H. flu, M. cat

-Amoxicillin covers Strep. pneumo
(Strep -> ß-lactam)

-Clavulanic acid covers H. flu and M. cat which produces a ß-lactamase

Question 35

How to treat Rhinosinusitis in case of Beta-lactam allergy

Answer 35

-Adults: Doxycycline and resp. Quinolone (Levofloxacin, Moxifloxacin) -> not for children (tendon rupture, impairs growth)

-Children: Clinda + Cephalosporin (3rd GEN: Omnicef (Cefdinir)

Question 36

What to think about when treating children with Clindamycin liquid?

Answer 36

Very bad taste

Question 37

What is the duration of treatment for Rhinosinusitis?

Answer 37

Adults: 5-7 days

Children: 10-14 days (we don’t have evidence for kids that shorter treatment works=

Question 38

Why are antihistamines and decongestants avoided in Rhinosinusitis?

Answer 38

-It dries up the infected material in the nasal cavity
-it causes it to get stuck in the sinuses
-consider nasal saline, blowing out the infected material in the nose