Rhinitis and sinusitis Flashcards
What symptoms characterize allergic rhinitis?
Sneezing, itchy nose, watery eyes, pale or violaceous nasal turbinates, and nasal polyps.
How is allergic rhinitis typically diagnosed?
Clinically, based on recurrent episodes of characteristic symptoms, though skin or blood testing may confirm allergen-specific IgE levels.
What is a significant finding on nasal smear in allergic rhinitis?
Increased eosinophils.
What environmental modifications help control allergic rhinitis?
Avoiding exposure to known allergens:
Close windows and use AC to avoid pollen.
Allergen-proof mattress and pillow covers.
Get rid of pets that cause alleric rxn.
Use of air purifiers.
What is the treatment of choice for allergic rhinitis?
Intranasal corticosteroid sprays
Antihistamines: loratadine, clemastine, fexofenadine, brompheniramine
Intranasal anticholinergic medications: ipratropium
In terms of managing allergic rhinitis, if an allergen can’t be avoided, what is the best treatment approach?
Desensitization to allergens that cannot be avoided
A runny nose that occurs with food, temperature change, or sudden bright light, is called?
Vasomotor rhinitis
Both _______ and vasomotor rhinitis can mimic allergic rhinitis
nonallergic rhinitis
Both Vasomotor rhinitis and nonallergic rhinitis are treated with Intranasal steroid sprays
What is the probably issue when a patient presents with inflammation, mucosal swelling, and increased mucus production, low-grade fever, facial discomfort, and purulent nasal drainage?
Acute viral rhinosinusitis
Treatment is symptomatic, with antipyretics, hydration, analgesics, and decongestants recommended, as needed. Spontaneous resolution occurs in 7–10 days.
Symptoms of rhinosinusitis (inflammation, mucosal swelling, and increased mucus production, low-grade fever, facial discomfort, and purulent nasal drainage) lasting beyond 7–10 days, or worsening after 5 days, suggest …. ?
Acute (Bacterial) Rhinosinusitis
Patients may exhibit several of the major symptoms (facial pressure/ pain, facial congestion/fullness, purulent nasal discharge, nasal obstruction, anosmia) and one or more of the minor symptoms (headache, fever, fatigue, cough, toothache, halitosis, ear fullness/pressure).
The organisms responsible are similar to the organisms that cause acute otitis media and include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
At what point in time does a patient have Chronic sinusitis?
symptoms that persist more than three months
Usually has a different underlying microbiology with increased numbers of anaerobic organisms.
At what point in time does a patient have Subacute sinusitis?
symptoms that last more than one month but less than three months
What is the treatment for sinusitis?
10-day course of either amoxicillin or trimethoprim/sulfamethoxazole.
Resistance to amoxicillin has prompted some physicians to consider using amoxicillin/clavulanate or a second-generation cephalosporin or macrolide or a quinolone instead of amoxicillin as the
first-line therapy. More recently, the appearance of penicillin resistance in S. pneumoniae infection (which has a different resistance mechanism than beta-lactamase production) has resulted in the recommendation that higher doses of amoxicillin be used routinely.
Adjunctive measures may include topical decongestants (oxymetazoline) for three days, mucolytics (guaifenisen), and oral decongestants. Severe or recurrent cases may require systemic steroids.
sinusitis should be referred to an otolaryngologist if
three to four infections per year
an infection that does not respond to two three-week courses of antibiotics
nasal polyps on exam
or any complications of sinusitis.
What is a major complication of Frontal Sinusitis
Meningitis and Brain Abscesses
This is due to the penetration of organisms or the propagation of an infected clot into the posterior sinus that leads directly into the dura from the frontal sinus lining.
How is Meningitis or Brain Abscesses treated when a patient also has acute frontal sinusitis with an air-fluid levels?
Pain is severe, and patients usually require hospital admission for treatment and close observation.
Aggressive antibiotic therapy to cover S. pneumoniae and H. influenzae, as well as get good cerebrospinal fluid penetration.
Topical vasoconstriction to shrink the swollen mucosa around the nasofrontal duct and restore natural drainage into the nose should begin in the clinic and continue throughout the hospital stay.
Systemic steroids may also be considered to decrease swelling. If frontal sinusitis does not greatly improved within 24 hours, the frontal sinus should be surgically drained to prevent serious intracranial infections.
What is a major complication of ethmoid sinusitis?
Orbital cellulitis or abscesses
These patients present with eyelid swelling, proptosis, and double vision.
How is ethmoid sinusitis treated?
A CT scan will generally show the presence (or absence) of an abscess, which is always accompanied by ethmoid sinusitis. If an abscess is present, it will require surgical drainage as soon as possible, so the patient should be referred to an otolaryngologist.
If the condition is severe ethmoid sinusitis without abscess, it may be treated with intravenous antibiotics and nasal flushes with decongestant nose drops. Severe ethmoid sinusitis will often resolve with nonoperative therapy, but if the patient’s condition worsens, then surgery is indicated
What is a major complication of sphenoid sinusitis?
Sphenoid sinusitis can cause ophthalmoplegia, meningitis, and even cavernous sinus thrombosis.
Cavernous sinus thrombosis is a complication with even more grave implications than meningitis or brain abscess, and it carries a mortality of approximately 50 percent. The veins of the face that drain the sinuses do not have valves, and they may drain posteriorly into the cavernous sinus.
Infectious venous thrombophlebitis can spread into the cavernous sinus from a source on the face or in the sinus. The most common cause of this serious infection is rhinosinusitis. The nerves that run through the cavernous sinus are the oculomotor (III), trochlear (IV), and first and second divisions of the trigeminal (V) and the abducens (VI). A patient who has double vision and rhinosinusitis should be assumed to have cavernous sinus thrombosis until it is ruled out by a CT and/or MRI scan.
How is sphenoid sinusitis treated?
The preferred treatment is high-dose intravenous antibiotics and surgical drainage of the paranasal sinuses. Anticoagulation is also a consideration in the treatment regimen.
What is the likely issue when a patient has a runny nose and a preponderance of eosinophils?
Allergic fungal sinusitis
Although fungal elements are commonly found in the nasal cavity of normal patients, some patients develop a sensitivity or immunoreactivity to fungi. This allergic disorder to fungi can result in severe symptoms of chronic sinusitis and significant inflammation in the sinonasal mucosa.
How is Allergic fungal sinusitis treated?
Effective treatment requires surgery to remove the offending fungal mucin. Fungal spores can also get trapped in a sinus, where they germinate and fill the sinus with debris, forming a “fungal ball” or mycetoma. Typically, mycetomas do not cause a significant inflammatory response, and they are easily cured by surgical removal. If a patient is immunocompromised or has diabetes, certain fungal infections (e.g., mucormycosis) can become “invasive,” resulting in destruction of the sinus with erosion into the orbit or brain. These invasive fungal infections constitute an ENT emergency, since they are life threatening and can advance quite rapidly.
What condition develops with repeated use of nasal decongestants that can manifest with nasal blockage?
Rhinitis medicamentosa is a relatively frequent cause of nasal blockage when people repeatedly use decongestant nasal sprays over a long period. This is due to the rebound effect. Cocaine abuse can also cause this problem. Cocaine may also induce ischemic necrosis in the nasal septum because of the amount of vasoconstriction. The ischemia then may result in a nasal septal perforation, which interferes with nasal airflow and is very difficult to repair surgically.
The treatment is discontinuation of the decongestant sprays. Symptoms can be reduced by intranasal steroid spray, occasionally accompanied by short bursts of systemic steroids.
What is the likely issue with a patient who may have a very straight septum with no nasal polyposis or inflammation, but still suffers from chronic rhinosinusitis due to blockage of sinus drainage?
This may be due to the anatomy of the patient, where the uncinate process comes very close to the ethmoid bulla, forming the infundibulum through which the maxillary sinus drains.
Only one mm of swelling in the mucosa in this area will obstruct the sinus ostium. Patients with chronic obstruction in this area and recurrent sinusitis often undergo surgery to either dilate the osteomeatal complex with a balloon, or remove the uncinate process and open the bulla to let the ethmoid and maxillary sinuses drain more freely.
After the surgery, a small amount of swelling will not obstruct the drainage flow from these sinuses. This procedure is done completely through the nose endoscopically, and patients tolerate it very well.
What is the likely issue when a patient has symptoms of nasal congestion, clear rhinorrhea, itchy watery eyes, and sometimes ear or palatal itching, post-nasal drip, and throat irritation?
Allergies
Fatigue is also a common, caused by sleep disturbance from nasal obstruction, perhaps with other immune contributors. Symptoms may occur only in certain seasons or locations.
Allergic symptoms are initiated by inhalation of dander, pollen, mold spores, or other antigens. Typically, trees pollinate and cause symptoms in the spring, grasses pollinate in the summer, and weeds, such as ragweed, pollinate in the fall. Allergens, such as house dust mites, cockroaches, animal dander, and molds, can cause symptoms year-round. Allergies represent an abnormal immune response to an environmental protein tolerated by the majority of people.
At least 20 percent of the U.S. population has the genetic capacity to produce excess immunoglobulin E (IgE), the immunoglobulin that mediates allergic symptoms. Having inhalant allergy symptoms requires an initial contact with that specific allergen, which results in development of the allergen-specific IgE.
Does allergies have a genetic component?
If one parent has inhalant allergies, a child has about a 30 percent chance of developing allergies. If both parents have allergies, this increases to about 60 percent.
What are the three mainstays of treating inhalant allergies?
Pharm, avoidance, immunotherapy
What is the mechanism for developing allergies?
Gell & Coombs Type I hypersensitivity, the allergen-IgE populates the outside of mast cells in tissues. On recontact, the allergen binds to this allergen-specific IgE on the mast cell, triggering release from the mast cell of preformed allergic mediators (histamine, proteoglycans, proteases), causing immediate symptoms, and initiating the production of further allergic mediators (leukotrienes and prostaglandins) responsible for the late-phase allergic response (3–12 hours later).
The percentage of the population with allergy problems has been increasing in developed countries. One possible explanation for this is that the infectious diseases more common in less developed countries help tilt an individual’s immune system more toward the T-helper 1 (Th1) system, minimizing the chance of developing the Th2-mediated atopic reaction, and the resulting allergic symptoms.
Which patients should get an allergy test?
Those with allergies and/or an increased level of IgE.
In vitro studies for : Pregnant, poorly controlled asthma, dermatographism, Beta-blockers, TCAs, MOAIs, Hx of anaphylaxis.
Antihistamine medications (oral or nasal) must be discontinued three to five days before testing to avoid false negative results. Antileukotrienes, nasal steroid sprays and oral and topical decongestants may be continued without interfering with allergy skin testing. Patients need to stop taking BBs, TCAs, and MOAIs before testing.
Testing can cause anaphylaxis.
What is a concha bullosa?
An air cell within the middle turbinate
What is the osteomeatal complex (OMC)?
The OMC is the region through which the maxillary, ethmoid, and frontal sinuses drain in the nose. An obstruction of the OMC will frequently lead to sinusitis, and is often due to mucosal edema or anatomic abnormalities.
What is the significance of the agger nasi cell?
The anterior-most ethmoid sinus—the agger nasi cell—is frequently clouded. Edema in this sinus may be associated with obstruction of the nasal frontal duct and results in frontal sinusitis.
This region is best visualized on a sagittal CT scan
