Rhinitis/CRS Flashcards
Environmental changes that have contributed to pollen allergy?
- Increased PM.2.5 increases asthma exacerbations and lung injury
- longer summers lead to longer pollination of oak and hickory.
- longer periods of warmth increase fungal pollination
- Increase in humidity may increase asthma exacerbations
- increase in CO2 leads to longer pollination seasons
Which dust mite is seen in tropical countries?
Blomia tropicalis
What are the dust mite allergens?
Cysteine proteases: Der p 1 and Der f 1
Serine proteases: Der p 3, 6, 9
What is the % of cross reaction between dust mite and crustacean?
5-15%
What is the cross reactive component in dust mite?
Tropomyosin (Der p 10)
What is the most important factor needed for dust mite growth?
humidity.
mites requite RH higher than 65% to prevent water loss and to thrive. Once humidity is <50% mite proliferation decreased and survival is decreased.
Dust mite belongs to which Taxonomic category?
Arachnids that below to taxonomic order called Acari
Allergen in dust mite - cysteine proteinases
Der f 1, der p 1
Allergen in dust mite - Lipid binding proteins
Der f 2, Der p 2
Dust mite allergen which is peritrophin (chitin binding)
Der p 23
dust mite allergen which cross reacts with shrimp and cockroach
Der f 10, Der p 10
Tropomyosins
Major cat allergen
Fel d 1
Minor cat allergens
Fel d 2 (albumin) , Fel d 3 (cystatin) and Fel d 4 (lipocalin)
Major dog allergen
Can f 1
Lipocalin cysteine protease inhibitor
found in hair, dander and saliva
Minor dog allergens
Can f 2 (lipocalin), Can f 3 (albumin), Can f 4 (dog dander)
Where is mouse allergen found?
In mouse urine - MUP - mouse urine protein
Mus m 1 - pre albumin
Cockroach allergen
Bla g 1 and Bla g 2
What is chitin
2nd most abundant polysaccharide in the world.
Present in insects, crustaceans, parasites and fungi
Define ABRS (Canadian Guidelines)
ABRS requires the presence of
- nasal obstruction or purulence/drainage AND
- 2 of PODS
- pain
- obstruction
- discharge
- anosmia - Timing: > 7 days, <4 weeks
Define recurrent ABRS
4+ episodes of ABRS a year
Gold standard for diagnosis of ABRS
sinus aspirates, however not recommended in a clinical setting bc invasive
CDC diagnostic criteria for ABRS
- Symptoms lasting at least 7 days ANS
- purulent nasal secretions AND
- 1 of the following
- maxillary pain
- tenderness in the face (esp. unilateral)
- tenderness of the teeth (esp. unilateral)
ABRS diagnosis requires the presence of at least 2 major symptoms:
P - pain (facial) O - nasal Obstruction D - nasal Discharge S - Hyposmia/anosmia (smell) one of which must be O or D, and symptom duration of > 7 days without improvement
Red flags for urgent referral in ABRS
- Alt. mental status
- HA
- Systemic toxicity
- swelling of the orbit, or changes in visual acuity
- neurological findings
- Intracranial complications
- meningitis
- intracranial abscesses
- CV thrombosis - Involvement of associated structures
- periorbital cellulitis
- pots puffy tumour
First line antibiotics in ABRS
Amoxicillin
for beta lactam allergic ppl: TMP/SMX
2nd line: Flouroquinolones or amoxi-clav
Berg prediction rule for CRS based on signs and symptoms
- Purulent rhinorrhea with unilateral predominance - 50% PPV
- Local pain with unilateral predominance - 41% PPV
- Pus in nasal cavity - 17% PPV
- Bilateral purulent rhinorrhea - 15% PPV
William prediction rule based on signs and symptoms of ABRS
- Maxillary toothache LR 2.5
- Poor response to AH/ decongestants LR 2.1
- Purulent nasal secretions LR 2.1
- Abnormal transillumination LR 1.6
- Coloured nasal discharge LR 1.5
Presence of >/= 4 symptoms has a positive LR of 6.4
What are the 2 main causative infective bacteria implemented in ABRS (AAAAI)
What are the main bugs in CRS
- Strep pneumonia
- H. influenza
Other - M. catarrhalis, s. aureus, gram neg bacilli, and oral anerobes
CRS
1. S.aureus, enterobacter, pseudomonas
Adjunct therapy for ABRS
- Topical INCS
- Analgesics
- Oral decongestants
- Topical decongestants
- Saline irrigation
Diagnosis of CRS
2 or more major symptoms are present for at least 8- 12 weeks along with documented inflammation of the paranasal sinuses or nasal mucosa
(classified as CRSwNP or CRSsNP)
(ie. 1 objective finding on CT or endoscopy)
CRSsNP diagnosis requires the presence of what?
- At least 2 symptoms (CPODS) and
- Inflammation documented by endoscopy
- Absence of NPs in the middle meatus (by endoscopy) and/or demonstration of purulence originating from the osteomeatal complex on endoscopy or rhinosinusitis confirmed by CT imaging
Diagnosis of CRSwNP requires:
- At least 2 symptoms (CPODS) and
- The presence of bilateral polyps in the middle meatus confirmed by endoscopy and
- Bilateral mucosal disease confirmed by CT imaging
origins and contributors to CRS
CRS is an inflammatory disease of unclear origin, contributors includes:
- bacterial colonization
- bacterial biofilms
- eosinophilic, neutrophilic, and lymphocytic infiltrations
- Upregulation of numerous th2 assoc. cytokines
- tissue remodeling
- atopy determines allergic versus non allergic classification
CRS bacteria are different from ABRS
- s. aureus
- enterobacter spp.
- pseudomonas spp.
Less common
- s. pneumoniae
- h. influenza
- b hemolytic step
- CONs
Prevention of acute exacerbations in CRS
as per CSACI
- Avoid predisposing allergic triggering factors
- Use proper hand hygiene
- Avoid smoking
- Perform saline nasal irrigation
Indications for sinus surgery
- restoration of sinus ventilation
- Debulking of severe polyposis
- Failure of intensive medical therapy
- Bony erosion or extension of disease beyond the sinus cavities
What is functional endoscopic sinus surgery?
FESS
- telescopes with a variety of viewing angles illuminates the inside of the nose and sinus
- helps with identifying and restoring proper drainage and ventilation of the nose
- 98% of patients at 18 months reported improvement in symptoms
What is balloon ostial dilation (BOD)?
- the frontal, sphenoid or maxillary sinus ostium is dilated or ethmoid cells are pushed aside using a balloon catheter
- efficacy compared to FESS is unclear
Adenoidectomy for CRS?
suggested in young children with CRS and adenoid hypertrophy
but high level evidence is lacking
endorsed by 2014 consensus statement on ped CRS in those not responding to medical management
Name 2 medical adjuncts to sinus surgery
- Steroid impregnated nasal dressings - insert into middle meatus
- Steroid eluting stent - placed in ethmoid cavity following surgery
Management of allergic fungal rhinosinusitis
- endoscopic intervention for dx and mgmt
- removal of polyps, mucin, debris
- sinuses opened up as widely as can be
Etiology of rhinosinusitis
Obstruction of the various ostia Increased visocosity of secretions Impaired immunity Mucus accumulates Decrease in oxygenation in the sinuses Bacterial overgrowth
Factors associated with ARS
ICAM1 – receptor for rhinovirus is up-regulated in ARS
Smoking – affects ciliary function
Pollution
Anatomic variants – Haller cells, concha bullosa, septal deviation
Dental infections
?Allergic Rhinitis
Steroid management of CRS (AAAAI 2014)
- Consider a short course of oral steroids for treatment of CRSsNP and CRSwNP because it decreases polyp size and alleviates symptoms
- Treatment usually results in clinical improvement & transient improvement in sense of smell, although the duration of clinical benefit is variable & may decrease w/ repeated courses (expert opinion)
Complications of acute sinusitis
Orbital extension – dipolopia, proptosis, periorbital erythema, swelling
Bone – periosteal abscess
Brain – intracranial abscess or frontal/sphenoid sinusitis can cause meningitis
Orbital phlegmona – can lead to cavernous sinus thrombosis and loss of vision
Management of ABRS
- Antibiotics are not useful in mild or uncomplicated ARS
- Amoxicillin is first line for moderate or severe ABRS
- Nasal steroids
- Nasal irrigation
- Supportive treatment/pain control
- Hydration
- Treatment should be reassessed after 72 hours and changed in no improvement (add or change antibiotics)
Contributors too high risk of antibiotic resistance
Abx in last 3 months
Symptoms >3 weeks
Parents of children in daycare
Pathophysiology of CRSsNP
- Likely begins with obstruction of sinus ostium leading to ABRS
- If it fails to resolve, it sets up a chronic inflammatory process
- Presence of bacterial biofilm in 45-80% of cases
Or may become intracellular between exacerbations - Primarily a Th1 response – IL-3 driven
Pathophysiology of CRSwNP
- Polyp tissue contains high levels of Th2 cells, IL-5, IL-13, and histamine
- May be localized IgE to S. aureus – sIgE to staph enterotoxins (superantigens) have been isolated
- May also have decreased Treg function – low IL-10
- tight junction proteins are reduced
80% of nasal polyps are eosinophilic
CF is neutrophilic in 50%
Asian polyps are Th1/Th17 in 50% - again neutrophilic`
Management of CRSsNP
Antibiotics
- If possible, choice should be made based on cultures obtained from middle meatus/ostia
- Macrolides are generally not effective
- Clavulin or moxifloxacin are reasonable empiric choices
- Given for at least 3 weeks but can be extended for up to 10 in refractory cases
Steroids
- Nasal steroids are definitely useful; unclear about risk vs. benefit of oral steroids
- Topical steroid instillations rather than sprays may be more effective
- Recommendation in guidelines is Prednisone 40 mg for 8 to 10 days concurrently with antibiotics
Nasal saline rinses
Management of CRSwNP
Nasal steroids
- Steroid rinses are again more effective
- First line therapy
- Mometasone 200 mcg BID used in studies (improves congestion by day 3 and smell by day 13)
Oral steroids
- Oral steroid plus topical steroid therapy is more effective over 6 months than just topical steroid therapy in decreasing polyp size and improving olfaction
Antibiotics
Saline irrigation
Surgery for medical failures or complications
Biologics
- Omalizumab – reduced polyp size and improved symptoms in allergic and non-allergic CRSwNP and comorbid asthma
- Anti-IL5
- Mepolizumab – 50% response
- Reslizumab – 50% response – particularly those
with elevated IL-5 in nasal secretions
Complications of CRS
Mucocele – epithelial lined sac full of mucus – fills the paranasal sinus and capable of expansion
- Usually unilateral (90% of the time)
- Most commonly affects the fronto-ethmoid region
- Treatment is with surgery
CSF leak – due to trauma (90%), surgery, or idiopathic
- Presents as clear fluid or salty PND
- Beta 2 transferrin in nasal secretions
- Need head imaging to localize leak
- Endoscopic surgery to repair
Name 3 sinusitis syndromes
- CF
- PCD
- Fungal rhinosinusitis (ABPA)
What is paradoxical vocal fold motion?
inappropriate motion of the true vocal cords
AAAAI first line treatment for CRSsNP
Topical steroids, nasal saline irrigation, consider antibiotic PO culture based if possible
Comorbidities associated with VCP
- asthma
- post extubation
- irritants
- neurological injury
- larygopharyngeal reflux
- psychosocial disorders
evaluation and diagnosis of VCP
- Laryngoscopy is the gold standard for diagnosis
- PFT and imaging may be performed prior depending on the clinical presentation
- PFT usually show normal expiratory phase in PVFM – some may show restrictive pattern
- Inspiratory phase may show flattening
FEF50:FIF50 may be >1 (normal is <1)
Management of VCP
Acute Management
- Reassurance and supportive care until episode resolves – panting may help abort the episode
- CPAP may be helpful; heliox also reported as having some benefit
- Intubation/tracheostomy are not needed and considered only if at risk for airway obstruction for another cause
Long-Term Management
- Requires a multi-disciplinary approach
- Behavioural speech/voice therapy
- SLP can assist in retraining and education
- Evidence for breathing, voice, and neck relaxation exercises
- Biofeedback with video laryngoscopy can be helpful
- Psychological counseling and avoidance of irritants
- ?Atrovent prior to exercise in patients with exercise-associated PVFM may be helpful
What is the concha bullosa?
Pneumotization of the middle turbinate
often associated with deviated septum
No association to sinus disease, unless very large and blocking the maxillary sinus
What are Haller cells?
They are ethmoidal air cells that extend on the medial floor of the orbit and can increase risk of acute sinusitis
First line treatment of acute bacterial rhinosinusitis (ABRS)
- Intranasal corticosteroids in mild/moderate disease
- consider adding antibiotics in severe disease
adjunct therapies: saline rinses
histopathology of nasal polyps
edema, thickened BM, fibrotic stromal tissue, infiltrating eosinophils
Nose is lined by 3 epithelium:
- stratified squamous epithelium
- pseudo stratified columnar epithelium
- specialized olfactory epithelium
How to steroids work?
Blocks T cell derived and APC derived cytokine expression and release
- reduced inflammatory cells in the nasal mucosa
- reduced inflammatory cytokine release
cyclosporin MOA
Tacrolimus MOA
forms complexes with cyclophilin to inhibit calcineurin
tacrolimus binds FKBP12 and forms complexes to also inhibit calcineurin
mycophenolate MOA
inhibits ionosine monophosphate dehydrogenase
SE: diarrhea, n/v, anemia, leukopenia, thrombocytopenia
how do you classify AR?
- intermitten
- persistent > 4 days a week
(ARIA)
seasonal vs. perennial (US)
RFs for AR
- fam hx of atopy
- sIgE > 100 before age 6
- maternal smoking
- high SES
- positive SPT
- particulate air pollution
mechanism of gustatory rhinitis
stimulation of C fibres
treat with ipratriopium (anti cholinergic)
mgmt of rhinitis of pregnancy
- nasal decongestant
- nasal strips
- nasal lavage
- ICNS do not work!
meds that can causes rhinitis
- anti htns
- psychotropics like risperidone, chlorpromazine, and hydralazine
- PDE-5 inhibitor like sildenafil
- NSAIDs
- Others - OCP and gabapentin
what is chitin
2nd most abundant polysaccaride in the world
comes from insencts, fungi, parasites, crustaceans
size dependant lung inflammation
