Rhinitis + Rhinosinusitis Flashcards
What type of reaction is allergic rhinitis?
IgE mediated type 1 hypersensitivity
How is allergic rhinitis categorised?
Intermittent (seasonal) - hayfever
Persistent - dust mites, cats etc
What are the clinical features of allergic rhinitis?
Rhinorrhoea, nasal irritation/itching Sneezing Nasal obstruction Itchy/watery eyes Allergic crease on nose
What might be seen on rhinoscopy in allergic rhinitis?
Inflamed nasal turbinates/hypertrophy
Watery discharge
Which investigations can be done for allergic rhinitis?
Diagnosis clinical +
Skin prick allergy testing
Serum RAST test can be done
How is skin prick testing done?
Common allergens applied to skin
+ve result is wheal response after 20 minutes
Cheap + easy to do in clinic
What is a RAST test and what are its advantages/disadvantages?
Blood test for specific IgE to antigens
More expensive + time to get results
But no risk of anaphylaxis
What are the options for treatment of allergic rhinitis?
Avoidance
Nasal douching + barrier ointments/creams
Oral non-sedating antihistamines (mild symptoms)
Intranasal steroids (if nasal blockage)
Combo steroid + anti-histamine nasal spray
Leukotriene antagonist
Immunotherapy
Which oral non-sedating antihistamine are used in allergic rhinitis?
Loratidine
Cetirizine
Which steroids are used intra-nasally in allergic rhinitis?
Fluticasone
Mometasone
Beclomethasone (not as good)
Which combination nasal spray is used in allergic rhinitis?
Fluticasone + azelastine
Which treatment for allergic rhinitis is particularly good if the patient also has asthma?
Leukotriene antagonist e.g. montelukast
How do nasal polyps present?
Nasal blockage +/- change in smell
What is the medical management for nasal polyps?
Steroids + intranasal rinses:
- short course of oral steroid –> 7 days prednisolone + PPI
- then intranasal steroid drops for 4-6 weeks
- then maintenance intra-nasal steroid spray e.g. Mometasone
When and which operation is indicated for management of nasal polyps?
For polyps + chronic rhinosinusitis
–> Functional endoscopic sinus surgery (FESS)
What are the complications of FESS?
Pain Infection Bleeding CSF leak Meningitis Intra-orbital complications Recurrence
What is rhino sinusitis?
Inflammation of the mucosal linings of nasal passage + paranasal sinuses
What causes rhinosinusitis?
Viral (most commonly): rhinovirus, coronavirus, parainfluenza, RSV
Bacterial: S. pneumoniae, H. influenzae, M. catarrhalis
What are the risk factors for rhinosinusitis?
Smoking, air pollution Septal deviation, nasal polyps, sinus hypoplasia Anxiety, depression Asthma Diabetes
What is the diagnostic criteria for rhinosinusitis?
Sudden onset of 2 or more of:
- nasal obstruction
- discoloured nasal discharge (from nose or drip at back of throat)
- facial pain or pressure, usually unilateral over maxillary or frontal sinus
- altered sense of smell
Which features of rhinosinusitis would suggest a bacterial cause rather than viral?
Severe local pain
Discoloured discharge
Fever
Worsening after initial improvement (post viral)
What is the management of simple rhinosinusitis?
Analgesia + nasal decongestants
(most cases do not require antibiotics)
Add topical nasal steroids if symptoms > 10 days or worsening after 5 days
Give two examples of nasal decongestants and how long as they taken for?
Xylometazoline
Pseudo-ephidrine
–> take for 1 week only
What would be considered severe bacterial rhinosinusitis?
3 or more of:
- coloured discharge
- severe pain
- fever
- raised ESR/CRP
- worsening after initially improvement
What is the treatment for severe bacterial rhinosinusitis?
Antibiotics + intranasal steroids
- first line = penicillin
- second line = doxycycline (not in children)
What are the red flags for rhinosinusitis complications?
Periorbital swelling/erythema, displaced globe, visual changes, ophthalmoplegia
Severe unilateral headache, bilateral frontal headache or frontal swelling
Neurological or reduced consciousness
When should rhinosinusitis be referred to ENT?
Recurrent, persistent or chronic
Any red flag symptoms
Which investigations will be done on referral to ENT for rhinosinusitis?
Nasal endoscopy + culture of discharge
CT scan of paranasal sinuses
What are the complications of sinusitis?
Preseptal cellulitis, orbital cellulitis or abscesses Osteomyelitis Pott's puffy tumour Intracranial abscess Venous sinus thrombosis
What is Pott’s puffy tumour?
Osteomyelitis of frontal sinus –> soft boggy swelling on forehead
What is considered ‘chronic’ rhinosinusitis?
Symptoms > 12 weeks
What are the risk factors for chronic rhinosinusitis?
Asthma/atopy Aspirin sensitivity Ciliary impairment Smoking Immunosuppression
What will be seen on nasal endoscopy in a patient with chronic rhinosinusitis?
Swelling
Discharge
Occlusion of the middle meatus
Polyps (around the middle meatus)
What is the non-surgical management of chronic sinusitis?
Nasal douching + intranasal steroids
If more severe –> long term antibiotics + intranasal steroids
What is the surgical management of chronic sinusitis?
If refractory to conservative management –>
Functional endoscopic sinus surgery (FESS)
What is the aim of FESS?
Remove any polyps and open up sinuses, reduce obstruction + drain mucus
This allows topical treatments to reach all areas –> must continue post-op
What is a complication of chronic rhinosinusitis?
Mucocele
- occurs rarely in frontal sinus
- can erode bone + local structures
