Rhinitis/Sinusitis Flashcards by Cami Goyette

Rhinitis 3 types

Allergic
Vasomotor
Viral

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Allergic Rhinitis

AKA “hay fever”

seasonal vs perennial causes (pollen/spores; flower shrub/tree; and dust; household mites, air pollution)

atopic derm commonly associated

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Allergic Rhinitis Clin Pres

CLEAR, watery rhinorrhea

tearing, irritation, pruritus (eye sympt)

think allergy symptoms

nasal mucosa swollen, boggy, pale (even blue) or violaceous

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Allergic Rhinitis PE

“allergic salute” may lead to nasal crease

allergic “shiners”

nasal polyps

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Allergic rhinitis dx

clinical w/ good hx and PE

for definitive cause can do skin prick test/ IgE immunoassay

distinguish from vasomotor rhin

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Allergic Rhinitis Tx

AVOID ALLERGEN

environmental measures (remove carpets, curtains, etc)

Nasal saline rinses

CS nasal sprays - Flonase (fluticasone) {tx both nostrils, head down, and spray hoirzontally}

antihistamines - in tolerance, switch classes
Leukotriene inhibitor
Desensitization immunotherapy (“allergy shots”)

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Vasomotor Rhinitis

causes by increased sensitivity of vidian nerve

can be form multiple stimuli (warm cold air, scents, light)

clear rhinorrh in elderly

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Vasomotor Rhinitis 2 forms

Wet “runners” rhinorrhea
Dry - nasal obstruction, airflow resist little rhinorrhea

my see post nasal drip on PE

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Vasomotor rhinorrhea TX

Step 1
(rhinor, sneezing, post nasal drip = topical antihist - Azelastine)

(rhino only = topical anticholinergic (ipratropium)

nasal obstruction and congestion = topical CS
(mometasone- Nasonex)

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Viral Rhinitis

AKA; “common cold”

self-limited - may create latent infxn (2 bacter sinusitis, OM,etc)

adenoviruses, rhinoviruses

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Viral Rhinitis HX/clin pres

clear to green mucus ; symptoms last <10 days, self-limited ; low or no fever

other common rhinitis symp

NO sinus tenderness

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Viral Rhinitis TX

(supportive) fluids and rest
nasal saline rinses
oral and nasal decongestants

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Bacterial Sinusitis

…compared to viral
can be …
MC causes….

uncommon compared to viral

can be COMPLICATION of viral URI or allergic rhinitis

S. pneumo, H. influ, M. cat MC

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Bacterial sinusitis Clin Pres

facial pain/pressure (sinus pressure)
Alt. smell (“bad smell”) / Anosmia/hyposmia
+/- cough/F
nasal congestion
purulent nasal drainage ***

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Bacterial Sinusitis Acute

<4 weeks

imaging not indicated - unless complication suspected

symptoms PLUS facial pain/pressure or dental pain at least 10 days beyond onset URI

double worsening w/i 10 days

3+ days high fever, specific sinus cavity

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Bacterial Sinusitis Chronic

> 12 weeks

clinical sympt. - confirm w/ OBJECTIVE documentation
- anterior rhinoscopy
- nasal endoscopy
- CT (need to ENT)

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Bacterial Sinusitis HX and PE

facial pain above or below eye (ask does pain increase w/ bending forward)

tenderness w/ tapping maxillary teeth

check ears for OM/serous otitis, nasopharynx, cervical lymph nodes

smoking/second hand smoke

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Bacterial sinusitis TX

abx + decongestant + analgesics
- (amox, augmentin, doxycyline) 5-10 days

no improvement 72 hrs, change class

intranasal steriods - recurrent sinusitis

Refer ENT for continued sinusitis

Complication of acute Bact. sinusitis

Preseptal Cellulitis
Orbital cellulitis
Subperiosteal abscess
Intracranial abscess
Meningitis
Septic cavernous sinus thrombosis
Osteomyelitis

Viral vs Bacterial

DURATION OF SYMPTOMS
<10 days likely VIRAL
>10 days likely BACTERIAL

“double worsening”; recurrent symp; High grade fever; purulent nasal discharge

Nasal Foreign Bodies Clin Pres

usually KIDS

UNILATERAL thick, FOUL-SMELLING nasal discharge
No fever or other symptoms

nasal obstruction

Nasal foreign bodies Tx

Remove object (alligator forceps) - if seen NOT BLINDLY

close unaffected nostril and blow

check for signs of trauma and other nostril

Epistaxis Causes/Risk factors

DIGITAL TRAUMA
external trauma to nose
dry nasal mucosa/ nose blowing
HTN (must rule out)

Epistaxis Anterior

Bleeding from Kiessalbach’s Plexus or ant. septum

MC site 90-95%

kids/young adults
Less severe

Epistaxis Posterior

usually ethmoid artery, internal maxillary, or branches (WOODRUFF'S plexus) MORE SERIOUS elderly HTN, atherosclerosis, blood thinners Hospitalization, post. pack

Epistaxis TX

direct control - press nares together 10-15 mins sitting up and leaning slightly FORWARD if 2 attempts fail = cautery, nasal tampon, anterior balloon, Gauze, thrombogenci foams and gels

Epistaxis Tx PACKING

Anterior = use if pressure, cautery/vasoconstri. unsuccessful and gels/foams unavail. Posterior = longer packing material (call ENT for help); surgical ligation or embolization of sphenopalatine a. complications of packing = pressure necrosis, hypoxia, infxn - need ICU if bilateral post packs

Benign tumors of Nose

Nasal polyps Papillomas Angiofibromas

Nasal Polyps MC ..? appearance suggest what in kids SAMTER'S TRIAD

MC benign tumor of nose and sinuses pale, edematous mucosal masses nasal polyps in kids suggest CF! SAMTER'S TRIAD = nasal polyps, asthma, aspirin sensitivity

Nasal Polyps Tx

Topical nasal steroids (improves quality of life, chronic sinusitis, use 1-3 mos.) Oral steroids (2-3 weeks) when topicals fail Surgical removal is above unsuccess. or 'massive" ENT

Inverted Papilloma

Locally aggressive tumor HPV causing; 10% assoc. with SCC lateral nasal wall CAULIFLOWER like growths in/around middle meatus

Inverted Papilloma - Clin Pres

Unilateral nasal obstruction Occass. hemorrhage Decreased sense of smell

Inverted Papilloma- Tx

Complete excision F/u (20% recurrence)

Benign Juvenile Angiofibroma

very VASCULAR TUMOR originates in NASOPHARYNX benign, can expand into sinuses and skull base MC adolescent males

Benign Juvenile Angiofibroma - Clin Pres

nasal obstruction and hemorrhage (heavy epistaxis)

Benign Juvenile Angiofibroma - Dx

Avoid bx b/c profuse bleeding Nasopharyngoscopy CT/MRI

Benign Juvenile Angiofibroma - Tx

Embolization techniques Surgical excision Radiologic f/u

Malignant tumors of nose/sinuses

Rare SCC MC Chinese at higher risk; nasopharynx obstructs eustachian tube causes serous otitis media high index suspicion important for early dx!

Malignant tumors of nose/sinuses - Early Pres

UNILATERAL nasal obstruction Serous otitis media Dysgeusia/Anosmia Discharge/Epistaxis Decreased hearing (unilateral)

Malignant tumors of nose/sinuses - Late Pres

Pain and recurrent "hemorrhage" Expansion of cheek (facial asymm.) Proptosis Cheek hyperesthesia Poorly fitting dentures, change unilaterally Cranial nerve palsies

Malignant tumors of nose/sinuses - When to work up

esp. smokers/drinkers NEW UNIlateral nasal symp, UNILATERAL otitis media or serous otitis refractory to tx - presume nasopharngeal carcinoma until proven otherwise

Malignant tumors of nose/sinuses - DX

Nasal endoscopy and nasopharygnoscopy Bx needed for def dx MRI

Malignant tumors of nose/sinuses - TX

Depends on type of CA and extent Very early = radiation Advanced = concurrent radiation chemo Surgical resection (combo w/ radiation; cranial base; endoscopic)