Rhinitis/Sinusitis Flashcards
Rhinitis 3 types
Allergic
Vasomotor
Viral
Allergic Rhinitis
AKA “hay fever”
seasonal vs perennial causes (pollen/spores; flower shrub/tree; and dust; household mites, air pollution)
atopic derm commonly associated
Allergic Rhinitis Clin Pres
CLEAR, watery rhinorrhea
tearing, irritation, pruritus (eye sympt)
think allergy symptoms
nasal mucosa swollen, boggy, pale (even blue) or violaceous
Allergic Rhinitis PE
“allergic salute” may lead to nasal crease
allergic “shiners”
nasal polyps
Allergic rhinitis dx
clinical w/ good hx and PE
for definitive cause can do skin prick test/ IgE immunoassay
distinguish from vasomotor rhin
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”)
Vasomotor Rhinitis
causes by increased sensitivity of vidian nerve
can be form multiple stimuli (warm cold air, scents, light)
clear rhinorrh in elderly
Vasomotor Rhinitis 2 forms
Wet “runners” rhinorrhea
Dry - nasal obstruction, airflow resist little rhinorrhea
my see post nasal drip on PE
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)
Viral Rhinitis
AKA; “common cold”
self-limited - may create latent infxn (2 bacter sinusitis, OM,etc)
adenoviruses, rhinoviruses
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
Viral Rhinitis TX
(supportive) fluids and rest
nasal saline rinses
oral and nasal decongestants
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
Bacterial sinusitis Clin Pres
facial pain/pressure (sinus pressure)
Alt. smell (“bad smell”) / Anosmia/hyposmia
+/- cough/F
nasal congestion
purulent nasal drainage ***
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
Bacterial Sinusitis Chronic
> 12 weeks
clinical sympt. - confirm w/ OBJECTIVE documentation
- anterior rhinoscopy
- nasal endoscopy
- CT (need to ENT)
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
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)
