Rhinitis/Sinusitis-ENT Flashcards
Symptoms of rhinitis?
- Nasal Obstruction
- Nasal Drainage
- Itchy, watery eyes
- Facial Pressure and Pain
- Sneezing
- Asthma
Types of Rhinitis?
- Allergic Rhinitis: Seasonal and Perennial
- Acute Rhinitis
- Vasomotor Rhinitis
- Smoker’s Rhinitis
- Allergic Fungal Rhinitis (cover with fungal rhinosinusitis)
Allergic Rhinitis is what?
- Afebrile, clear nasal drainage, may have polyps
- Allergy tests positive
- IgE positive
- Family History Positive
Symptoms of Allergic Rhinitis?
- Seasonal symptoms. –Pollen
- Bluegrass, Timothy, Ragweed
- Perennial symptoms: –Household allergens
- Dust mites, molds, feathers, animal dander
- Sensitive to chemical irritants
Seasonal allergic rhinitis?
• Ideal for medical treatment
– Antihistamines
– Decongestants
– Nasal Steroids • (Flonase, Nasonex, Nasocort AQ, Rhinocort Aqua)
– Singulair (montelukast) • 10 mg po daily • Selectively binds to cysteinyl leukotriene receptors
• Allergy desensitization: SCIT or SLIT
Perennial allergic rhinitis causative factors?
- Animals outside
- No smoking in house
- Molds are found in: – Houseplants – Basements – Showers – Humidifiers (also increases house mites)
- Minimize use of rugs
- House Mites: a fecal antigen –Live off of skin flakes –Wash bed linen in 140 degree water –Plastic pillow liner and and water bed
- Electric HEPA air filters
Common cause of acute rhinitis?
• Most common cause viral.
Factors of vasomotor rhinitis?
- Afebrile, clear nasal drainage.
- Allergy tests negative.
- IgE negative
- Family history negative.
Pathophysiology/triggers of Vasomotor rhinitis?
Pathophysiology: rhinitis secondary to overactive parasympathetic activity a from wide variety of triggers.
–Environmental triggers: humidity and temperature changes, dust, smoke, and pollution
–Endocrine and metabolic: pregnancy, oral contraceptives (estrogen inhibits anticholinesterases)
- Medications: antihypertensives, antipsychotics, cocaine
- Psychotropic: anxiety, stress, exercise
Treatment of Vasomotor rhinitis?
- Chemical cautery
- Anticholinergic nasal sprays (ipratopium bromide) – Atrovent Nasal 2 sprays each nostril tid/qid
- Azelastine (Astelin) Nasal Spray – 2 sprays each nostril bid
- Oral antihistamines and nasal steroids DO NOT give symptomatic relief in most patients.
- Surgical Management:
–Surface turbinate cautery: Electrocautery, chemical cautery, cryotherapy
–Septoplasty removes mechanical points of irritation
–Partial Turbinectomy
–Division of parasympathetic fibers
Explain smoker’s rhinitis?
- Chronic rhinitis
- Resistant to medications and surgery
- Hypertonic saline rinses help
- Smoking cessation may transiently worsen symptoms if goblet cell activity and secretions recover without recovery in cilliary clearance.
Pathogens for sinusitis?
–Haemophilus influenzae
–Moraxella catarrhalis
–Streptococcus pneumoniae
–Anaerobic organisms
Major factors and minor factors related to sinusitis?
When do we refer to otolaryngology for sinsusitis?
- 3-4 infections per year
- An infection that does not respond to two three-week courses of antibiotics
- Nasal polyps
- A complication of sinusitis
Diagnosis of sinusitis in the primary care setting
In a primary care setting, a good history and physical examination to detect the presence of most or all of the commonly presenting signs and symptoms can provide a reliable diagnosis of acute sinusitis.
Radiographic diagnosis of sinusitis?
• CT of the paranasal sinuses is the imaging study of choice.
– Cost is similar to that of plain radiographs as many centers do limited axial views.
– MRI not recommended for evaluating acute sinusitis because it does not distinguish air from bone.
Endoscopically cultures for sinusitis?
Endoscopically Directed Middle Meatal (EDMM) Cultures are more sensitive than the old fashioned maxillary sinus tap.
What to do once you have established the diagnosis for sinusitis?
Classify and treat
Acute Vs. Subacute Vs. Chronic sinusitis?
- Acute: symptom duration less than 4 weeks
- Subacute: duration between 4-12 weeks.
- Chronic: duration greater than 12 weeks.
- Recurrent acute: 4 or more episodes in one year.
Treatment of Rhinosinusitis?
- In the absence of allergic symptoms oral antihistamines have a questionable role in the treatment of rhinosinusitis.
- Topical nasal steroids are better for prevention in allergic patients, but can be used as an adjunct to care.
adjunct treatments for recurrent and chronic sinusitis?
- Moisturizer such as saline nasal spray.
- Decongestants –Be careful with hypertensive patients.
Treatment of chronic bacterial sinusitis?
- Antibiotics: 3-6 week regimen with broad spectrum agents
- Medical management often fails with chronic sinus disease, surgical management frequently required.
Allergic fungal rhinosinusitis is also called?
–Intrinsic rhinitis.
–Hyperplastic rhinitis
–Eosinophilic Nonallergic rhinitis
Allergic fungal rhinosinusitis is what?
- Accounts for 5-10% of chronic rhinosinusitis –Marked variability in incidence by geographical location
- Allergic rhinitis seen in 67% of these patients
- Asthma seen in 50% of these patients
Profile of allergic fungal rhinosinusitis?
- Analogous to Allergic Bronchopulmonary Aspergillosis (ABPA)
- Alternaria, Exserohilum, Curvularia, Dreschlera, and Biploaris are all also reported to cause allergic fungal sinusitis.
- Aspergillus fumigatus
Symptom progression of allergic fungal rhinosinusitis?
- Early symptoms: nasal airway obstruction
- Late symptoms: extensive nasal polyposis
- Pain is uncommon (pain suggests a bacterial infection)
Diagnosis of allergic fungal rhinosinusitis?
- Afebrile, clear nasal drainage, intranasal polyps
- IgE positive
- eMBP antigen (Eosinophil Major Basic Protein)
- Alt-1 antigen (Alternaria)
Allergic fungal rhinosinusitis treatment?
- Surgical Debridement of obstructed sinuses to remove fungal debris.
- Itraconazole – 200 mg po bid (studies have used 400 mg bid, but this is above the recommend max of 600 mg/day)
- Antifungal nasal washes
- SinuNEB: Nasal nebulizer
- Intranasal steroids
- Marple 2001: Immunotherapy (Laryngoscope)
- Three pronged-attack –Immunotherapy must be initiated postoperatively –Remove antigenic burden with a FESS –Halt inflammatory cascade: Topical and systemic steroids
- Monitor disease with total serum IgE
Chronic invasive fungal sinusitis pathogens? diagnosis? treatment?
- Pathogens: Aspergillus, Mucor, Rhizopus, Absidia
- Diagnosis: biopsy and culture, MRI (best) and CT of paranasal sinuses
- Treatment: surgical debridement and long-term amphotericin B and itraconazole.
Fulminent fungal sinusitis and mucormycosis?
- Mucormycosis invades vessel walls causing local vascular occlusion, thrombosis, infarction, and tissue necrosis.
- Pathogens: Aspergillus most common as well as the Saprophytics
- Manifest almost exculsively in an immunocompromised host. – DKA, HIV, chemotherapy, bone marrow transplant.
Diagnosis of Mucormycosis?
- Necrotic, black turbinates
- Biopsy and culture
- Cranial nerve involvement
- MRI best: enhancement in T2weighted images from fungal elements
Treatment of mucormycosis?
Aggressive and urgent surgical debridement and long-term amphotericin B, maximal medical management of underlying derangements.
What is Samter’s Triad?
• Nasal Polyposis • ASA intolerance • Asthma
Antihistamine nasal spray?
• Astelin (Azelastine) nasal spray. –Inhibits secretions, serotonin, leukotrienes, and histamine. –No sedation.
Rhinitis Medicamentosa is brought on by?
- Do not use intranasal decongestant sprays (such as oxymetazoline )for more than 5 days!!!
- This stuff can be very addicting.
- Mucosal damage.
- Rebound hypertension.
- Treatment: use nasal steroids and nasal saline
Nasal septum perforation symptoms and treatment?
- Whistling • Nasal deformity. • Bleeding.
- Treatment: –Septal button –Surgery has high failure rate. –Moisturizers
Allergy testing types?
- Prick testing: – Well tolerated – Not as accurate as SET, cannot be on beta-blockers.
- SET (Skin End Point Titration) – Gold standard. – Uncomfortable, cannot be on beta-blockers.
- RAST testing – Great for kids, can be on beta-blockers. – Not as accurate as SET
surgical treatments of sinusitis?
- Endoscopic sinus surgery
- Turbinate surgery
- Septoplasty
what is this?
Septal spur protruding into middle meatus
What if we see unilateral sinusitis?
- RED FLAG!!!!
- Consider inverting papilloma, Squamous cell carcinoma, lymphoma, angiofibroma.
Nasal forgein bodies? More common in? Presentation? Treatment?
• More common in children • Unilateral obstruction and discharge • Treatment—removal. You must do an exam with a headlight and a nasal speculum before you call the specialist.
