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HENT > Rhinosinusitis > Flashcards

Rhinosinusitis Flashcards

1
Q

Big 3 bacterial bugs in rhino-sinusitis

A

strep pnuemo, Haemophilus influenza (H flu), M. cat

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2
Q

Why is it called RHINO-sinusitis?

A

because nasal, pharyngeal sinus, & middle ear spaces are all contiguous and connected
-infections in the nose go into sinuses

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3
Q

What is ABRS

A

bacterial sinus infxn

maxillary, frontal, or ethmoid sinuses

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4
Q

What type of onset is seen in ABRS?

A

acute onset

near-normal sinus fun prior to infxn

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5
Q

What are two types of bacterial causes (not specific organisms)

A
  • community acquired

- nosocomial

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6
Q

What % of cold/flu like illnesses per year are bacterial?

A

0.5-2%

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7
Q

what does ABRS result from? (what is infected)

A

infection of one or more parasinuses

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8
Q

What is ABRS often associated with?

A

usually associated with common cold

-viral rhinosinusitis

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9
Q

What % of viral rhino sinusitis develop bacterial sinusitis? and when?

A

2%

after 7-10 days

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10
Q

Rhinitis leads to_____

A

sinusitis

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11
Q

cold causes _______ which leads to ________

A

cold causes inflammation which leads to bacterial infection

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12
Q

Examples of community acquired bacterial sinusitis

A

S. pneumoniae,
H. influenza,
M. catarrhalis & Group A strp
Staph aureus

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13
Q

examples of causes of nosocomial bacterial sinusitis

A
  • nasogastric tubes

- staph, pseudomonas, other gram-s

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14
Q

Viruses don’t normally last longer than _____days

A

10 days

so greater than 10 days, think bacteria

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15
Q

as soon as you clinically dx ABRS you should begin _____________ therapy

A

empiric antimicrobial therapy

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16
Q

what empiric antimicrobial therapy i the recommendation for adults and children

A

augmentin

amoxicillin-clavulanate

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17
Q

When do you use alternative management for ABRS

A

if symptoms worsen or fail to improve

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18
Q

How should cultures be obtained for sinus infections?

A

direct sinus aspiration (rather than a nasopharyngeal swab)

-alternative: culture middle meatus in adults

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19
Q

when should you refer a pt. with ABRS to a specialist?

A

seriously ill & immunocompromised, continue to deteriorate clinically even with abs, recurrent bouts of acute rhinosinusitis

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20
Q

Signs and Sx of ABRS that may not help distinguish b/t viral

A
  • nasal secretions (even purulent green/yellow) are universal
  • congestion and facial pressure/headache
  • recent onset with no fevers, UNLIKELY to be ABRS
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21
Q

Specific Sx to ABRS

A
  • failure to resolve 7-10 days
  • higher fever/ severe sx
  • re-sickening
  • foul odor
  • maxillary dental pain
  • anosmia
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22
Q

ABRS red flags

A
  • abnormal vision
  • change in mental status
  • periorbital edema
  • high fevers
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23
Q

physical exam ABRS

-vitals

A

may be febrile, otherwise wnl

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24
Q

physical exam ABRS

-eyes

A

possible clear discharge

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25
Q

physical exam ABRS

-throat

A
  • likely inflamed
  • absence of tonsillar exudates
  • possibe foul breath
  • possible posterior drainage
  • possible posterior pharyngeal cobblestoning if chronic drainage
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26
Q

physical exam ABRS

-face

A

tenderness to palpation/percussion of maxillary and/or frontal sinuses

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27
Q

physical exam ABRS

-neck

A

possible anterior cervical lymphadenopathy

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28
Q

physical exam ABRS

-chest

A

normal exam, but cough possible

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29
Q

Whenever an inflammatory lesion is found, what should you look for?

A

involvement of there regional lymph nodes that drain it

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30
Q

if a node is enlarged or tender, what should you look for?

A

source such as infection in the area that it drains

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31
Q

What is Cobblestoning?

A

clumps of hypertrophied lymphoid tissue at the posterior pharynx
-due to chronic postnasal drainage and irritation of tissues

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32
Q

what are some ABRS tests

A

Transillumination, sinus puncture & aspiration, radiology (CT)

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33
Q

what does transillumination show you

A

asymmetry is significant (one sinus to the other)

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34
Q

What is the gold standard of ABRS tests?

A

sinus puncture & aspirate

-but only done in clinical research

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35
Q

When should you consider doing a CT for ABRS

A
  • with recurrent ABRS if you suspect a structural cause

- shows abnormalities very well

36
Q

ABRS Tx

A
  • abx
  • antiinflammatories (for pain/fever)
  • decongestants
  • expectorants (guaifenisen may help thin secretions)
  • saline irrigation
37
Q

What should you avoid in ABRS tx and why?

A

avoid 1st generation antihistamines (thicken secretions)

38
Q

Always cover ________ when prescribing abx for ABRS

A

-cover the big 3 pathogens (three biggest suspects)

39
Q

Ways to avoid abx resistance

A
  • don’t use unless needed!!
  • use narrowest spectrum that will work for the infection
  • use for shortest effective time
  • avoid chronic use of low doses
40
Q

complications of ABRS

A
  • periorbital tissues
  • osteomyelitis
  • meningitis, brain abscess
  • chronic sinusitis
41
Q

what should always be a differential of sinusitis

A

paranasal sinus cancer

persistent pain, epistaxis, prolonged clinical course

42
Q

AVRS is like ABRS but ___

A

less so

43
Q

AVRS sx lack the ______

A

ABRS-specific signs

44
Q

duration of AVRS compared to ABRS

A

AVRS shorter duration

45
Q

Complaints in AVRS similar to ABRS

A
  • congestion
  • nasal discharge, postnasal drip
  • headache, pressure, possible tenderness
  • fluid in sinuses
  • possbile associated hx of allergies
46
Q

AVRS treatment

A
  • treat sx
  • avoid abs
  • be alert for ABRS
47
Q

goal of viral treatments of sinusitis

A
  • block the inflammation events

- nasal fluid production & inflammation

48
Q

Options for viral tx to block inflammation

A
  • antihistamines
  • NSAIDs
  • cough suppressant
  • decongestants
  • mucolytics
49
Q

What is recurrent sinusitis vs. chronic sinusitis

A

recurrent sinusitis- 4 or more episodes per year with absent sx between episodes

50
Q

Chronic sinusitis formally includes

A

> 12 wks of

  • anterior or posterior mucopurulent drainage
  • nasal obstruction
  • facial pain/fullness/tenderness
  • AND
    • purulent mucus or edema
    • OR polyps in nasal cavity or middle meatus
    • OR imaging showing inflammation of the paranasal sinuses
51
Q

causes of chronic sinusitis (etiology)

A
  • persistent infection
  • allergy/immunologic disorders
  • intrinsic factors of upper airway
  • superantigens
  • colonizing fungi that induce and sustain eosinophilic inflammation
  • metabolic abnormalities like aspirin sensitivity
52
Q

all of the chronic sinusitis causes affect _____________

A

mucociliary clearance

53
Q

Physical exam findings for chronic sinusitis

-nasal exam with speculum

A

-purulent drainage, polyps, septal deviation, turbinate hypertrophy/edema

54
Q

Chronic sinusitis studies:

Endoscopically guided culture

A

from middle meatus, especially if empiric tx fails

55
Q

Chronic sinusitis studies:

-maxillary sinus tap

A

not done often b/c pain and reliable cultures rom middle meatus

56
Q

Chronic sinusitis causes (what organisms)

A

staph aureus, coagulase negative staph, anaerobes, gram-neg, fungus

57
Q

chronic sinusitis tx

A
  • abx (choice dictated by culture)

- intranasal steroids, saline, ,oral steroids, decongestants, mucolytics

58
Q

allergic (non infectious ) rhinosinusitis sx

A
  • clear rhinorrhea with associated allergic symptoms
  • allergic shiners (?)
  • allergic salute
  • transverse nasal crease
59
Q

allergic rhino sinusitis physical exam findings

A
  • benign PE
  • possible swollen turbinates
  • cobblestoning of posterior pharynx
  • clear eye discharge
  • clear fluid behind TMs
60
Q

allergic disorders result from…

A

immune responses to exogenous and endogenous antigens that produce inflammation and tissue damage

61
Q

What type of hypersensitivity causes allergies

A
  • type I hypersensitivity

- IgE mediated immune response leads to release of inflammatory mediators from sensitized mast cells

62
Q

mast cells are located in areas that are exposed to _______, such as….

A

mast cells are located in areas that are exposed to antigens such as skin and mucous membranes of the respiratory tract

63
Q

What are mast cells filled with

A

mediators that initiate Type I hypersensitivity rxn

  • histamine
  • ACh
  • Kinins
64
Q

Histamine

A

-vasodilator and increases permeability of vessels (h1 receptor)

65
Q

actylcholine

A

-dilation of small vessels

66
Q

kinins

A
  • inflammatory peptides

- prompt influx of eosinophils & leukocytes to site of allergen contact

67
Q

Allergic triggers for seasonal allergic rhinitis

A
  • usually pollens
  • spring season b/c tree pollen
  • hay fever = seasonal allergic rhinitis
68
Q

allergic triggers for perennial allergic rhinitis

A
  • year round sx

- allergens often dust mites, family pets, mold spores

69
Q

Allergic treatment

A
  • avoidance therapy
  • drug therapy
  • immunotherapy
70
Q

avoidance therapy for seasonal vs perennial

A
  • seasonal stay in side during worst periods

- perennial control dust mites, pet dander

71
Q

allergic tx: drug therapy

A
  • inhibit release of mediators
  • inhibit action of released mediators on target cells
  • reversal of vascular and inflammatory responses
72
Q

allergic tx: immunotherapy

A

repeated long term injection of allergen in effect blunts the rxn

73
Q

allergic tx: nasal saline lavage

A

wash away mucus that may help deliver medication

74
Q

examples of drugs for allergic tx

A
  • antihistamines: H1 blockers
  • corticosteroids: nasal spray anti inflammatory
  • mast cell stabilizers: keep mast cell contents inside
  • anticholinergic agents: can stop mucus secretion
  • leukotriene antagonists: relieve sx, inhibit vascular permeability and eosinophilic inflammation
75
Q

what type of rhinitis is vasomotor rhinitis

A

nonallergic

76
Q

triggers of vasomotor rhinitis

A

cold air, strong odors, stress, inhaled irritants

77
Q

sx vasomotor rhinitis

A
  • rhinorrhea
  • sneezing
  • congestion
78
Q

vasomotor rhinitis is due to ___________ overactivity in the nasopharynx

A

parasympathetic overactivity

79
Q

tx vasomotor rhinitis

A
  • avoid known triggers
  • ipratropium anticholinergic nasal spray
  • oral antihistamines (anti cholinergic effect not anti hist effect)
  • intranasal antihistamine astelazine has antiinflammatory effect
  • sympathomimetics which promote vasoconstriction
80
Q

Other nonallergic rhinitis

A
  • occupational
  • hormonal
  • drug induced
  • gustatory
81
Q

nasal polyps are associated with what other conditions/disorders

A
  • asthma
  • chronic sinus infections
  • cystic fibrosis
  • allergic rhinitis
  • hypoosmia
82
Q

what are nasal polyps

A
  • inflamed outgrowth of nasal mucosa

- may be removed but most return

83
Q

nasal polyps triad (samter’s triad)

A

-chronic rhinitis, bronchial asthma & aspirin sensitivity, nasal polyps

84
Q

______ sensitivity is found in 1/3 patients with polyps, rhinosinusitis, and asthma

A

aspirin

85
Q

sx of samter’s triad on exposure to aspirin or nsaids

A
  • watery rhinorrhea
  • head, neck, chest flushing
  • bronchoconstriction
  • wheezing
  • nausea, vom, cramps (occasional)
86
Q

tx of samter’s triad

A

bronchodilators

HENT (7 decks)

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