Rhinosinusitis Flashcards
1
Q
Big 3 bacterial bugs in rhino-sinusitis
A
strep pnuemo, Haemophilus influenza (H flu), M. cat
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
3
Q
What is ABRS
A
bacterial sinus infxn
maxillary, frontal, or ethmoid sinuses
4
Q
What type of onset is seen in ABRS?
A
acute onset
near-normal sinus fun prior to infxn
5
Q
What are two types of bacterial causes (not specific organisms)
A
- community acquired
- nosocomial
6
Q
What % of cold/flu like illnesses per year are bacterial?
A
0.5-2%
7
Q
what does ABRS result from? (what is infected)
A
infection of one or more parasinuses
8
Q
What is ABRS often associated with?
A
usually associated with common cold
-viral rhinosinusitis
9
Q
What % of viral rhino sinusitis develop bacterial sinusitis? and when?
A
2%
after 7-10 days
10
Q
Rhinitis leads to_____
A
sinusitis
11
Q
cold causes _______ which leads to ________
A
cold causes inflammation which leads to bacterial infection
12
Q
Examples of community acquired bacterial sinusitis
A
S. pneumoniae,
H. influenza,
M. catarrhalis & Group A strp
Staph aureus
13
Q
examples of causes of nosocomial bacterial sinusitis
A
- nasogastric tubes
- staph, pseudomonas, other gram-s
14
Q
Viruses don’t normally last longer than _____days
A
10 days
so greater than 10 days, think bacteria
15
Q
as soon as you clinically dx ABRS you should begin _____________ therapy
A
empiric antimicrobial therapy
16
Q
what empiric antimicrobial therapy i the recommendation for adults and children
A
augmentin
amoxicillin-clavulanate
17
Q
When do you use alternative management for ABRS
A
if symptoms worsen or fail to improve
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
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
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
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
22
Q
ABRS red flags
A
- abnormal vision
- change in mental status
- periorbital edema
- high fevers
23
Q
physical exam ABRS
-vitals
A
may be febrile, otherwise wnl
24
Q
physical exam ABRS
-eyes
A
possible clear discharge
25
physical exam ABRS
| -throat
- likely inflamed
- absence of tonsillar exudates
- possibe foul breath
- possible posterior drainage
- possible posterior pharyngeal cobblestoning if chronic drainage
26
physical exam ABRS
| -face
tenderness to palpation/percussion of maxillary and/or frontal sinuses
27
physical exam ABRS
| -neck
possible anterior cervical lymphadenopathy
28
physical exam ABRS
| -chest
normal exam, but cough possible
29
Whenever an inflammatory lesion is found, what should you look for?
involvement of there regional lymph nodes that drain it
30
if a node is enlarged or tender, what should you look for?
source such as infection in the area that it drains
31
What is Cobblestoning?
clumps of hypertrophied lymphoid tissue at the posterior pharynx
-due to chronic postnasal drainage and irritation of tissues
32
what are some ABRS tests
Transillumination, sinus puncture & aspiration, radiology (CT)
33
what does transillumination show you
asymmetry is significant (one sinus to the other)
34
What is the gold standard of ABRS tests?
sinus puncture & aspirate
| -but only done in clinical research
35
When should you consider doing a CT for ABRS
- with recurrent ABRS if you suspect a structural cause
| - shows abnormalities very well
36
ABRS Tx
- abx
- antiinflammatories (for pain/fever)
- decongestants
- expectorants (guaifenisen may help thin secretions)
- saline irrigation
37
What should you avoid in ABRS tx and why?
avoid 1st generation antihistamines (thicken secretions)
38
Always cover ________ when prescribing abx for ABRS
-cover the big 3 pathogens (three biggest suspects)
39
Ways to avoid abx resistance
- 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
complications of ABRS
- periorbital tissues
- osteomyelitis
- meningitis, brain abscess
- chronic sinusitis
41
what should always be a differential of sinusitis
paranasal sinus cancer
| persistent pain, epistaxis, prolonged clinical course
42
AVRS is like ABRS but ___
less so
43
AVRS sx lack the ______
ABRS-specific signs
44
duration of AVRS compared to ABRS
AVRS shorter duration
45
Complaints in AVRS similar to ABRS
- congestion
- nasal discharge, postnasal drip
- headache, pressure, possible tenderness
- fluid in sinuses
- possbile associated hx of allergies
46
AVRS treatment
- treat sx
- avoid abs
- be alert for ABRS
47
goal of viral treatments of sinusitis
- block the inflammation events
| - nasal fluid production & inflammation
48
Options for viral tx to block inflammation
- antihistamines
- NSAIDs
- cough suppressant
- decongestants
- mucolytics
49
What is recurrent sinusitis vs. chronic sinusitis
recurrent sinusitis- 4 or more episodes per year with absent sx between episodes
50
Chronic sinusitis formally includes
>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
causes of chronic sinusitis (etiology)
- 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
all of the chronic sinusitis causes affect _____________
mucociliary clearance
53
Physical exam findings for chronic sinusitis
| -nasal exam with speculum
-purulent drainage, polyps, septal deviation, turbinate hypertrophy/edema
54
Chronic sinusitis studies:
| Endoscopically guided culture
from middle meatus, especially if empiric tx fails
55
Chronic sinusitis studies:
| -maxillary sinus tap
not done often b/c pain and reliable cultures rom middle meatus
56
Chronic sinusitis causes (what organisms)
staph aureus, coagulase negative staph, anaerobes, gram-neg, fungus
57
chronic sinusitis tx
- abx (choice dictated by culture)
| - intranasal steroids, saline, ,oral steroids, decongestants, mucolytics
58
allergic (non infectious ) rhinosinusitis sx
- clear rhinorrhea with associated allergic symptoms
- allergic shiners (?)
- allergic salute
- transverse nasal crease
59
allergic rhino sinusitis physical exam findings
- benign PE
- possible swollen turbinates
- cobblestoning of posterior pharynx
- clear eye discharge
- clear fluid behind TMs
60
allergic disorders result from...
immune responses to exogenous and endogenous antigens that produce inflammation and tissue damage
61
What type of hypersensitivity causes allergies
- type I hypersensitivity
| - IgE mediated immune response leads to release of inflammatory mediators from sensitized mast cells
62
mast cells are located in areas that are exposed to _______, such as....
mast cells are located in areas that are exposed to antigens such as skin and mucous membranes of the respiratory tract
63
What are mast cells filled with
mediators that initiate Type I hypersensitivity rxn
- histamine
- ACh
- Kinins
64
Histamine
-vasodilator and increases permeability of vessels (h1 receptor)
65
actylcholine
-dilation of small vessels
66
kinins
- inflammatory peptides
| - prompt influx of eosinophils & leukocytes to site of allergen contact
67
Allergic triggers for seasonal allergic rhinitis
- usually pollens
- spring season b/c tree pollen
- hay fever = seasonal allergic rhinitis
68
allergic triggers for perennial allergic rhinitis
- year round sx
| - allergens often dust mites, family pets, mold spores
69
Allergic treatment
- avoidance therapy
- drug therapy
- immunotherapy
70
avoidance therapy for seasonal vs perennial
- seasonal stay in side during worst periods
| - perennial control dust mites, pet dander
71
allergic tx: drug therapy
- inhibit release of mediators
- inhibit action of released mediators on target cells
- reversal of vascular and inflammatory responses
72
allergic tx: immunotherapy
repeated long term injection of allergen in effect blunts the rxn
73
allergic tx: nasal saline lavage
wash away mucus that may help deliver medication
74
examples of drugs for allergic tx
- 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
what type of rhinitis is vasomotor rhinitis
nonallergic
76
triggers of vasomotor rhinitis
cold air, strong odors, stress, inhaled irritants
77
sx vasomotor rhinitis
- rhinorrhea
- sneezing
- congestion
78
vasomotor rhinitis is due to ___________ overactivity in the nasopharynx
parasympathetic overactivity
79
tx vasomotor rhinitis
- 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
Other nonallergic rhinitis
- occupational
- hormonal
- drug induced
- gustatory
81
nasal polyps are associated with what other conditions/disorders
- asthma
- chronic sinus infections
- cystic fibrosis
- allergic rhinitis
- hypoosmia
82
what are nasal polyps
- inflamed outgrowth of nasal mucosa
| - may be removed but most return
83
nasal polyps triad (samter's triad)
-chronic rhinitis, bronchial asthma & aspirin sensitivity, nasal polyps
84
______ sensitivity is found in 1/3 patients with polyps, rhinosinusitis, and asthma
aspirin
85
sx of samter's triad on exposure to aspirin or nsaids
- watery rhinorrhea
- head, neck, chest flushing
- bronchoconstriction
- wheezing
- nausea, vom, cramps (occasional)
86
tx of samter's triad
bronchodilators
