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clin med I exam II > rhinosinusitis > Flashcards

rhinosinusitis Flashcards

1
Q

what is chronic rhinosinusitis

A

inflam disorder of paranasal sinuses + linings of nasal passages lasting >12wks
may present abruptly as nonspecific URI, acute over months or yrs, occasionally as sinusitis that fails to resolve, slowly + insidiously (may be relatively acute presentation w severe headaches or facial pain or visual changes)

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2
Q

3 subtypes of chronic rhinosinusitis

A

CRS w nasal polyposis (20-33%)
CRS w/o nasal polyposis (60-65%)
allergic fungal rhinosinusitis (AFRS 8-12%)

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3
Q

what age group is most affected by chronic rhinosinusitis

A

younger or middle-aged adults

but can also occur in children

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4
Q

risk factors for rhinosinusitis

A

allergic rhinitis
asthma
CRS pts are typically sensitized to perennial rather than seasonal allergies
smoking
sustained exposure to irritants/pollutants (Dec mucociliary function)
immunodeficiency
defects in mucociliary clearance (cystic fibrosis, nasal polyposis)
viral or dental infections
anatomic abnormalities
drug-resistant infections

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5
Q

diagnosis of chronic rhinosinusitis

A

12wk duration + 2/4 cardinal sx of CRS must be present
anterior and/or posterior mucopurulent drainage
nasal obstruction (bilateral)
facial pain, pressure +/or fullness
decreased sense of smell (cough in children)

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6
Q

CRS w nasal polyposis

A

presence of BILATERAL nasal polyps in middle meatus

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7
Q

what are nasal polyps

A

translucent, yellowish-gray to white, glistening masses filled w gelatinous inflamm material
can form in nasal cavity or paranasal sinuses

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8
Q

presentation of CRS w nasal polyposis

A

gradually worsening nasal congestion/obstruction
sinus fullness + pressure
fatige
posterior nasal drainage + hyposmia or anosmia
fever + severe facial pain (uncommon)

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9
Q

what is associated w CRS w nasal polyposis

A

asthma

ADR to aspirin + other COX-1 NSAIDs (occur w.i 1-4hrs after ingestion)

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10
Q

imaging for CRS w nasal polyposis

A

CT shows characteristically marked + bilateral mucosal thickening
density of polyps is similar to thickened mucosa but polyps are differentiated by shape + contours
sinus opacification in absence of facial pain/pressure/headaches is typical of pt w CRS w NP + is unlikely to represent chronic bacterial infection

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11
Q

how can you see nasal polyps

A

large polyps- anterior rhinoscopy

small polyps- nasal endoscopy or imaging

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12
Q

what is commonly mistaken for nasal polyps

A

swollen nasal turbinates

turbinates have similar appearance to nasal mucosa + are very sensitive to touch

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13
Q

where do nasal polyps typically begin to form

A

ostiomeatal complex

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14
Q

what is samters triad

A

pt has combo of astha, CRS w NP and aspirin sensitivity

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15
Q

what is aspirin sensitivity

A

non allergic- not IgE based, blockage of COX-1 leads to excess of leukotrienes

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16
Q

if a pt experiences onset of asthma as an adult is it a true allergy

A

no

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17
Q

presentation of CRS w/o polyposis

A

persistent sx w periodic exacerbations characterized by increased facial pain/pressure +/or increased anterior or posterior drainage
fatigue
absent or low grade fever

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18
Q

what pts get CRS w.o polyposis

A

allergic + nonallergic rhinitis
structural abnormalities
immunodeficiency

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19
Q

imaging of CRS w.o polyposis

A

CT shows sinus opacification or sinus ostial obstruction w nonpolypoid mucosal thickening of associated sinus cavity

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20
Q

tx of CRS w.o polyposis

A

recurrent acute rhinosinusitis sx- respond well to abx

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21
Q

what causes allergic fungal rhinosinusitis

A

chronic, intense allergic inflamm directed at colonizing fungi

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22
Q

presentation of allergic fungal rhinosinusitis

A

immunocompetent pt w allergy to 1+ fungi
presents subtly over years w symptoms similar to CRS w NP but has presence of allergic mucin containing viable fungal hyphae
usually have nasal polyposis
semi-solid nasal crusts or rubbery globs of dark-colored mucus periodically expelled
fever is uncommon
occasional pts present dramatically w complete nasal obstruction, gross facial asymmetry +/or visual changes
children may present w proptosis more commonly than adults

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23
Q

what distinguishes AFRS from CRS w NP?

A

presence of allergic mucin containing viable fungal hyphae

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24
Q

physical exam of pt w AFRS

A

purulent mucus or edema in middle meatus or ethmoid regions

polyps in nasal cavity or middle meatus

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25
Q

imaging for AFRS

A

CT scan of sinsues- modality of choice
usually reveals nasal polyposis w opacification in 1+sinus
characteristic CT finding- hyperattenuated mucin w.i opacified sinuses which indicate dense accumulation of allergic mucin

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26
Q

most common findings in CRS

A

mucosal thickening- suggests infection/obstruction of sinus ostium
obstruction of ostiomeatal complex- variable degrees
sinus opacification- complete filling of sinus w inflam material or fluid

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27
Q

in what conditions is sinus opacification seen

A

seen in persistent bacterial infection, purulent secretions, mucus inspissation, polypoid mucosal thickening or an accumulation of allergic mucin

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28
Q

diagnosis of CRS

A

1+ of the following
purulent mucus/edema in middle meatus or ethmoid regions
polyps in nasal cavity or middle meatus
radiographic imaging demonstrating mucosal thickening or partial or complete opacification of paranasal sinuses

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29
Q

can CRS be cured

A

most cases cannot

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30
Q

goal of tx of CRS

A

reduce sx + improve QOL

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31
Q

tx of CRS w NP

A 
oral glucocorticoids (shrink polyps)
nasal glucocorticoids to follow
add leukotriene inhibitor for maintenance
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32
Q

tx of CRS w/o NP

A 
oral glucocorticoids
Abx for 6wks (7days after sx clear)
follow w nasal glucocorticoids
2nd gen H1 antihistamines
leukotriene inhibitors
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33
Q

tx of allergic fungal rhinosinusitis

A

surgery to remove inspissated mucus

prolonged course of oral glucocorticoids

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34
Q

what is rhinosinusitis

A

inflammation of sinuses that rarely occurs 2/o concurrent inflammation of nasal mucosa

35
Q

maxillary sinuses

A

largest sinuses, located behind cheeks

36
Q

frontal sinuses

A

in midface over the eyes + drain through frontal recess into hiatus semilunaris in ostiomeatal complex

37
Q

ethmoid sinuses

A

btw eyes behind bridge of nose filled w fluid at birth

pneumatization of ethmoids begins at 1yr

38
Q

paranasal sinuses

A

paired, air filled cavities located in anterior midface

each has an ostium (distinct bony opening) through which it drains

39
Q

how does the ostium connect to disease processes

A

disease may lead to obstruction of ostia +/or nasal cavity –> nasal congestion + obstructive sx

40
Q

sphenoid sinus

A

behind eyes + nasal structures- present at birth

pneumatization begins around age 3 + continues to develop throughout adulthood

41
Q

ostiomeatal complex

A

series of narrow bony openings + clefts along lateral wall of nose

42
Q

what is included in ostiomeatal complex

A

includes middle turbinates, uncinate process, hiatus semilunaris, ethmoid bulla + natural ostium of maxillary sinus

43
Q

functions of paranasal sinus

A

reduce skull weight
vocal resonance
protect important structures (Eyes, dental roots) against temp extremes
protect vital structures in case of facial trauma
humidify + heat inhaled air

44
Q

classifications of rhinosinusitis

A

acute (<4wks)- includes viral + bacterial
subacute (4-12wks)
chronic (>12wks)
recurrent acute rhinosinusitis

45
Q

recurrent acute rhinosinusitis

A

4+ episodes of ARS/yr w interim sx resolution

46
Q

what is the most common cause of acute rhinosinusitis

A

viral- rhinovirus, influenza virus, parainfluenza virus

47
Q

what percent of viral rhinosinusitis is complicated by bacterial infection

A

0.5-2%

48
Q

how does acute viral rhinitis begin

A

viral inoculation via contact w conjunctiva or nasal mucosa
viral replication leads to detectable levels in 8-10 hrs
sx develop in first day after inoculation

49
Q

how does viral rhinitis spread to paranasal sinuses

A

direct or indirect
nose blowing propels fluid from nasal cavity to sinuses
direct toxic effect on nasal cavity cilia causing dec motility
mucosal edema, thick secretions + ciliary dyskinesia obstruct sinsues

50
Q

sx of acute viral rhinosinusitis

A 
sx for <4wks (usually <10days)
nasal congestion/obstruction
purulent nasal discharge
fever + fatigue
cough
hyposmia/anosmia
ear pressure
headache
maxillary tooth discomfort
halitosis
facial pain/pressure worse w bending forward
51
Q

physical exam for acute viral rhinosinusitis

A 
viral signs
HEENT exam
assess for sinus tenderness
lymph nodes
chest/lungs
52
Q

what is the best way to localize pain from acute viral rhinosinusitis to the sinuses

A

have pt bend forward

percussing sinuses is less reliable

53
Q

findings of otoscopic exam in acute viral rhinosinusitis

A 
diffuse mucosal edema
narrowing of middle meatus
inferior turbinate hypertrophy 
copious rhinorrhea or purulent discharge
polyps or septal deviation
54
Q

major symptoms for diagnosis of acute viral rhinosinusitis

A 
purulent anterior/posterior nasal discharge
nasal congestion/obstruction
facial congestion or fullness
hypomia or anosmia
fever (in acute only)
55
Q

minor sx for diagnosis of acute viral rhinosinusitis

A 
headache
ear pain/pressure/fullness
halitosis
dental pain
fever (subacute or chronic)
fatigue
56
Q

diagnostics for acute viral rhinosinusiis

A 
nasal culture
endoscopic culture
radiology studies
sinus x ray 
ct scan 
MRI
57
Q

nasal culture for rhinosinusitis

A

not reflective of sinus contents + should not be used to guide tx
viral culture unnecessary, bacterial culture not reliable

58
Q

when is an endoscopic culture for rhinosinusitis indicated

A

when pt is not responding to empiric abx therapy or if there is concern for intracranial extension of infection
performed by ENT, usually in their office

59
Q

are x rays indicated in AVRS

A

not in initial eval of uncomplicated AVRS

not adequate because abnormalities detected are neither sensitive nor specific for rhinosinusitis

60
Q

common CT findings in AVRS

A

air-fluid level
mucosal edema
air bubble w.i sinuses
some mucosal abnormality also seen in healthy pts

61
Q

imaging modality of choice for rhinosinusitis

A

ct scan if there is complication or involvement of orbital intracranial soft tissue

62
Q

tx of acute viral rhinosinusitis

A 
resolves w.i 10 days
relieve sx 
encourage fluids, OTC decongestants
intranasal corticosteroids
limit decongestants to 3-5 days to avoid rhinitis medicamentosa
63
Q

does tx of AVRS shorten clinical course

A

no

64
Q

how long do sx of acute bacterial rhinosinusitis usually last

A

> 7-10days

65
Q

sx of acute bacterial rhinosinusitis

A

purulent discharge
often unilateral
sinus pain worse when bending forward
URI that began to improve then worsened

66
Q

most common bacteria that cause ABRS

A

S.pneumo
H.flu
M.cat

67
Q

what causes ABRS

A

community acquired- secondary infection of inflamed sinus cavity; usually a complication of viral infection
bacteria

68
Q

predisposing factors of ABRS

A 
allergy
nasal mechanical obstruction
tooth infection
impaired mucociliary clearance (cystic fibrosis)
immunodeficiency
smoker
intranasal cocaine use
69
Q

who is at risk for nosocomial acquired ABRS

A

extended stay in ICU
burn victim
prolonged intubation (Esp. nasotracheal)

70
Q

how does nosocomial acquired ABRS usually present

A

fever of unknown origin

71
Q

what bacteria are most likely responsible for nosocomial acquired ABRS

A 
G-
p.aeruginosa
klebsiella pneumonia
enterobacter
proteus mirabilis
serratia marcescens

G+
s.aureus

72
Q

how do you treat ABRS

A

may resolve spontaneously w.i 1st 10 days

watchful waiting or abx

73
Q

antimicrobial tx of ABRS

A

empirical
culture-guided is optimal but obtaining cultures requires endoscopy + is generally reserved for pts w complications

amoxicillin
augmentin
doxycycline

others- not recommended for empirical therapy
macrolides
respiratory fqs
bactrim (Rarely)
2nd or 3rd gen CPN
74
Q

amoxicillin for ABRS

A

previously 1st line b/c of narrow spectrum + low cost
increased resistance
dont use

75
Q

augmentin for ABRS

A

covers resistand H.flu + M.cat
5-7 day course
shorter course is recommended

76
Q

doxycycline for ABRS

A

reasonable for 1st line
DOC in pt w PCN allergy
avoid sunlight while on doxy

77
Q

if ABRS pt fails to respond to abx in 3-5 days after or worsens after 2-3 days on abx….

A

switch to augmentin

78
Q

if ABRS pt has orbital, epidural/brain abscess or meningitis…

A

PROMPT HOSPITALIZATION

79
Q

invasive fungal rhinosinusitis

A

acute
disease of immunocompromised (HIV, heme malignancies, chemo-induced neutropenia, organ transplant) or pt w poorly-controlled diabetes

80
Q

most common species of invasive fungal rhinosinusitis

A 
mucor
rhizopus
aspergillus
absidia
basidiobolus
81
Q

clinical presentation of invasive fungal rhinosinusitis

A 
immunocompromised pt w sinus complaints (primarily facial pain)
nasal congestion 
\+/- fever
epistaxis
facial numbness/diplopia if CN involved
82
Q

physical exam of pt w invasive fungal rhinosinusitis

A

same as other rhinosinusitis
nares + oropharynx examined for necrotic tissue (from vascular invasion) - can appear as palatal gingival eschars or sloughing of the nasal septum w perforation

83
Q

diagnosis of invasive fungal rhinosinusitis

A

pathology of fungal invasion of affected areas
done by ENT via endoscope
immediate referral if fungal rhinosinusitis is suspected

84
Q

tx of invasive fungal rhinosinusitis

A

amp B
voriconazole
urgent surgical eval for diagnostic biopsy + debridement
restoration of immune function or control of underlying dz

clin med I exam II (10 decks)

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