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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
imaging for AFRS
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
26
most common findings in CRS
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
27
in what conditions is sinus opacification seen
seen in persistent bacterial infection, purulent secretions, mucus inspissation, polypoid mucosal thickening or an accumulation of allergic mucin
28
diagnosis of CRS
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
29
can CRS be cured
most cases cannot
30
goal of tx of CRS
reduce sx + improve QOL
31
tx of CRS w NP
``` oral glucocorticoids (shrink polyps) nasal glucocorticoids to follow add leukotriene inhibitor for maintenance ```
32
tx of CRS w/o NP
``` oral glucocorticoids Abx for 6wks (7days after sx clear) follow w nasal glucocorticoids 2nd gen H1 antihistamines leukotriene inhibitors ```
33
tx of allergic fungal rhinosinusitis
surgery to remove inspissated mucus | prolonged course of oral glucocorticoids
34
what is rhinosinusitis
inflammation of sinuses that rarely occurs 2/o concurrent inflammation of nasal mucosa
35
maxillary sinuses
largest sinuses, located behind cheeks
36
frontal sinuses
in midface over the eyes + drain through frontal recess into hiatus semilunaris in ostiomeatal complex
37
ethmoid sinuses
btw eyes behind bridge of nose filled w fluid at birth | pneumatization of ethmoids begins at 1yr
38
paranasal sinuses
paired, air filled cavities located in anterior midface | each has an ostium (distinct bony opening) through which it drains
39
how does the ostium connect to disease processes
disease may lead to obstruction of ostia +/or nasal cavity --> nasal congestion + obstructive sx
40
sphenoid sinus
behind eyes + nasal structures- present at birth | pneumatization begins around age 3 + continues to develop throughout adulthood
41
ostiomeatal complex
series of narrow bony openings + clefts along lateral wall of nose
42
what is included in ostiomeatal complex
includes middle turbinates, uncinate process, hiatus semilunaris, ethmoid bulla + natural ostium of maxillary sinus
43
functions of paranasal sinus
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
classifications of rhinosinusitis
acute (<4wks)- includes viral + bacterial subacute (4-12wks) chronic (>12wks) recurrent acute rhinosinusitis
45
recurrent acute rhinosinusitis
4+ episodes of ARS/yr w interim sx resolution
46
what is the most common cause of acute rhinosinusitis
viral- rhinovirus, influenza virus, parainfluenza virus
47
what percent of viral rhinosinusitis is complicated by bacterial infection
0.5-2%
48
how does acute viral rhinitis begin
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
how does viral rhinitis spread to paranasal sinuses
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
sx of acute viral rhinosinusitis
``` 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
physical exam for acute viral rhinosinusitis
``` viral signs HEENT exam assess for sinus tenderness lymph nodes chest/lungs ```
52
what is the best way to localize pain from acute viral rhinosinusitis to the sinuses
have pt bend forward | percussing sinuses is less reliable
53
findings of otoscopic exam in acute viral rhinosinusitis
``` diffuse mucosal edema narrowing of middle meatus inferior turbinate hypertrophy copious rhinorrhea or purulent discharge polyps or septal deviation ```
54
major symptoms for diagnosis of acute viral rhinosinusitis
``` purulent anterior/posterior nasal discharge nasal congestion/obstruction facial congestion or fullness hypomia or anosmia fever (in acute only) ```
55
minor sx for diagnosis of acute viral rhinosinusitis
``` headache ear pain/pressure/fullness halitosis dental pain fever (subacute or chronic) fatigue ```
56
diagnostics for acute viral rhinosinusiis
``` nasal culture endoscopic culture radiology studies sinus x ray ct scan MRI ```
57
nasal culture for rhinosinusitis
not reflective of sinus contents + should not be used to guide tx viral culture unnecessary, bacterial culture not reliable
58
when is an endoscopic culture for rhinosinusitis indicated
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
are x rays indicated in AVRS
not in initial eval of uncomplicated AVRS | not adequate because abnormalities detected are neither sensitive nor specific for rhinosinusitis
60
common CT findings in AVRS
air-fluid level mucosal edema air bubble w.i sinuses some mucosal abnormality also seen in healthy pts
61
imaging modality of choice for rhinosinusitis
ct scan if there is complication or involvement of orbital intracranial soft tissue
62
tx of acute viral rhinosinusitis
``` resolves w.i 10 days relieve sx encourage fluids, OTC decongestants intranasal corticosteroids limit decongestants to 3-5 days to avoid rhinitis medicamentosa ```
63
does tx of AVRS shorten clinical course
no
64
how long do sx of acute bacterial rhinosinusitis usually last
>7-10days
65
sx of acute bacterial rhinosinusitis
purulent discharge often unilateral sinus pain worse when bending forward URI that began to improve then worsened
66
most common bacteria that cause ABRS
S.pneumo H.flu M.cat
67
what causes ABRS
community acquired- secondary infection of inflamed sinus cavity; usually a complication of viral infection bacteria
68
predisposing factors of ABRS
``` allergy nasal mechanical obstruction tooth infection impaired mucociliary clearance (cystic fibrosis) immunodeficiency smoker intranasal cocaine use ```
69
who is at risk for nosocomial acquired ABRS
extended stay in ICU burn victim prolonged intubation (Esp. nasotracheal)
70
how does nosocomial acquired ABRS usually present
fever of unknown origin
71
what bacteria are most likely responsible for nosocomial acquired ABRS
``` G- p.aeruginosa klebsiella pneumonia enterobacter proteus mirabilis serratia marcescens ``` G+ s.aureus
72
how do you treat ABRS
may resolve spontaneously w.i 1st 10 days | watchful waiting or abx
73
antimicrobial tx of ABRS
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
amoxicillin for ABRS
previously 1st line b/c of narrow spectrum + low cost increased resistance dont use
75
augmentin for ABRS
covers resistand H.flu + M.cat 5-7 day course shorter course is recommended
76
doxycycline for ABRS
reasonable for 1st line DOC in pt w PCN allergy avoid sunlight while on doxy
77
if ABRS pt fails to respond to abx in 3-5 days after or worsens after 2-3 days on abx....
switch to augmentin
78
if ABRS pt has orbital, epidural/brain abscess or meningitis...
PROMPT HOSPITALIZATION
79
invasive fungal rhinosinusitis
acute disease of immunocompromised (HIV, heme malignancies, chemo-induced neutropenia, organ transplant) or pt w poorly-controlled diabetes
80
most common species of invasive fungal rhinosinusitis
``` mucor rhizopus aspergillus absidia basidiobolus ```
81
clinical presentation of invasive fungal rhinosinusitis
``` immunocompromised pt w sinus complaints (primarily facial pain) nasal congestion +/- fever epistaxis facial numbness/diplopia if CN involved ```
82
physical exam of pt w invasive fungal rhinosinusitis
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
diagnosis of invasive fungal rhinosinusitis
pathology of fungal invasion of affected areas done by ENT via endoscope immediate referral if fungal rhinosinusitis is suspected
84
tx of invasive fungal rhinosinusitis
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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