Rhinosinusitis

Question 1

define

Answer 1

inflammation of nose and paranasal sinuses with ≥2 symptoms, one of which must be nasal congestion or discharge

Question 2

other symptoms

Answer 2

facial pain or pressure

decreased olfaction

endoscopic signs of nasal polyps or mucus ± pus discharged primarily from the sinuses

sneezing, itch, crusting, epistaxis

Question 3

what may a CT show

Answer 3

mucosal changes within the sinuses

Question 4

2y symptoms

Answer 4

dry mouth, sore throat, snoring, halitosis, loss of taste

Question 5

nasal examination

Answer 5

airway patency

external nose - front, sides, behind

rhinscopy

Question 6

how does one examine for nasal patency

Answer 6

cold metal to visualize steam under nostrils or block one nostril and ask patient to sniff

Question 7

investigations

Answer 7

test for allergy -skin prick and RAST to measure specific IgE levels

Question 8

what is there a risk of with skin prick test

Answer 8

severe allergic or anaphylactic reaction

Question 9

mechanism of action of corticosteroids

Answer 9

• Anti-inflammatory: cause vasodilation and inhibit prostaglandin formation

Question 10

how long can steroid puffers and drops be used for

Answer 10

• Steroid puffers may be used indefinitely, but steroid drops are systemically absorbed so must be used for <1 month at a time, <6 times a year

Question 11

mechanism of action of anti histamines

Answer 11

• Block H₁ histamine receptors

Question 12

mechanism of action of decongestants

Answer 12

eg pseudoephedrine

• Vasoconstrictors that shrink the lining of the nose allowing one to breathe
• Reduction of blood supply can cause rebound congestion

Question 13

mechanism of action of anti-cholinergics

Answer 13

block muscarinic ACh receptors - reducing parasympathetic activity

Question 14

mechanism of action of LTR blockers

Answer 14

eg montelukast

• Block CysLT receptors, which when activated by mast cell derived CysLTs (e.g. LTC₄) cause smooth muscle contraction, oedema and mucus secretion
• Mast cell activation causes release of arachidonic acid, which stimulates LTA₄

Question 15

describe the immunology of allergic rhinitis

Answer 15

IgE mediated inflammation from allergen exposure to nasal mucosa causing inflammatory mediator release from mast cells (preformed histamine, tryptase and heparin and other inflammatory mediators that are synthesized on demand e.g. leukotrienes, prostaglandins and cytokines)

Fc part of IgE antibody binds to Fc receptor on mast cells on 1st exposure, on subsequent exposure the allergen binds to the bound IgE and causes mast cell degranulation

Question 16

what can cause intermittent allergic rhinitis

Answer 16

grass pollen (hayfever), tree pollen (in spring) and fungal spores

Question 17

what can cause persistent allergic rhinitis

Answer 17

house dust mite, cat or dog

Question 18

criteria for intermittent/persistent ARIA classification of allergic rhinitis

Answer 18

intermittent: ≤4 days/week or ≤4 weeks
persistent: >4 days/week and >4 weeks

Question 19

criteria for mild/moderate-severe ARIA classification of allergic rhinitis

Answer 19

impairement of/abnormal:

• sleep
• work and school
• daily activities, sport, leisure

troublesome symptoms?

Question 20

symptoms of allergic rhinitis

Answer 20

sneezing, pruritus, rhinorrhoea (bilateral and variable)

Question 21

signs of allergic rhinitis

Answer 21

skin tests may show allergen, consider RAST

allergic crease from rubbing nose (itch)

turbinates may be swollen and mucosae pale or mauve

nasal polyps

Question 22

managment ladder of allergic rhinitis

Answer 22

Question 23

when is surgery indicated in allergic rhinitis

Answer 23

fibrosis and scarring due to chronic inflammation

Question 24

non-allergic rhinitis

Answer 24

vasomotor rhinitis - parasympathetic stimulation causes excessive secretion from nasal gland and vasodilation and engorgement, leading to rhinorrhoea and nasal congestion

Question 25

causes of non-allergic rhinitis

Answer 25

drug induced, hormonal (anxiety, stress, hyperventilation), idiopathic, occupational (dry/cold air)

emotions play a significant role as the ANS is under control of the hypothalamus

Question 26

treatment of non-allergic rhinitis

Answer 26

muscarinic ACh receptor antagonist eg ipatropium

Question 27

what can non-allergic rhinitis often lead to the development of

Answer 27

nasal polyps

Question 28

symptoms of acute infective rhinosinusitis

Answer 28

facial pain, discharge (green/yellow), nasal blockage

Question 29

causes of acute infective rhinosinusitis

Answer 29

98% are viral - from URTI

Question 30

management of acute infective rhinosinusitis

Answer 30

decongestant and analgesic

if persistent or worsening add an ABx

Question 31

complications of rhinosinusitis

Answer 31

orbital cellulitis - spread from ethmoid sinuses to orbit

cavernous sinus thrombosis

Question 32

other causes of stuffy nose

Answer 32

• Enlarged adenoids can block nose and Eustachian tube
• Foreign body
• Tumour (unilateral symptoms)
• The Pill

Question 33

what would make you suspect development of cavernous sinus thrombosis

Answer 33

• Symptoms: decrease/loss of vision, chemosis, exophthalmos, headaches, paralysis of cranial nerves which course through the cavernous sinus (CNIII, IV, V1, V2 and VI)