rhinosinusitis Flashcards
when to image and do CT or xray of the sinus
if its unilateral ARS (foreign body, tumor, anatomic issue)
if surgery needed
if complications though -tumor or infxn of the sphenoid sinus can involve optic nerve, cavernous sinus and carotid artery
define 6 sx of ARS
persistent URI purulent rhinorrhea anosmia nasal congestion facial pain headache fever purulent discharge cough
how many episodes or ABRS do u need to have RARS
3
if you have allergic fungal rhinosinustis what entitity do u have wiht Eo
CRSwNP - some have AFRS allergic fungal rhinosinusitis (AFRS), which is a disntinct entity associated with eosinophillic mucin and type I hypersensitivty to fungi
tx is surgery and ssytemic or topical steroids
Consider systemic or topical antifungal as adjuvunctive treatment for AFRS
how you would manage CRS in CF patients
dornase alfa and/or antibiotic solutions in addition to endoscopic sinus surgery
children with reccurent otitis media, rhinosinusitis, and pnuemonia with bronchiectasis, if situs inversus
Diagnosis?
PCD
manage CRSwNP
oral steroids
Topical intranasal sterids
consider abx (better with CRSsNP)
give irrigiation
some benefit with rezlizumab or meolizumab
do NOT give terbinafine
rhinosinusitis refractory to medical therapy OR for ABRS in immunocompromised patient where pathogenic organisms determination is paramount.
what do you do?
antral puncture and irrigation
management of ARS in children
and CRS
mostly self limited
can do abx and INS
otherwise nothing else useful (irrigqation/decongestant//antihistamine/muclotyc)
with CRS
- INS is used, consider abx for acute exacerbation but not just CRS. surgery less used
consider adenoiectomy with or without maxilarry sinus irrigation as first line surgeical intervention
top three bugs of ARS
additional 2 for CRS
Bugs of ARBS Streptococus pneumonia H flu Moraxella catrahalis Additional bugs of CRS S aureus P aeruginosa Certain anaerobes
what is the diagnostic criteria for CRS
CPODS
12w
pressure and pain of face
nasal obstructin
discharge purulent
smell reduce
name 6 abx to use for ABRS
Treatment: 10-14d abx, if no improvement in 3-5d, change the abx Amox Amox clav Cefaclor Cefproxil Cefuroxime Cefixime Azithro Levo - avoid in childre Septra Doxy - avoid in children clinda
name the order of sinus development
Maxillary sinus first to pneumatization from birth to 12mo and floor of max sinus reaches nose at 12yo
Rudimentary ethmoid sinus present at birth and reach adult size at 12yo
Forntal and sphenoid start later and complete pneumatization in late adolescne
Frontal is absent in 15% of popn
Sphenoid is rudeimentary in 26% of patiemts
which three sinuses depend on the osteiomeatal complex
frontal, anterior ethmoid and maxiallary
what is a concha bullosa
if the ethmoid pneumatize into the head of the middle turbinate, it is called concha bullosa and extreme middle turbinate aeration which narrows the ostiomeatal complex which predipose to RS
The ostiomeatal complex is at risk from environemnetal exposure and its the most involved with CRS
how high is the pressure of sinus in ABRS
100 mm h20
causing pain from inflamed mucosa and intra sinus secretions presing on the walls of sinus
deep sea diving pressure can 350-500mm h20
what is the role of a biofilm in CRS
recalcitrant CRS can have sinonasal biofilm which is bacteria and fungi that anchor to mucsal surface and have towers with layers of embedded live bacteria with intervening water channels and mortar composed of bacterially extruded exo-polymeric matrix → allows for evading host defense, dec abx effectiveness and release of planktoic bacteria → implantation and population of new locations → acute infxn in indidual (possible genetic predispisition)
what bugs are in a middle meatus of healthy person
CONS, corynebacterium, S aureus and Propionobacterium acne
list the differential for CRS
Allergic rhinitis
Non allergic rhinitis: nonallergic rhinopathy, vasomotor rhinitis, non allergic rhinitis with nasal eosinophilia syndrome
Mixied rhinitis (allergic and non allergic components)
Rhinitis medicamentosa: decongestants, antiHTN (beta blocker), birth control pills
Rhinitis or Nasal congestion secondary to pregnancy, hypothyroidism, Horner syndrome, GPA, midline granuloma, peripapical abscess
Anatomic abormalities: FB, septal deviation, enlarged tonsil and adenoids, concha bullosa and other middle turbinate abnromalities, paradoxical curvature of the middle turbinate, haller cells
Migraine and facial pain syndromes
whats the EAR and LAR in allergic rhinitis
EAR is withi min of mast cell releae of yptase get the sneezing nad itchininess
LATE is 4-8 hours later and more with baso eo monocytie and th2 cells which increase IL4.513 and have CONGESTIOn as the mian sympyom
what are allergens for IT
grass - phl p 1 and 5 ragweed amb a 1 birch bet v 1 cat fel d 1 dog can f 1 HDM der p 1/2 der f 12
indications for AIT
1) symptosm induced by alelrgen exposure
2) failed conventional med therapy
3) no want long term meds
4) do not tolerate meds
5) worsening asthma and AR during peak pollen
6) venom
CONTrdaindication for AIT
1) beta blocker or Ace (except venom)
2) unctonrotled asthma
3) significant cardiovascular diseasw
reaction rates for AIT usu 73% within 30min
can be scored with AWAO subctu reaction grading systemi GRADE 1-5 (5 is death)
grade 1 is one system
grade 2 is MORE then oe system or (lower or gi sxO
grade 3 is lower resp (not respondign to bronchodialte) or upper airway closer
grade 4 is resp ro cardiovasc compromise
1) local reactions 1/20
2) anaphylaxis 2/1000 shots, and 2% of people
3) fatal 1/8 mllion
SPT
skin test 0.07% for allergen
venom is 0.3% of IDT
your patient has anaphylaxis to SCIT - wht is the next indicated dose
10% of prev dose
if mild ystemic 50%
name 7 reasons of inc risk of anaphylaxis to SCIT
- unctornoled asthma 705 fev1
- asthma sx before shot
- beta blockers
- prev hx of systemic rxn with shot
- IV isntead of IM
- new vial
- wrong dose
when should u avoid giving a SCIT when the patient arrives to prevent anahplyaxis
exercise 2 hours afer
sickness, astham worsening, resp illlness or fever
other things to prepare train your staff have equiptment wathc patient 30min slower buidl ups for sensitive patients ensure proceudres and tranign doen for staff
name 4 reasons to reduce doss
new vial
in pollen season
pt prev reactiod
longer interval
doses of SLIT and age range
wrriten as
ragwiteck 12 amb a 1 unit, sublinguil, disepends 30, refeill 5, first dose in alllergy clinic under obs
oral air 100, 200 and 300 IU 5-50yo 16w before
grasstek 2800 BAU 5-65 yo and 12 w before
ragwitcek 12 amb a 1 U - 18+_ 12 w
40% local sx, first week
eoe risk
pre seasonal dose for grass prescription?
CEntre AI grass immunotherapy
9 injectios, one week apart
injection 1-2 months before season
3 vial set (50 PNU, 500 PNU and 5000 PNU)
final maitnenace dose 0.3ml per injfection
(alum pre cipated grass 1500 PNU/in)
preseasonal ragweed rx
pollinex R start in JUNE
four injection total one weekly
top dose 2150 PNU in o.5ml
rejember its gluteraldehyde and adsorbed tto tryrosine to retain immunogeneticty and dec anaphylaxis
tyrosine releases slowly to dec anaphylaxis
wahts teh frist dose of VIT
0.1 ml of 0.01 mcg/ml solution and increase accoridng to product monogrpah for matienance dose goal of honey bee 1ml of 100 mcg/ml soltion
once build up complete then injection interval inc to monthly and usu for 5 years
mechanisms of AIT
can be useful for AD
?OAS
prevents kids from mono sens to poly sens and AR to asthma
1) dec end organ rwuith dec in EAR and LER - dec allergen induced Eo, baso and mast
blunt mucosal priming
reduce bronchial snesitive tto histamine
inc in T reg and Il10 and tgf beta
the2 to th1
igg1 and Igg4 and IgA increase - not correlated with icliniacl improvement
reasons for NOT improving on AIT
1) failure to remove the allergen
2) non alelrgen exposrue like tobacco
3) missing cliniaclyl relevant allergens
exposure to HIGH lerevbls og allergen
failure to treat with adequate dose
1 year after should have sx resolvement
