rhinosinusitis Flashcards
when evaluating a pt with sinusitis-like symptoms, what will you expect if they start with a runny nose? sore throat? if there is presence of exudate?
runny nose: sinusitis
sore throat: strep
exudate: bacterial over viral
what is the likely cause of rhinosinusitis?
viral: makes up 90-99% of sinusitis cases
bacterial 0.5-2% …except in children admitted to ER for high fever.. liklihood for either is about the same
which clinical presentations qualify pts to be evaluated for AVRS vs ABRS (one of three)?
- PERSISTENT S&S of rhinosinusitis for >10 days, no improvement
- SEVERE symp (high fever, purulent nasal discharge, or facial pain): 3-4 consecutive days
- WORSENING symp. or “double-sickening” (better then worse again) >3-4 days.
what do we use for empiric treatment of ABRS in children and adults?
Amox-clav (augmentin)
what 5 pt populations are at risk for antibiotic resistance?
<2 or >65, daycare prior ABX in past month prior hospitalization in the past 5 days comorbidities immunocomprimised
what symptomatic management will you use for pts with AVRS or ABRS? those at risk for Abx resistance? those not at risk?
at risk: 2nd-line antimicrobial therapy
no risk: 1st line antimicrobial therapy
for both at-risk and not at risk pts what do you do if they are improving on treatment in 3-5 days?
at-risk: complete 7-10 days of abx
not at-risk: complete 5-7 days of abx
what to do if pt (at-risk or not at-risk) if worsening or no improvement in 3-5 days?
if improvement?
if still no improvement in 3-5 days after?
broaden coverage or switch to another abx class
improvement:
no-risk: finish 5-7 days
at-risk: finish 7-10 days
if still not improving 3-5 days, refer to specialist:
- sinus CT or MRI
- direct sinus puncture culture/sinus tap (GOLD STANDARD) or middle meatal cultures
by definition a URI (cold) is bacterial or viral?
viral
bacterial sinusitis: what are the two causes?
community acquired: S. PNEUMO, H. FLU, M. CATARRHALIS & Strep A, Staph (caps= 3 most common)
nosocomial (hospital): nasogastric tubes, staph/pseudomonas/other gram neg.
what does “high value care” mean?
that the test is WORTH doing, not necessarily that it is cheap
what three signs/symptoms distinguish bacterial from viral?
foul odor dental pain (maxillary) ansomnia (can't smell)
what are the 4 red flags for ABRS?
- abnormal vision, esp double vision
- periorbital edema
- change in mental status (could be brain infection)
- very high fever (esp. bad if adult)
ABRS PE: vital signs, eyes, nose, throat, face, neck, chest
Vital signs – may be febrile, otherwise wnl
Eyes – possible clear D/C, otherwise wnl
Nose – turbinates swollen, possible purulent D/C visible
Throat – likely inflamed, absence of tonsillar exudates, possible foul breath, possible posterior drainage, possible posterior pharyngeal cobblestoning if chronic drainage
Face – tenderness to palpation/percussion of maxillary and/or frontal sinuses
Neck – possible anterior cervical lymphadenopathy
Chest – normal exam, but cough possible
what is cobble-stoning in the throat? what is a sign of ?
clumps of hypertrophic lymphoid tissue @ posterior pharynx
chronic inflammation, significant PND
3 tests for ABRS
- transillumination: shine light through sinus into the mouth, only significant if asymm (detects if sinus is full)
- sinus puncture/sinus tap & aspirate (GOLD STANDARD) but only done in clinical research
- radiology: CT for recurrent ABRS (maybe a structural cause)
treatment for ABRS
cover big 3 pathogens (M. Catt, H. Flu, S. Pneumo)
- amox-clav (augmentin
- if PCN allergic….3rd gen cephalosporins
- respiratory fluoroQs (levofloxacin) ONLY if no other good alternative (bad ADRs)
* 5-7 txt for adults, 10-14 for kids, longer txt for chronic or recurrent
* once symptoms subside, take for 2 more days the stop
what should always be included in Ddx of sinusitis?
paranasal sinus cancer (persistent pain, epistaxis, prolonged clinical course)
AVRS vs ABRS: S&S?
same S&S, viral is less severe (aka URI)
almost never have a fever
resolves on its own 5-7 days (shorter than ABRS)
Hadley’s txt of garden variety sinus infections
- bacterial = augmentin
- afrin: 2 sprays BID for 4 days
- anti-inflamm meds for comfort (ibuprofen or naproxen)
- guafenesin (mucinex/robitussin) & fluids
- saline rinse
- allergic trigger? nasal steroid spray w/ afrin (maybe chronic antiHistamine?)
- pt education
AVRS txt: what events do you want to block? what 5 meds do you want to use?
block inflamm events: nasal fluid production & inflamm. meds: antihistamines NSAIDS cough suppressant decongestants mucolytics
why do you want to avoid 1st gen antihistamines for ABRS:?
they thicken secretions
*while expectorants (guafenisin aka mucinex) will thin them
what is chronic sinusitis?
> 12 wks of S&S, issues w/ mucociliary clearance
- mucopurulent drainage
- nasal obstruction
- facial pain
- purulent mucus/edema in meatus/ethmoid OR polyps OR image showing inflamm of sinuses
what is recurrent sinusitis?
4+ episodes a year with absent symptoms between episodes
what is included in the PE for chronic sinusitis?
- nasal exam w/ speculum & endoscope (purulent drainage, polyps, septal deviation, turbinate hypertrophy/edema)
- sinus palpation/percussion for tenderness
- ears for TM fluid, neck for LAD, throat for PND, ocular for oculomotor involvement, lung for lower RI/asthma
txt for chronic sinusitis? if it is bacterial-chronic?
no gold standard, refer to ENT
(maybe intranasal steroids, decong., mucolytics)
true chronic is rare
1 month abx if bacterial-chronic
what to look at for general Dx of allergic rhinosinusitis
look at history: (perennial (likely from house) vs seasonal(hay fever))
chronicity: maybe recurrent ABRS/AVRS (3-4 infections/year
S&S: clear rhinorrhea with allergy symp. (sneezy, itchy)
*clear fluid behind TM
3 giveaway signs of allergic rhinosinusitis
- allergic salute
- crease in nose (from allergic salute)
- allergic shiners
allergies are closely tied to what other illness?
asthma
3 types of therapy for allergies Rh?
- avoidance
- drug: inhibit action of released mediators, reversal of vascular and inflamm response
- immunotherapy: repeated long-term injection of allergen to blunt rxn
what meds are used for drug therapy of allergic rhinosinutisis?
antiH1
anticholinergic (atrovent spray)
nasal steroid spray
mast cell stabilizers (inhibit degradation)
leukotriene antagonists (inhibit vascular permeability & inflamm)
what is vasomotor rhinosinusitis?
trigger by smells, stress, and substances (smoke, cold air)
= sneezing and runny nose, congestion (parasymp overactivity of nasopharynx)
txt for vasomotor rhinosinusitis?
atrovent (aka ipratropium) spray PRN
*don’t use nasal steroid spray
* don’t use decongestants
maintenance med so you don’t want to use steroids or decongestants all the time
pts who are sensitive to vasomotos Rh also tend to get what?
migraines
nasal polyps: what are they? can they be removed?
inflamed outgrowths of nasal mucosa
-may be removed but most return
what are nasal polyps assosciated with?
asthma chronic sinus infections cystic fibrosis allergic rhinitis hyposmia (reduced ability to smell)
what is samter’s triad?
type 1 hypersens.
- rhino-sinusitis
- asthma and aspirin sensitivity
- nasal polyps
symptoms of exposure to aspirin or NSAIDS for those with samter’s triad? txt for this?
flushing of head/neck/chest bronchoconstriction wheezing cyanosis N/V/D txt: bronchodilators
