Rhinosinusitis (acute and chronic) Flashcards
What are the diagnostic features of rhinosinusitis?
- Block
- 1 of: Facial pressure or Hyposmia
- Examination findings
For 12 weeks = chronic
What defines chronic RS?
12 weeks
What may be found in CRS?
Nasal polyps
How can you tell between a polyp and turbinate on examination of nose?
Polyps - insensate
Turbinate - pain if poked
What is the difference?
Right there is nasal polyposis filling all sinuses –> poor sense of smell, poor sleep, mouth breathing
What type of imaging may be used in CRS?
CT
What is the management of CRS?
- Long term topical steroids
- Surgical - if polyposis present, then use steroids to prevent recurrence
mAbs - being trialled e.g. Mepolizumab (anti-IL-5) helps with polyposis
What are the main features of acute sinusitis?
- Painful
- Purulent discharge
- Can follow viral URTI
Bacterial cause
Is purulent discharge unilateral or bilateral in acute sinusitis?
Unilateral
How do you manage acute sinusitis?
Antibiotics (co-amoxiclav)
Patient comes in saying their nasal decongestant no longer helps. Exam as below. What is the diagnosis?
Rhinitis Medicamentosa
Tx: few weeks weaned off. Seroids may be added but will not help much
What are the types of rhinosinusitis?
Allergic - seasonal or perennial or occupational
Non-allergic - infective or non-infective
How common is allergic rhinitis?
20 to 30% of adults and up to
40% of children
What are the clinical features of allergic rhinitis?
- rhinorrhoea
- nasal blockage
- sneezing attacks for longer than 1 hour per day lasting longer than 2 weeks
- itching—eyes, nose
- watery eyes
- interference with sleep leading to daytime sleepiness
- malaise
- headache
- wheezing
- shortness of breath
- clear nasal discharge
Other: reduced hearing from ET dysfunction, headaches, epiphora, reddening of conjunctivae, swollen eyelids, nasal crease or nasal salute (in children), oedematous nasal mucosa
What diagnostic tests can be done for allergic rhinitis?
History most important
Skin prick testing
RAST - radioallergosorbent testing; highly specific but not as sensitive as skin prick testing
High serum IgE
Nasolaryngoscopy
What is the management of allergic rhinitis?
Conservative:
- Avoidance of allergen
- Remove carpeted floors
- Air conditioning
Medical:
Antihistamines - do not reduce nasal congestion
- Oral non-sedating - loratadine or cetirizine
- Nasal - faster onset of action and reduce itching and sneezing
- Eye drop - to reduce eye itching
Corticosteroids:
- Nasal - first line in moderate to severe allergic rhinitis and more effective than oral antihistamines; help with congestion e.g. betamethasone, fluticasone
- Systemic - if severe symptoms; IM or short oral course e.g. 5day OFD 20mg prednisolone
LTRA - montelukast
Mast cell stabilisers - IN sodium cromoglycate
Anticholinergics - IN ipratropium
Allergen immunotherapy - sublingual (SLIT) or subcut (SCIT). May last ~3yrs.
Surgical:
Which allergens is SLIT/SCIT available for?
House dust mite
Grass/weed pollens
When is surgery indicated in rhinosinusitis?
- nasal polyps
- septal deviation
- inferior turbinate hypertrophy; reserved for patients with nasal airway obstruction and enlarged inferior turbinates who have failed medical management
What are the most common perennial allergens?
- Dust
- Mites in mattresses, carpets, furry toys
- Feathers
- Animal dander
What are the causes of acute and chronic infective rhinitis?
Acute infective - common cold i.e. viral, sometimes with secondary infection with S. pneumoniae or H. influenzae
Chronic infective - bacterial (e.g. HI), fungal (e.g. aspergillus, candida or cryptococcus), tuberculosis, syphilis or Yaws
What are some causes of rhinitis due to abnormal mucociliary clearance?
primary:
- impaired ciliary action e.g. Kartagener’s syndrome
- hyperviscus mucus with normal ciliary action e.g. Young’s syndrome
secondary - following upper respiratory tract infection
How do you diagnose mucociliary rhinitis?
Nasal saccharin clearance test - a small particle of saccharin is placed 1cm behind the anterior end of the inferior turbinate; normally it is swept backwards to the nasopharynx and sweet taste perceived but if this does not occur in 10-20mins then there is defective mucociliary clearance
What is atrophic rhinitis?
Rhinitis due to squamous metaplasia followed by atrophy. Nose becomes filled with foul smelling crusts.
What are the causes of atrophic rhinitis?
- Following radical nasal surgery
- Secondary to rhinitis medicamentosa
- Chronic infection with specific organisms e.g. Klebsiella
Treat with nasal hygiene, nasal drops with glucose 50% in glycerine, then surgical treatment involving closure of nostrils with circumferential flap.
What is the management of acute infective rhinosinusitis?
AVOID antibiotics
Analgesia
Decongestant e.g. pseudoephedrine
Intranasal corticosteroid e.g. mometasone
Topical anticholinergic e.g. ipratropium
Saline nasal irrigation - thins mucus and helps with relief of nasal symptoms
If purulent discharge then delayed antibiotics e.g. amoxicillin 500mg TDS 1g
What is a complication of prolonged nasal decongestant use?
rhinitis medicamentosa
What are the causes of non-infective rhinitis?
- hyperreactive or vasomotor rhinitis
- rhinitis medicamentosa
- anatomical or mechanical rhinitis
- tumours causing rhinitis: benign (osteoma, papilloma, angioma) OR malignant: primary or secondary
- non-healing granulomas
What is vasomotor rhinitis?
AKA hyperreactive rhinitis - patients with evidence of rhinitis but no obvious cause such as allergy, infection, neoplasia or anatomical abnormality
What is the pathophysiology of rhinitis medicamentosa?
Sympathomimetic decongestants cause vasoconstriction of the nasal mucosal blood vessels providing relief from the symptom of nasal congestion. However, as their effects wear off, secondary vasodilatation occurs causing the sense of congestion to return. This prompts further application of the decongestant and a vicious circle of use develops.
