Sinus and Allergy Disorders Flashcards
What can a patient with rhinitis present with?
congestion, rhinorrea, sneezing and pruritus
A patient presents to the office with a history of nasal congestion, rhinorrhea, sore throat and a fever that has lasted 5 days. Upon doing the PE, you note that the patient has nasal mucosa edema, clear rhinorrhea, and pharyngeal injection/cobble-stoning. What is the dx?
Viral URI (common cold)
What can you give/recommend to a patient for a cold?
decongestants, antihistamines, NSAIDs (Ibuprofen), Tylenol for fever, saline spray/nasal irrigations, intranasal corticosteroids, beta agonists (albuterol) if wheezing present.
What causes rhinitis medicamentosa?
intranasal decongestants (Afrin- dont use more than 3 days in a row), cocaine, rebound nasal congestion.
What medications can cause rhinitis?
NSAIDs, Aspirin, ACEI, phosphodiasterase 5 selective inhibitors, alpha receptor antagonists
An elderly patient comes in and complains of having a constant runny nose for the past 2 months. The patient states that they experience it when eating certain foods. What is the likely dx?
vasomotor rhinitis
This is the abnormal autonomic responsiveness and vascular dilation of submucosal vessels
vasomotor rhinitis
Deviated septum
snoring, nasal blockage, history of nasal fracture
Foreign body
unilateral obstruction, purulent nasal discharge, malodorous
Neoplasm
unilateral bloody discharge unresponsive to antibiotic
Nasal polyp
pearly, gray sac-like growths consisting of inflamed nasal mucosa, mobile and non-tender
What is Samter’s Triad as it pertains to nasal obstruction?
- Aspirin sensitivity/allergy
- asthma
- nasal polyps
What are the treatments for nasal obstruction?
oral/nasal steroids, leukotrine inhibitors, sx, aspirin, desensitization
A pregnant patient presents with nasal vascular poolin, vascular dilation and increasing blood volumes. What is the dx and what are the treatment options?
Dx: rhinitis gravidarum (starts before 6 weeks and ends 2 weeks post partum)
Tx: delivery, 1st and 2nd gen antihistamines, rhinocort-category B, saline
A patient presents to the office complaining of having a sweet taste following a trauma they had to the head. They recently have been experiencing HA’s for the past two weeks. When taking their sx history they mention that they had ear surgery in the past. What is the likely dx?
CSF rhinorrhea
With CSF Rhinorrhea, when the CSF dries on filter paper, what does it produce?
ring or halo sign
CSF Rhinorrhea can cause _________ or __________
headache, meningitis
__________ Rhinitis is a type of Gell and Combs Type I hypersensitivity reaction
Allergic
Explain the pathophysiology of allergic rhinitis
mast cells bind to antigen specific IgE molecules > mast cell degranulates > releases mediators such as histamine, leukotrines, kinins
What are the 5 comorbidities of allergic rhinitis?
asthma, otitis media, sinusitus, atopic dermatitis, allergic conjunctivitis
A patient presents complaining of sneezing, itching/watery eyes, congestion and rhinorrhea. They mention that this only occurs when they are outdoors during the spring time. What is the dx?
allergic rhinitis
What are likely PE findings as it pertains to the eyes for a pt that has allergic rhinitis?
allergic lashes - long, silky lashes.
dennie’s lines (meuller’s muscle spasm)
allergic shiners: venous stasis and hemosiderin deposits
What are likely PE findings as it pertains to the nose for a pt that has allergic rhinitis?
inferior turbinate hypertrophy
deviated septum
pale nasal mucosa
nasal polyp
What are likely PE findings as it pertains to the pharynx for a pt that has allergic rhinitis?
posterior pharyngeal cobbblestoning
Discuss what the different types of allergy tests are and which is the gold standard?
- RAST- serum sample, measures antigen specific IgE antibodies and total serum IgE level, low sensitivity, high specificity
- Skin Test- Gold Standard- intradilutional testing (IDT), skin prick, intradermal, patch test
What does pale/blue color of the turbinates indicate?
allergies
What are some of the treatment options for allergies?
- avoidance- pets, dust mites, mold, environmental irritants
- meds- topical steroids are first line, they have very little adverse rxns (however can get nosebleeds), leukotriene inhibitors (singulair-montelukast)
- intranasal steroids e.g. flonase (fluticasone)
-intranasal antihistamines e.g. astelin (azelastine)
-oral antihistamines e.g. claritin (loratadine), zyretic (cetrizine)
-combo- Dysmista- fluticasone/Azelastine - Immunotherapy- develop tolerance to environmental allergens, increases IgG4 which blocks the antigen from binding to IgE molecule, decreases antigen specific IgE molecules
What are the two types of routes for allergy immunotherapy?
- SubQ
-efficacy and safety well studies
-risk for anaphylaxis - Sublingual
-Multi-allergen- not FDA approved
-but no risk for anaphylaxis and people tend to be more compliant
____________ epistaxis is more common and less severe.
Anterior
When does epistaxis occur?
when the mucosa is eroded and vessels become exposed and break
What are the differences between anterior and posterior epistaxis?
anterior occurs in the kiesselbach plexus or can also be from an inferior turbinate whereas the posterior has arterial origin and it is more difficult to control, risk of airway compromise
What is the most common cause of epistaxis?
digital trauma
What is the acute management of epistaxis?
control HTN (if hypertensive)
labs: CBC, PT, PTT, platelets (in recurrent cases)
ENT FU
What is the treatment for minor anterior epistaxis?
minor: spray afrin into side of bleed then soak a piece of cotton with afrin to anterior cavity and apply pressure to cartilage. respray every 5 min until stopped
minor but recurrent: anesthetize septal area with lidocaine, apply silver nitrate to bleeding vessels. do not overspray bc can cause septal perforation
if bleeding doesnt stop consider nasal pack
antibiotics to prevent sinusitis/infection
electrocautery for bulging vessels > refer to ENT
In posterior epistaxis bleeding, the bleeding is mainly down the back of the throat. The bleeding is most often from the ________________
internal maxillary artery (IMA)
What are the reasons as to why patients can die from posterior epistaxis?
because their airway is compromised, aspiration, uncontrolled hemorrhage
What is the most common cause of posterior epistasis?
HTN
What is the tx plan for posterior epistaxis?
posterior nasal pack, hospitalize for ENT referral for nasal endoscopy, may require IMA embolization, arterial ligation (sphenopalatine, ethmoid)
A 5 year old presents with a unilateral nose obstruction with persistent malodorous mucopurulent nasal drainage. Based on this, one can say that it is a ___________ until proven otherwise.
foreign body
When removing FB’s you want to take precautions to prevent dislodgment into __________________
lower airway
What is sinusitis, what does it lead to?
it is the inflammation of the sinuses which are air filled cavities in the skull.
The inflammation leads to blockade of the normal sinus drainage pathways (sinus ostia)
Leads to mucus retention, hypoxia, decreased mucociliary
clearance, predisposition to bacterial growth
What is the etiology of sinusitus?
- viral
- bacterial (strep, H influenza, M catarrhalis), atypicals (mycoplasma, pseudomonas), resistant bacteria
- fungal (aspergillus)
immunocompromised pts
foul smelling, nasal discharge
What are the differential dx associated with sinusitus?
viral rhinitis
TMJ
HA syndrome, migraine, sinus migraines
allergic rhinitis
dental infection
trigeminal neuralgia
sinus neoplasm- visual changes, unilateral nasal obstruction, unilateral epistaxis, CN deficits
A patient presents with acute sinusitus. What would you expect their clinical presentation to be?
persistent symptoms for more than 7-10 days
nasal congestion
purulent nasal discharge- thick green/yellow mucus
post nasal drip
sinus pressure
may result from a dental infection
A patient presents with chronic sinusitis. What would you expect their clinical presentation to be?
same sx as acute plus chronic cough, HA, halitosis, decreased smell, ear pressure
A patient presents with sinusitus. What are you documenting for the physical exam?
face: possible localized tenderness
nasal: mucosal edema, inferior turbinate hypertrophy, mucosal erythema, mucopus
Ear: normal TM’s
Pharynx: thick postnasal drip, posterior pharyngeal cobble-stoning
Neck: cervical adenopathy
Lungs: clear
What is the duration for acute sinusitus?
less than 4 weeks
What is the duration for chronic sinusitus?
infection causing sx for more than 3 months
Which diagnostic tool is used to evaluate sinuses, nasal cavity, air fluid levels and ostia?
CT scan
A patient with acute sinusitus comes back to the office after 7 days complaining that their symptoms are getting worse. They state that when they last took their temperature, they had a fever of 102 degrees. What is the appropriate treatment?
Antibiotics- initial should be augmentin
PCN allergy should take doxycycline or clindamycin
Respiratory fluoroquinolone should be reserved for those who dont have alt tx options
Flonase
Prednisone
What are the surgical options for sinusitus?
functional endoscopic sinus surgery (FESS)
Balloon sinuplasty
Septoplasty
Turbinate Reduction (Coblation)
What are the complications of sinusitus?
orbital infection (orbital cellulitis)
pott’s puffy tumor- osteomyelitis with bone destruction “doughy” edema over involved frontal bone
cavernous sinus thrombosis
epidural abscess
invasive fungal sinusitus
A patient presents with rhinitis. What do you want to tell them in regards to how their quality of life will change?
they can experience fatigue, headaches, sleep disturbances, cognitive impairment, and can complicate respiratory conditions. Due to this, they will have reduced work/school.
