Sinuses Flashcards
actions of the sinuses
Warm, moisturize, and filter air
Olfaction
Continuous mucosal lining lined with cilia
Unilateral purulent drainage
Foul odor, epistaxis
Nasal Foreign Body
where do 95% of epistaxis occur?
Kiesselbach’s plexus
Epistaxis Management
- Direct pressure
- Cautery
- Nasal packing
- Treat the underlying cause: prevention!
NS nasal sprays and humidifiers to add moisture
Cautery with silver nitrate- keep from re-bleeding
when do you need a referral with nasal trauma
if orbital involvement is suspected, airway compromise, evidence of intracranial injury, leaking CSF or c-spine injury
collection of blood in the septum, or space between the two nostrils Don’t miss-may cause chronic deformity Often bilateral Cover with antibiotics Refer for drainage immediate ENT referral
septal hematoma
Assc. w/ Unilateral nasal obstruction, pain, recurrent nosebleeds, headache, visual or smell changes are all red flag symptoms
nasal tumors
Carcinomas (squamous), lymphomas, sarcomas, and melanomas
Represent an inflammatory disorder
May cause chronic symptoms with a diminished sense of smell
Associated with chronic rhinosinusitis and cystic fibrosis
may initiate nasal corticosteroids topically and refer to ENT if no improvement after an initial period of treatment
nasal polyps
- common across all age groups
- May be benign—look for red flag symptoms
- Identify the underlying etiology
- Patient centered management plan
- Refer when appropriate
Nasal Congestion
an immunoglobulin E (IgE) mediated inflammatory response of the nasal mucous membranes after exposure to inhaled allergens
Common symptoms: nasal congestion, post-nasal drip, nasal itching, sneezing, ocular symptoms
Seasonal vs. perennial vs. episodic
Allergic Rhinitis
Physical Exam for AP diagnosis
- Allergic shiners
- Injected conjunctivae
- Allergic salute
- Stigmata of atopic disease
- “Boggy, pale” turbinate
AR Classification?
Present <4 days/week
OR
<4 weeks/year
Intermittent
AR Classification?
Present >4 days/week
OR
>4 weeks/year
Persistent
AR Classification?
Isolated exposure to an allergen such as pet dander that is not part of the individual’s environment
Episodic
Best way to manage AR
environmental control
3 A’s of AR H&P
family hx of asthma, allergies, atopy
most common physical sign of AR
boggy pale nasal turbinates
Factors that may lead to a severe classification of AR
exacerbation of co-morbid asthma, sleep disturbance, impairment of daily activities or participation in sports, impairment of schoolwork due to missed school days
There should be no clinical evidence of ____ for AR dx
endonasal infection or structural abnormality
Benefits of intranasal corticosteroids (INCS)
Recognized as most effective treatment for AR by all practice guidelines
- Low systemic bioavailability (second-generation agents)
- May also benefit ocular symptoms
- Available OTC
Disadvantages of intranasal corticosteroids
- Side effects (nasal irritation, dryness, epistaxis. Taste and smell disturbances, HA, cataract and glaucoma)
- Improper administration or use
- Concern in pediatric population regarding growth suppression
Benefits of Nasal Antihistamines
- Quick action
- More effective for nasal congestion than oral antihistamines
- More tolerable side effect profile
- Recognized as effective in conjunction with INCS for patients without benefit of INCS alone
Disadvantages of Nasal Antihistamines
- More expensive
* Less effective than INCS
Benefits of Oral Antihistamines
- Low cost/available OTC
- Second generation advised (less sedating)
- Addresses multiple allergy symptoms
- Generally well tolerated
Disadvantages of Oral Antihistamines
- Drowsiness
- Not as effective as INCS
- Clinical trials show no added benefit as add on to INCS
Good for pts that have hx of asthma of allergy to aspirin
May have limited role for those patients with comorbid asthma/allergy
•Very costly
•No added benefit seen as an add onto INCS
Leukotriene Antagonist (LTRA)
widely used- effective against histamine mediated allergic rhinitis symptoms, (rhinorrhea, sneezing, itching, and also ocular symptoms)
Oral Antihistamines
The chronic presence of one or more symptoms of rhinitis (nasal obstruction, rhinorrhea, sneezing, and/or itchy nose.) , diagnosis of exclusion, syndrome not a disease
- No clinical signs of infection
- No signs of allergic inflammation
Nonallergic, Noninfectious Rhinitis (NAR)
drug-induced rhinitis- can happen with the overuse or extended use of some over-the-counter nasal sprays, vasoconstrictor agents like metazoline.
rhinitis medicamentosa
•Acute and self-limited •Spread by hand contact to secretions or aerosol •Multi-symptom •Most common culprit is rhinovirus Nasal congestion with rhinorrhea
Upper Respiratory Infection (URI)
Best evidence for the
prevention of the common cold
physical interventions (e.g., handwashing) and possibly the use of zinc supplements.
best evidence for traditional
treatments for URI support
acetaminophen and nonsteroidal anti-inflammatory drugs (for pain and fever) and possibly antihistamine—decongestant combinations and intranasal
ipratropium. Ibuprofen appears to be superior to acetaminophen for
the treatment of fever in children
best evidence for
nontraditional treatments of
the common cold
use of oral zinc
supplements in adults and
honey at bedtime for cough
in children over one year
Children under six years of age should not receive cough medication
Inflammation of maxillary and ethmoid sinuses a/w URI (chronic if persistent 12 wks).
Typically viral, rarely bacterial complication can occur
Facial pain/pressure along with sx of URI
Rhinosinusitis
Most cases are viral and resolve spontaneously
• Uncomplicated cases can be managed with intranasal corticosteroids and nasal saline irrigation
- Can be acute or chronic
- Acute refers to symptoms lasting
Rhinosinusitis
ARS can be further classified into viral and acute bacterial rhinosinusitis (ABRS)
Three cardinal features of ABRS
purulent rhinorrhea
facial pain/pressure/fullness
nasal obstruction
One of the two criteria below: of ABRS
- Onset and duration of ABRS symptoms persisting for ≥10 days (without evidence of improvement)
- Onset with worsening symptoms that were initially improving in first five days “double-sickening”
First-line (Daily Dose) for
Acute rhinosinusitis 1qa
Pregnant patients with a PCN allergy will need a _____ as first line treatment for acute rhinosinusitis
macrolide
- Previously thought to be entirely infectious in nature, now recognized as inflammatory
- Medical treatments reduce mucosal inflammation, remove mucus, and modulate environmental triggers
- May involve co-management with ENT
Chronic Rhinosinusitis
Diagnostic Criteria for CRS (Chronic Rhinosinusitis)
12-week duration of more than two of the following:
• Nasal discharge (anterior, posterior, or both)
•Nasal obstruction and congestion
•Facial pain, pressure, or fullness
•Reduction/loss of smell
- Associated with high tissue eosinophilia, tissue edema
* May have a higher prevalence of anosmia
CRS with nasal polyps
CRSsNP- Fibrosis, less eosinophilic infiltration
CRS without nasal polyps
Treatment for Chronic Rhinosinusitis
- Nasal steroid for 4–6 weeks
- Oral antimicrobials in case of acute exacerbation
- Treat comorbid allergy
- Avoid smoking and irritants
- Consider high volume nasal irrigation
Treatment for Uncontrolled CRS
- Continue treatment
- Add oral steroid
- Consider long term macrolides/ doxycycline
- Reconsider diagnosis
- Consider surgical options
How to confirm inflammation for Chronic Rhinosinusitis?
Endoscopy: purulent mucus, mucosal edema,
CT Imaging demonstrating inflammation of paranasal sinuses
What is mainstay of treatment for chronic rhinosinusitis?
What if it is uncontrolled?
Glucocorticoids
may need to add oral steroid if it is uncontrolled (but comes with lots of complications)
Often confused with URI, inflammation of nasal mucosa (<4wks)
Clinical Findings:
Nasal congestion & purulent discharge, HA -> more intense when bends over, Fever, fatigue, SINUS PAIN
Abrupt onset
suspect BACTERIAL if pt presents w. Worsening sx after 10 days
Acute Sinusitis
Tx for Acute Sinusitis?
NOT recommended (acute is typically viral) unless sx worsen or do not improve after 7 days
amoxicillin -clavulanate (1st line)
Doxycycline if PCN allergy
Treatment adults: BID 5-7days
Treatment in children: 14 days
Pregnant/ PCN allergy: NO doxy, Macrolide
Analgesics and NSAIDs
Nasal saline or decongestants
sinus infection more than 12 wks that resist tx or are recurrent (d/t continued inflammation and impaired drainage)
Chronic Sinusitis
aka idiopathic or nonallergic rhinitis→ falls under NAR
Patho: abnormal balance favoring parasympathetic control leading to vascular engorgement on nasal mucosa
Causes:
Medications (ACE inhibitors, beta blockers)
Increased estrogen (pregnancy)
Vasomotor Rhinitis
Clinical Manifestations:
Perennial nasal congestion with little discharge
ABSENCE of itching of eyes and nose, sneezing, and tearing
Vasomotor Rhinitis
How to Tx Rhinosinusitis?
ABX if URI sx don’t improve after 10 days- Amoxicillin Q12
<2 yo, recent antimicrobial use, or in daycare: amoxicillin-clavulanate
tylenol/ibuprofen for pain
Pale edema (BOGGINESS) of nasal mucous membranes
Redness/”cobblestone” of the conjunctiva, TEARING- REDNESS, injection, Clear TM
No s/s of infection
Allergic Rhinitis
How to tx episodic allergic rhinitis?
H1 antihistamines w/ decongestants: fexofenadine & pseudoephedrine (Allegra-D), or loratadine & pseudoephedrine (Claritin-D)
How to tx perinneal/ seasonal allergic rhinitis?
inhaled nasal corticosteroids (first line tx), and/or H1 antihistamine (oral, second generation)
What to avoid for allergic rhinitis while pregnant (1st trimester) and breastfeeding?
avoid oral decongestants
tx option for severe allergies to decrease need for epinephrine or daily medication. Desensitization takes months through controlled allergen exposure. Weekly injections
Allergy immunotherapy
Viral (adenovirus, rhinovirus, RSV, etc) transmitted via contact or airborne droplets
Clinical Manifestations:
Nasal congestion with rhinorrhea
Coughing, sneezing, fever, hoarseness, pharyngitis.
Common cold (URI)
How to tx common cold?
supportive symptomatic tx (fever, saline nose drops) increased fluid intake; honey for cough if over 1yo
No cough meds under 6yo
Comorbid conditions may limit OTC med use (HTN)
posterior nose bleed = arterial bleed →
IMMEDIATE referral
bacterial rhinitis that originates from viral or allergic swelling of nasal mucosa. Swelling affects drainage and traps microorganisms in the sinuses. Strep. pneumoniae , H. influenzae, or Moraxella catarrhalis
Infectious Rhinitis
mouth breathing ( bruise, encapsulated) MUST document absence of this finding if nasal trauma occurred
Septal hematoma
Anosmia→ _____
Hyposmia→ ______
Parosmia → ________
Anosmia→ loss of smell
Hyposmia→ diminished smell
Parosmia → smell distortion
How to assess for smell changes?
Test CNI (close eyes identify coffee, PB, alcohol) Inspect nasopharynx (polyps? Mucus? Signs of URI?) Text CN IX(glossopharyngeal) and CN VII (facial) together: sweet, salty, sour, and bitter on each side of the tongue, then posterior portion
Diagnostics
Labs: CBC, BUN, creat, LFT, TSH, ESR, and antinuclear antibodies
How to tx Chronic Sinusitis
Nasal steroids for 4-6 weeks Acute exacerbation- antimicrobials Amoxicillin or doxy (if PCN allergy- careful with sun exposure) Avoid irritants Saline irrigation- high volume Refer if sx continue after 2 treatment
Epistaxis management
No vigorous exercise or ASA-containing products for 10 days
Call if bleeding occurs (esp while packing is in place)
Avoid tobacco and spicy foods → cause vasodilation
How to tx pregnancy rhinitis?
nasal lavage using distilled water
Ageusia
absent taste
Nasal congestion with RHINNORRHEA
Coughing, sneezing, fever, hoarseness, pharyngitis.
Common cold URI
