Tinnitus/Uticartia/Etc Flashcards
Barotrauma treatment
avoidance, oral or nasal decongestants, swallowing, valsalva, chewing gum
If rupture of TM, how to tx?
time/patience
Perilymphatic fistula treatment
ENT
Acoustic neuroma
vestibular schwannoma
Schwann cell tumors arise from
vestibular portion of CN VIII
Schwann cell tumors are
slow growing
What percent of intracranial tumors are schwann cell tumors
8%
Classic presentation of acoustic neuroma
classic presentation is unilateral sensorineural healing loss and tinnitus
In acoustic neuroma, you may or may not have
gait disturbance or other CN involvement
Diagnosis of acoustic neuroma
hearing test, mRI or CT (if need to avoid MRI)
Tx of acoustic neuroma
surgery, radiation, observation
Tinnitus definition
perception of sound in one or both ears
can be buzzing, ringing, hissing, continuous or intermittent, pulsatile or non-pulsatile
How many people in the US are affected by chronic tinnitis?
50 million
Pulsatile tinnitus is most commonly _____ in etiology.
Vascular (aneurysm)
Other causes of pulsatile tinnitus:
auditory
Tinnitus dx
history, physical - auscultate for bruits in patients, if pulsatile - refer to ENT
Tx goal of tinnitus
make them less aware of it: biofeedback, stress reduction, CBT, benzos, masking devices - white noise
What is barotrauma?
pain/trauma to ear related to pressure differences - flying/diving
Tinnitus is associated with
depression/anxiety
Allergic rhinitis
seasonal, perennial, “hay fever”
can happen all year round if dust, etc.
Vasomotor
perennial - non-allergic
happens all year round
Onset of allergic rhinitis
onset typically before 30, peak incidence in childhood/adolescence
Pathophysiology of allergic rhinitis: type of antibodies
response to allergen exposure by production of IgE antibodies
In allergic rhinitis: IgE binds to
mast cells, basophils
In allergic rhinitis: Mast cells exposed to allergies again….
release
Mast cells degenerate and release inflammatory mediators
histamine, cytokines, leukotrienes, prostaglandins which lead to signs and symptoms of allergic rhinitis
Clinical presentation - symptoms
rhinorrhea, sneezing, nasal congestion, itchy eyes, itchy nose/palate, post nasal drip, cough, fatigue
Risk factors of allergic rhinits
FH of atopy, male sex, birth during pollen season, firstborn, early use of antiobiotics, maternal smoking exposure, exposure to indoor allergies, serum IgE > 100 before age 6, presence of allergen-specific IgE
Allergic rhinitis symptoms in periorbital area
allergic shiners
denie-morgan lines
What are allergic shiners
bluish purple rings around both eyes
What are Denie-Morgan lines
skin folds under eyes consistent with allergic conjunctivitis
Eye symptoms - allergic rhinitis
palpelbral conjunctiva may be pale, sweollen; may see conjunctival injection
Physical exam findings of nose in allergic rhinitis
pale, boggy bluish mucosa, clear discharge nasal crease, allergic salute,
Physical exam findings of throat in allergic rhinits
post-nasal drainage in posterior pharynx, cobblestoning
Physical exam findings of ears in allergic rhinits
serous otitis media
What kind of dx is allergic rhinitis
clinical diagnosis
Allergy testing can be
confirmatory
Allergy testing can
identify candidates for immunotherapy
Allergy testing- skin testing
scratch or prick skin testing
wheal-and-flar reactions occur within 15-20 minutes
quick and cost effective
Serum testing for allergies
detects IgE antibodies, less risk but less sensitve, more expensive
RIsk associated with skin testing for allergic rhinitis
anaphylaxis
When wheal and flare reaction occurs, how large is wheal size
greater than or equal to 3 mm
Components of therapy for allergic rhinitis: pharmacotherapy
intranasal glucocorticosteroids, oral or intranasal antihistamines, sympathomimetics, decongestants, leukotriene receptor antagonists
3 types of treatment for allergic rhinitis
avoidance of allergens, pharmacotherapy, immunotherapy
Allergy is often caused by _____, _____ and _____ rather than hair.
dander, saliva, urine
If you have an allergy against animals, what should you do?
remove them
How long after removing the animal will it take to clear animal particles?
3-6 months
Pharmacotherapy for allergic rhinitis for children under 2 years old
cromolyn sodium nasal spray, 2nd generation antihistamines - zyrtec and allegra approved for kids over 6 months old
Mild treatments (or episodic, predictable exposure) in children over 2 and adults for allergic rhinitis
Loratadine, cetririzine, fezofenadine,
antihistamine nasal sprays: azelastine (Astelin) for over 5 years old, olopatadine (Patanase) for over 12 years old;
glucocorticoid nasal sprays (start 2-3 days prior to exposure),
cromolyn nasal spray
Persistent or Moderate to Severe symptom tx
glucocorticoid nasal sprays are considered first line treatment - most effective single agent and fewest side effects
Names of glucocorticoid nasal sprays
flonase, nasocort, rhinocort, nasoline (these four have highest risk of side effects)
flonase, nasonex, omnaris (less risk of side effects)
Allergic rhinitis with asthma
montelukast (singular) - useful additive therapty
AR with allergic conjunctivitis
glucocorticoid nasal spray and ophthalmic antihistamine drops
Avoid nasal sprays if:
glaucoma and cataracts
Pregnant woman with AR - moderate to severe
Avoid allergen is possible. If that is not enough - Zyrtec, Claritin, Rhinocort, Flonase, Nasonex
Lactating mothers, moderate to severe AR
Rhinocort, Cromolyn, zyrtec of claritin
In patients who FAIL TO RESPOND to initial glucocorticoid nasal spray, a second agent can be added:
antihistamine nasal spray, oral antihistamine, cromolyn, singulair, oral antihistamines/decongestant combo
1st generation of antihistamines do what
alleviate sneezing, rhinorrhea, and itching - will not relieve nasal congestion
1st generation of antihistamines will not offer relief of what
nasal congestion
Side effects of 1st generation antihistamines
dry mouth, sedation, constipation
1st generation antihistamines + dosage
benadryl - 25-50mg BID/TID
Chlor-trimeton - 4 mg q4-6 hours of 8-12 hours BID for sustained release
2nd generation antihistamines benefits
less sedating
Examples of 2nd generation
Claritin - 10mg/day, Allegra - 60 mg BID or 180 QD, Zyrtec - 5-10 mg/day
Nasal antihistamines sprays and montelukast (Singulair) have
similar effectiveness as oral antihistamines
Decongestants
sympathomimetics
Decongestants indicated for patients with marked:
nasal congestion despite antihistamine use
Decongestants are
vasoconstrictors
Vasoconstriction will decrease
edema and secretions
What are examples of decongestants?
pseudoephredrine (Sudafed) - 30-60mg q6-8 hours, or 120 mg BID for sustained release
Use caution with _____ when a patient has hypertension or cardiac disease
decongestants
Immunotherapy is effective for
allergic conjunctivitis, rhinitis, asthma
____ administration of increasing amounts of allergen
gradual
Immunotherapy requires:
multiple, regularly scheduled visits
How long is tx with immunotherapy for allergic rhinitis
3-5 years
Patient education for dust mite and mold avoidance
clean house, humidifiers can worsen symptoms, cover mattress and pillows with plastic, no feather pillows, wash bedding weekly
Patient education for pollens
close windows, HEPA filters
When to refer with allergic rhinitis
severe or refractory symptoms, AR and asthma, recurrent sinusitis or otitis media
Non allergic rhinitis aka
vasomotor rhinitis
What is non-allergic rhinitis
abnormal autonomic responsiveness
What triggers non-allergic rhinitis
stress, sexual arousal, perfumes, cigarette smoke, temperature changes
When does non-allergic rhinitis occur
later in life - greater than 20 years old
Non-allergic rhinitis is characterized by
nasal congestion, rhinorrhear, postnasal drip
Non-allergic rhinitis does not usually have
ocular or nasal itching, sneezing
How does nasal mucosa occur in non-allergic rhinitis
nasal mucosa may appear normal, erythematous, or boggy and edematous
Vasomotor rhinits tx
avoidance of triggers, nasal glucocorticoids, antihistamine nasal spray, ipratropium nasal spray - use if rhinorrhea is prominent symptoms
Adjunctive therapy with vasomotor rhinitis
oral decongestants, 1st generation oral antihistamines
Nasal polyps description
pedunculated, non-tender, grey soft tissue growths
Symptoms of nasal polpys
nasal congestion,
What are nasal symptoms often seen with
allergic rhinitis, chronic sinusitis, asthma
Tx of nasal polyps
nasal glucocorticoids
Rhinits Medicamentosa results from
regular use of OTC decongestant nasal spray
What happens with rhinitis medicamentosa?
mucous membranes swollen and erythematous
Rebound congestion with rhinitis medicamentosa
3 days of use leads to rebound congestion, leads to dependency
Tx of rhinitis medicamentosa
discontinue afrin, start nasal glucocorticoid spray
Uticaria
hives welts, wheals
Describe uticaria
well circumscribed, intensely pruritic, rasied wheals, pale to bright erythema
Acute uticaria
present less than 6 weeks
Chronis uritcaria
symptoms recurring most days of the week for greater than 6 weeks
Individual lesions are:
transient
Uticaria vary in:
shape and diameter
Uticaria is mediated by:
mediated by cutaneous mast cells in superficial epidermis
Uticaria releases
histamine and vasodilatory mediators causes ithcing and localized swelling
Uticaria may be accompanied by
angioedema (swelling of deeper skin, affecting face, lips, extremities, and/or genitals)
Common causes of uticaria
infections, allergic reaction to meds, foods, insect stings, direct mast cell activation by morphine, codeine, radioconstrast agents, NSAIDs
Uticaria may be confused with
uticarial vasculitis
Uticarial vasculitis description
fixed (lasts longer than 24 hours), painful, red, uticarial plaques with blanching halos, leaves residual hyperpigmentation, link with lupus
Tx of uticaria
H1 histamine blocker - 1st or 2nd generation
H2 histamine blocker in combo with H1
Examples of H1 histmaine blockers
hydroxyzine, diphenhydramine, chlorpheniramine, cetrizine, loratadine, fexofenadine
Examples of H2 histamine blockers
zantac, pepcid, tagamet
If angioedema or persistent symptoms, tx uticaria with
oral glucocorticoids
2nd generation H1 histamine blockers are preferred first line therapy for
uticaria
Zyrtec and Xyzal may be may effective why?
mast cell-stabilizing properties
If allergic etiology of uticaria is suspected
refer to allergist - may need EPIpen
