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M202 > W31 Nasal conditions > Flashcards

W31 Nasal conditions Flashcards

1
Q

What is congestion?
Accompanying symptoms of congestion?

A
  • Nasal obstruction, stuffy nose, blocked nose
  • Variance of severity between patients

Accompanied by other symptoms
* Nasal discharge/runny nose/rhinorrhoea
* Postnasal drip/catarrh
* Facial pain
* Loss of sense of smell
* Sneezing
* Itching
* Crusting

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2
Q

Causes of congestion? (6)

A
  • Nasal deformity
  • Foreign body in the nose
  • Swelling of nasal mucosa
  • Inflammation of nasal mucosa
  • Infection e.g. Sinusitis
  • Allergy e.g. Hay fever
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3
Q

Treatment for congestion?

A
  • Steam inhalation – can add menthol & eucalyptus
  • Saline sprays or drops e.g. Sterimar
  • Saline nasal irrigation
  • Corticosteroid nasal sprays e.g. Beconase
  • Oral or intranasal decongestants e.g. Pseudoephedrine, Xylometazoline
  • Oral antihistamines e.g. Cetirizine, Loratadine
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4
Q

Define Rhinitis
What are the symptoms?

A
  • Irritation & inflammation of mucosal membrane inside the nose
  • Allergic & Non- allergic
  • Sneezing
  • Blocked nose/Congestion
  • Runny nose (rhinorrhoea)
  • Itching nose
  • Postnasal drip
  • Itching roof of mouth
  • Cough
  • Eye symptoms – itching, redness, tearing
  • Mild, Moderate or Severe
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5
Q

Allergic Rhinitis

A
  • IgE mediated inflammatory disorder of the nose
  • Nasal mucosa exposed to allergens
    -Histamine release
    -Inflammatory mediator release
  • Seasonal – symptoms during a period each year in response to a seasonal allergen
  • Perennial – Symptoms all year round - constant exposure to allergen
  • Intermittent – Symptoms for less than 4 days a week or less than 4 consecutive weeks
  • Persistent – Symptoms for more than 4 days a week and for more than 4 consecutive week
  • Occupational – Symptoms due to allergen exposure in work
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6
Q

Causes of Allergic rhinitis?

A
  • Occupational
  • Genetic
  • House dust mites
  • Pollen
  • Moulds
  • Animal hair
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7
Q

Allergic Rhinitis
Diagnosis?
Assessment?
Differential diagnosis?

A
  • Sneezing, itching, rhinorrhoea, congestion
  • Bilateral symptoms
  • Associated symptoms
  • Personal or FH of Atopy
  • Occur after exposure to allergen
  • Type, frequency, persistence, location of symptoms
  • Severity of symptoms
  • Pets? Occupation?
  • Hx of treatment
  • Infective rhinitis
  • Non-allergic rhinitis
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8
Q

Management of allergic rhinitis

A
  • Nasal irrigation
    -Rinse nasal cavity with Saline (NaCl 0.9%) solution
    -OTC
  • Allergy testing
  • Avoid triggers/allergen
  • Pharmacological Treatments
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9
Q

Allergic Rhinitis - Pharmacological Treatments

A
  • Antihistamines
  • Intranasal cromones
  • Intranasal decongestants
  • Intranasal anticholinergics
  • Oral Leukotriene receptor antagonists
  • Intranasal corticosteroids
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10
Q

Antihistamines- Intranasal
Azelastine

A
  • 1 spray BD
  • From age 6+
  • Can taste bitter
  • Can irritate nasal mucosa
  • Possible hypersensitivity reaction
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11
Q

Antihistamines- Oral
Names and dose? ? (2)
SE?

A

Cetirizine
* 10mg daily
* Reduce to half dose in eGFR 30-59
* Reduce to half dose & alt. days in eGFR 15-29
* Avoid in eGFR below 15

Loratadine
* 10mg daily
* Reduce to alternate days in hepatic impairment

  • Side effects
  • Blurred vision, dry mouth, headache, diarrhoea
  • Drowsiness
  • Angioedema, arrythmias, blood disorders
  • Interaction with Betahistine
  • Caution in Pregnancy & Breastfeeding
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12
Q

Intranasal Cromones:
Sodium cromoglicate
dose?
P/BF?

A
  • 1 spray 2-4 times daily in each nostril
  • No contraindications or cautions with nasal use
  • Could cause bronchospasm and irritation of nasal mucosa
  • No drug interactions with nasal use
  • Can be used in pregnancy and breastfeeding
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13
Q

Intranasal Decongestants: Xylometazoline
Dose?
Cautions?
SE?
Interactions? (2)
Use in P/BF?

A
  • Child age 6-11 = 1-2 drops 1-2 times a day PRN for max. 5 days
  • Age 12+ = 2-3 drops, 2-3 times a day PRN for max. 7 days
    -Spray 1-3 times daily
  • Cautions – Diabetes, Hypertension, Hyperthyroidism, CVD, Angle-closure Glaucoma, BPH/Prostate enlargement
  • Side Effects – rebound congestion, hypertrophy of mucosa, headache, nausea, irritation, dryness, hallucination, restlessness, sleep disturbance
  • Drug Interactions – Rasagiline, Selegiline
  • Avoid in Pregnancy & Breastfeeding
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14
Q

Intranasal Anticholinergics

A

Ipratropium Bromide
* Age 12-17 – 2 sprays, 2-3 times daily in each nostril
* Adult – 2 sprays, 2-3 times daily in each nostril
* Avoid spraying near the eyes
* Cautions – Cystic Fibrosis, bladder obstruction, Benign Prostatic Hyperplasia (BPH), prostate enlargement
* Side Effects – Epistaxis, dryness, irritation, headache, nausea, GI motility disorders, palpitations, urinary
retention
* Drug Interactions – Antimuscarinics, bronchodilators
* Avoid in pregnancy & breastfeeding

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15
Q

Leukotriene Receptor Antagonists
SE?
Interactions?
Avoid in..?

A

Montelukast:
* Age 15+ - 10mg in the Evening
* Side Effects – Abdo pain, headache, hyperkinesia, thirst, eosinophilia, vasculitic rash, abnormal dreams, aggression/agitation, anxiety, antimuscarinic effects, peripheral neuropathy, cardiac complications
* Drug Interactions – carbamazepine, clopidogrel, leflunomide, phenobarbital, phenytoin, primidone, rifampicin
* Avoid in Pregnancy & Breastfeeding

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16
Q

Non-Allergic Rhinitis
What are the causes?

A
  • Change in temperature/humidity
  • Common cold
  • Exercise
  • Irritants - Smoke, perfume, paint fumes
  • Alcohol, spicy food
  • Drugs – Alpha blockers, ACE inhibitors, B-Blockers, Chlorpromazine, aspirin, NSAIDs, Cocaine
  • Rebound congestion – decongestant overuse
  • Hormonal – Pregnancy, HRT, Contraception, Hypothyroidism
  • Non-allergic rhinitis with eosinophilia syndromes (NARES)
  • Systemic & Structural defects
17
Q

What is Sinusitis?
3 categories?

A
  • Inflammation of the paranasal sinuses and nasal cavity
  • A.k.a. Rhinosinusitis
  • Acute – Resolves within 12 weeks
  • Recurrent Acute – 4+ episodes of acute sinusitis/year
  • Chronic – Symptoms last for over 12 weeks
    Sinusitis
18
Q

Sinusitis- Causes?

A
  • Viral URTI
  • Bacterial infection
  • Asthma
  • Allergic rhinitis
  • Seasonal
  • Smoking
  • Nasal defects – Polyps, deviated septum, trauma, foreign body, impaired ciliary motilility
  • Aspirin sensitivity
  • Immunocompromised
  • Genetic
  • Sinus surgery
19
Q

Sinusitis- Complications

A
  • Orbital -Orbital cellulitis, abscess, cavernous sinus thrombosis
  • Intracranial – meningitis, encephalitis, abscess, venous thrombosis
  • Osteomyelitis
  • Progression to chronic sinusitis
  • Sleep problems, fatigue, depression
  • QoL – Reduced social life, absence from work, ability at work
20
Q

Sinusitis - Diagnosis

A

Acute:
* Usually after a cold
* Worsening symptoms after 5 days, persisting for over 10 days but less than 12 weeks
* Nasal congestion or discharge
* Facial pain or pressure
* Reduced sense of smell
* Nasal voice
* Tenderness, swelling, inflammation
over cheekbone and periorbital
areas
* Cough

Chronic
* Nasal congestion or discharge
* Facial pain or pressure
* Reduced sense of smell
* Lasts for longer than 12 weeks
* Pain/swelling/ tender maxiofacial area
* Inflamed and swollen nasal mucosa
* Possible nasal polyps or anatomical defects

21
Q

Sinusitis – Differential Diagnosis

A
  • Upper RTI
  • Common cold
  • Allergic rhinitis
  • Foreign body in nose
  • Adenoiditis/tonsillitis
  • Tumour
  • Turbinate hypertrophy
  • Migraine
  • Giant cell arteritis
  • Temporomandibular disorder
  • Trigeminal neuralgia
  • Dental pain
22
Q

Acute Sinusitis - Management

A
  • Admit to hospital if systemically unwell or have orbital or intracranial complications
  • Do not offer antibiotic treatment if symptoms present for less than 10 days
  • Likely viral cause
  • Resolve in 2-3 weeks
  • Self manage fever
  • Lack of evidence for saline, decongestants, antihistamines, steam inhalation, mucolytic
23
Q

Intranasal Corticosteroids

A
  • Available as drops and sprays
  • Greater risk of systemic effects with drops
  • Use from age 12+
  • Beclometasone (Beconase)
  • Mometasone (Nasonex)
  • Fluticasone (Flixonase, Avamys, Dymista)

Contraindications
* Untreated fungal, bacterial or viral nasal infection
* Recent nasal surgery/trauma
* Pulmonary TB
* Can be used in pregnancy & breastfeeding
* Local adverse effects – Nasal dryness & irritation, nosebleeds, throat dryness & irritation, skin redness,
rash & itching, headache, disturbed smell & taste
* Systemic adverse effects – Less likely than with oral corticosteroids but risk with high doses and extended
treatment, lower risk with spray than drops

24
Q

Phenoxymethylpenicillin
What is its drug class and moA?
C/I?
Caution?
Interactions?
Adverse effects?

A
  • Β-lactam antibiotic
  • Interrupts bacterial cell wall synthesis
  • Narrow spectrum
  • Contraindications – Penicillin allergy, cephalosporin allergy
  • Caution – Renal impairment
  • Drug interactions – MTX, oral anticoagulants

Adverse effects:
* GI – Nausea, diarrhoea, vomiting, stomatitis, glossitis. Rarely cause abx associated colitis
* Skin – Rash, urticaria, pruritis
* Anaphylaxis

25
Q

Amoxicillin

A
  • Β-lactam antibiotic
  • Interrupts bacterial cell wall synthesis
  • Broad spectrum
  • Contraindications – Penicillin allergy, cephalosporin allergy
  • Caution – Renal impairment – Reduce dose if eGFR under 30mL/min/1.73m2
  • Adverse effects
  • GI – Nausea, diarrhoea, vomiting
  • Skin – Rash, urticaria, pruritis
  • Anaphylaxis
  • Thrombocytopenia
  • Rare – agranulocytosis, haemolytic anaemia, neutropenia, SCARs
26
Q

Co-Amoxiclav:

A
  • Amoxicillin + Clavulanic Acid
  • Clavulanic acid prevents breakdown of B-lactam ring by B-lactamase
  • Only treat if persistent symptoms in sinusitis
  • Contraindications – Penicillin allergy, Hx co-amoxiclav or penicillin associated jaundice, hepatic dysfunction
  • Caution – Renal impairment – Reduce dose if eGFR under 30mL/min/1.73m2, ALL, CLL, CMV, Glandular Fever
  • Adverse effects
  • GI – Nausea, diarrhoea, vomiting….C.diff
  • Skin – Rash, urticaria, pruritis, SJS
  • Anaphylaxis
  • Jaundice
  • Leucopenia, thrombocytopenia, haemolytic anaemia
27
Q

Clarithromycin/Erythromycin

A
  • Macrolides
  • Clarithromycin available as IR & MR
  • Broad Spectrum
  • Inhibit protein elongation, inhibit translocation
  • Prescribed as alternative in patients with Penicillin allergy
  • Erythromycin in pen allergy if patient is pregnant
  • 500mg BD 5/7 Clarithromycin
  • 250-500mg QDS 5/7 Erythromycin
28
Q

Clarithromycin/Erythromycin

A
  • Contraindications – Patients taking drugs that prolong QT interval e.g. Citalopram, Hx QT prolongation, Hx
    ventricular arrythmia, hypokalaemia, hepatic & renal impairment
  • Cautions – CAD, bradycardia, electrolyte disturbances, impaired hepatic function, myasthenia gravis, eGFR below
    30 (half dose)
  • Drug interactions – CCBs, Ciclosporin, Colchicine, CYP3A4 inducers, Digoxin, Edoxaban, Ergot alkaloids,
    Sulfonylureas, Insulin, Statins, Warfarin, QT interval prolonging drugs (e.g. Amiodarone)
  • Adverse effects
  • GI – Nausea, diarrhoea, vomiting, dyspepsia, abdominal pain
  • Skin – Rash, urticaria, pruritis, hyperhidrosis, SJS, DRESS
  • Anaphylaxis
  • Insomnia, anxiety
  • Arrythmia, QT prolongation
  • Hepatic failure, jaundice
29
Q

Doxycycline

A
  • Tetracycline antibiotic
  • Inhibits protein synthesis elongation – blocks tRNA binding to mRNA ribosome
  • Broad Spectrum
  • Used in patients with penicillin allergy
  • Contraindications – Pregnancy, breastfeeding, children under 12
  • Cautions – Hepatic impairment, patients taking hepatotoxic drugs, myasthenia gravis,
    lupus, renal impairment
30
Q

Doxycycline

A

Drug interactions
* Antacids (leave a gap between dose)
* CYP3A4 inducers
* Methotrexate
* Retinoids
* Rifampicin
* Warfarin

Adverse effects
* Haemolytic anaemia, thrombocytopenia, neutropenia, eosinophilia
* Nausea, vomiting, dyspepsia
* Hepatitis, jaundice, hepatic failure
* Hyperuricaemia
* Rash, Photosensitivity

31
Q

Antibiotics & Hormonal Contraception (for info)

A
  • Historically patients told that Antibiotics can affect efficacy of hormonal contraceptives
  • Still a belief this is the case amongst many patients
  • NO additional contraceptive precautions are required during or after courses of penicillins, macrolides or tetracyclines
  • Advise on importance of correct contraceptive practice if experience vomiting or diarrhoea

M202 (72 decks)

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