4 - Nose Flashcards
1
Q
Nose hole anatomy
A
Slide 5, 6, 7, 8
2
Q
Ostiomeatal complex (OMC)
A
Channel that links the frontal sinus, anterior ethmoid air cells and maxillary sinus to the middle meatus, allowing air flow and mucocilary drainage
3
Q
Essentials of diagnosis for acute viral rhinitis?
A
Clear rhinorrhea
Hyposmia
Nasal congestion
Malaise
HA
Cough
Erythematous engorged nasal mucosa
W/o intranasal purulence
4
Q
How long does the common cold last?
A
Generally 3-10 days but symptoms should be better in
- 10 days to 4 weeks
Self limited
5
Q
Fever with viral rhinitis?
A
Not common
6
Q
Complications for viral rhinitis?
A
Usually
- Benign and self limited
ETD
Otitis media w effusion
Acute bacterial sinusitis
7
Q
Tx for acute viral rhinitis?
A
Z pack
Jk dont do that
Symptomatic or zinc (75mg) (controversial)
- nasal irrigation
- decongestants
8
Q
Acute bacterial rhinosinuitis (ABRS) essentials?
A
Purulent yellow/green discharge/expectorant
Facial pain/pressure
Nasal obstruction
Acute onset
9
Q
What causers ABRS?
A
Impaired mucociliary clearance and obstruction of the ostiomeatal complex
Oatmeal complex is clogged
This gets infected in the sinuses
10
Q
Predisposing symptoms for ABRS?
A
URI
Allergies
Mechanical obstruction (deviated septum)
11
Q
MC community and hospital acquired bacteria for ABRS?
A
Community:
- S pneumonia
- H influenzae
Hospital:
- pseudomonas
- S. Aureus
12
Q
Presentation of ABRS?
A
Facial pain/pressure Fever Cough Hyposmia/anosmia Purulent nasal discharge Nasal congestion Maxillary tooth discomfort
13
Q
ABRS vs AVRS?
A
AVRS - complete resolution in 7-10 days
ABRS - no good criterai but may see
- 10+ days
- > 102*F
- purulent discharge/pain x 3-4 days
14
Q
Classification of ABRS?
A
Acute <4 weeks
Subacute: 4-12 wks
Chronic: >12 wks
Recurrent: >/= 4 per yr
15
Q
MC paranasal sinusitis?
A
Acute maxillary sinusitis
16
Q
Acute maxillary sinusitis specific sx?
A
- Unilateral facial fullness
- tenderness over cheeks
17
Q
Can mimic Acute maxillary sinusitis pain?
A
Tooth infection can refer to the maxillary sinus via CN V
18
Q
Acute ethmoid sinusitis sx?
A
Localized pain/pressure over high lateral wall of nose between eyes
- may radiate to orbit
19
Q
Acute sphenoid sinusitis?
A
HA “in the middle of the head”
- pt often points to vertex
20
Q
Acute frontal sinusitis
A
Tenderness of the forehead
- easily elicited by palpation
21
Q
Hospital associated sinusitis
A
May be the cause of fever in critical pts
Associated w prolonged NG tube
22
Q
PE for acute rhinosinusitis?
A
Pain in sinuses when bending forward
Direct percussion/palpation
Rhinoscopy
- diffuse mucosal edema
- narrowing/hypertrophy of middle meatus
- septal deviation or polyps
- purulent rhinorrhea
23
Q
Imaging for acute rhinosinusitis?
A
Not really indicated but:
- CT test of choice
- NOT Xray
24
Q
Tx of ABRS
A
Basically same as AVRS
Analgesics Saline irrigation Decongestants Topical decongestants Intranasal corticosteroids
Abx - (controversial in uncomplicated cases)
25
Abx for ABRS?
Amoxicillin-clavulante (first line)
PCN allergy (pick 1)
- doxy
- clinda
26
For ABRS never use?
Macrolides (azithromycin) or TMP/SMX due to high rates of resistance and poor sinus penetration
27
Which pts get abx for ABRS?
>10 days
Severe symptoms
Symptoms worsen after period of improvement
If <7 days; symptomatic tx only
28
Complications of ABRS?
Orbital cellulitis
Osteomyelitis
- “pott puffy tumor”
Intracranial extension (rare)
29
If you suspect orbital cellulitis you should?
Get a CT
IV abx
Surgery
Stat opthalmology consult
30
Intracranial extension pts need?
MRI of the Danger triangle
31
What is intracranial extension?
```
Hematogenous spread as in cavernous sinusthrombosis and meningitis
Sx
- opthalmoplegia
- chemosis
- visual loss
```
32
Intracranial extension can have direct extension. What does this mean?
Can become epidural and intraparenchymal brain abscess
33
When to refer ABRS?
```
Failure to respond to abx
Suspected extension outside sinus
Facial cellulitis
Proptosis
Immunocompromised pts
```
34
What is nasal vestibulitis/S. Aureus nasal colonization
Infection caused by colonization of S. Aureus (MC)
Beware the danger triangle
35
Tx for nasal colonization?
Dicloxacillin 250mg qid 7-10 days
Mupirocin nasally
Chlorhexidine facial wash bid
36
Invasive fungal sinusitis is aka?
Rhinocerebral mucormycosis
37
What is invasive fungal sinusitis?
Aspergillus or similar in the vascular space causing tissue necrosis
Found it your immunocompromised pts
- DM
- long term corticosteroids
- mustache wearing
38
Sx of invasive fungal sinusitis?
Similar to abrs though pain is more severe
39
Rhinocerebral mucormycosis can lead to?
Brain infection
- cavernous sinus thrombosis
- seizures
- thrombotic stroke
40
Tx for invasive fungal sinusitis?
Amphotericin B
| Surgery
41
Mortality rate for invasive fungal sinusitis?
DM - 20%
Kidney disease - >50%
Aids - 100%
42
Allergic rhinitis
You should know
But presence of allergen-specific IgE
43
MC cause of allergic rhinitis?
Pollens and spores
- flowering
- grass
- ragweed
- dust
- pollution
Often (though not always) seasonal
44
Allergic rhinitis PE?
```
General
- allergic shiners
Nose
- pale/violaceous turbinates
- nasal polyps
- rhinorrhea
- allergic salute
Oropharynx
- cobblestoning
```
Pics on 40-42
45
When treating allergies remind pts that tx may?
Take 2+ weeks to work
46
Common nasal allergy meds (corticosteroids)?
```
Beclomethasone
Flunisolide
Mometasone furoate
Budesonide
Fluticasone propionate
```
47
Oral allergy meds? (H1 blockers)
Non sedating
- loratadine
- desloratadine
- fexofenadine
Minimally sedating
- cetrizine
Sedating
- brompheniramine
- chlorpheniramine
Nasal spray
- azelastine
48
Adjunctive measures for allergy tx?
Antileukotriene: montelukast
Mast cell stabilizer: cromolyn sodium and sodium nedocromil
49
For extremely bothersom allergy symptoms what test can be done?
Radioallergosorbent test (RAST)
By an allergy doc
50
Nonallergic rhinitis?
Nasal symptoms caused by non allergic things
- Gustatory rhinitis
- Rhinitis medicamentosa
- Vasomotor rhinitis
- Occupational rhinitis
51
rhinitis medicamentosa?
Chronic inflammatory condition caused by too much topical decongestants
- afrin
Leads to rebound nasal congestion
52
Tx for rhinitis medicamentosa?
Cessation of med
Withdrawl meds
- flunisolide
- ipratropium
- PO prednisone
- NSAID
53
Essentials of diagnosis for olfactory dysfunction?
- Subjective diminished smell/taste
- lack of objective nasal obstruction
- objective decrease in olfaction demonstrated by testing
54
MCC of olfactory dysfunction?
Anatomic blockage
55
PE for olfactory dysfunction?
Nose
Nervous system CN1
UPSIT - university of pennsylvania smell ID test
56
Tx for olfactory dysfunction
Depends:
- Obstruction - surgery
- Primary disruption of olfaction - no tx
57
Greatest predictor fo recovery of olfactory dysfunction?
Degree of hyposmia is the greatest predictor of recovery
58
If your pt has permanent hypsoma you need to?
Counsel them about
- over seasoning
- abuse of table salt
- safety (smoke etc)
59
Epistaxis?
Nose bleed
Bleeding from unilateral anterior nasal cavity
60
Most epistaxis can be treated with?
Direct pressure x 15 min
Can go to
- Sympathomimetics
- Nasal tamponade methods
61
Posterior, bilateral or large volume epistaxis needs?
Triage immediately to specialist in critical care setting
62
Causes of epistaxis?
```
Trauma
Rhinitis
Dry mucosa (low humidity, o2 therapy)
Deviated septum
HTN,
atherosclerosis
hereditary diseases
Nasal drugs
Anticoagulation meds
```
63
Why are posterior bleeds more severe?
The arterial supply is bigger - woodruffs plexus
| - usually associated w HTN, atherosclerosis
64
Tx for anterior nosebleed
1. Direct pressure x 15 min
2. Inspect then try nasal decongestant (spray)
3. Reapply decongestant or cocaine
- also can cauterize w silver nitrate or electrocautery
4. Nasal packing
65
Instructions for packing the nose?
Slide 59, there are pics
66
Tx of posterior nose bleed?
Pneumatic tamponade
Nasal packing
Double balloon pack
Surgical ligation
Admission and monitoring
67
If packing nose you need?
Antistaphy abx to prevent toxic shock syndrome
68
What do the nose and bladder have in common?
Both can use the foley catheter
| - different uses though
69
What is the dual balloon tamponading system?
Sweet nose tube with 2 ballons
- can pack posterior and anterior chamber
Pic on 63
70
If bleeding goes beyond 15 min?
Take to local ED
71
Complications of epistaxis?
```
Complications:
§ Severe bleeding, syncope
§ Hypoxia, hypercarbia
§ Sinusitis, otitis media
§ Tissue necrosis
§ Toxic Shock Syndrome (TSS): If sudden nausea, vomiting, fever, erythrodermic rash
```
72
MC fractured bone in body?
Nasal fracture
73
With nasal fx you need to ensure?
No palpable step-off of the infraorbital rim (zygomatic compelx fx)
No infraorbital numbness
74
What is a septal hematoma
Blood clot between perichondrium and cartilage
75
Risk with septal hematoma?
Septal necrosis leading to perforation
Untreated leads to loss of cartilage and saddle nose deformatiy
76
Septal hematoma must be?
Incised and drained on both sides
77
Tx for nasal trauma?
Goal - ensure patent airway
There are more thoughts and ideas about tx varying by condition on slide 68 (sorry john, i know you hate these)
78
What is Le Fort?
A system for describing complex mid face fx
Le Fort 1
Le Fort 2
Le fort 3
79
Problem with le forte classification?
Many complex fx do not conform to such classifications and have comminution, additional levels or lines of fx
80
Le fort levels?
Le fort I - horizontal maxillary fx
Le fort II - pyramidal maxillary fx
Leforte III - craniofacial dysjunction
Pic on 72
81
Tumors and granulomatous disease includes?
Benign nasal tumors
- nasal polyps
- inverted papilloma
Malignant nasopharyngeal and paranasal sinus tumors
Sinonasal inflammatory disease
- granulomatosis w polyangiitis and sarcoidosis
82
What are nasal polyps?
Pale, yellow, endematous, mucosally covered masses commonly associated w allergic rhinitis
- chronic nasal obstruction and hyposmia
83
Traid asthma or samter triad?
Nasal polyps
Asthama
Aspirin sensitivity
- may precipate severe episode of bronchospasm
84
If nasal polyps are found in a child?
R/o cystic fibrosis
85
Tx for benign nasal polyps?
1-3 mo nasal steroids
Prednisone 6 day taper
Surgery
86
Inverted or schneiderian papillomas are caused by?
Human papillomavirus (HPV)
87
Inverted or schneiderian papillomas are?
Cauliflower-like growths in or around the middle meatus that cause:
- Unilateral nasal obstruction and occasional hemorrhage
88
Tx for Inverted or schneiderian papillomas?
Excision - Medial maxillectomy
F/u - 20% recurrence
89
Benign nasal polyps are associated w?
10% are squamous cell carcinoma
90
Symptoms of malignant nasopharyngeal and paranasal sinus tumors?
Often asymptomatic until late
Early - non-specific (rhinitis/sinusitis)
Late - after invasion of adjacent areas
- proptosis, pain/expansion of cheek or ill-fitting maxillary dentures
91
Dx for malignant nasopharyngeal and paranasal sinus tumors?
Biopsy
| MRI to plan surgery
92
Granulomatosis w polyangiitis (wegeners) is?
rare blood vessel disease
- 90% involve nose and paranasal sinus
PE: Bloodstained crusts and friable mucosa.
Biopsy: Necrotizing granulomas and vasculitis
93
Sarcoidosis is?
Multisystem granulomatous disorder that can involve nose and paranasal sinus
PE: turbinates engorged w small white granulomas
Biopsy: noncaseating granulomas
94
What is polymorphic reticulosis?
Lethal midline granuloma
- not well understood (lymphoma maybe)
PE: may include extensive bone destruction
Biopsy: nasal T-cell or NK-cell lymphoma
95
Slide 81
The red is pance stuff
The rest is important stuff i guess
96
What do you call someone with no body and no nose?
Nobody knows
