Disorders of the Nose

Question 1

Definition of allergic rhinitis

Answer 1

• inflammation of the mucous membranes of the nose, eyes, eustachian tubes, middle ear, sinuses and pharynx
• triggered by IgE mediated response

Question 2

Complications of allergic rhinitis

Answer 2

• Otitis media
• ETD
• Sinusitis (acute and chronic)
• impairment in quality of life

Question 3

What is early response

Answer 3

With allergen re-exposure, the specific protein binds to the IgE on the mast cells resulting in an immediate and delayed release of inflammatory mediators (histamines) which lead to symptoms of AR

Question 4

What is late response

Answer 4

4-10 hours after allergen exposure, you have a second release of inflammatory mediators (eosinophils), continued inflammation with persistent symptoms

Question 5

Symptoms of allergic rhinitis

Answer 5

• rhinorrhea
• sneezing
• itching
• post nasal drip/sore throat
• nasal congestion/obstruction
• increased lacrimation/red eyes
• eye swelling
• fatigue/drowsiness

Question 6

What is allergic salute?

Answer 6

transverse crease across the nasal bridge d/t upward rubbing of the nose

Question 7

PE of nose in AR

Answer 7

Allergic salute
Nasal mucosa is pale and boggy
thin, watery nasal secretions

Question 8

What are allergic shiners

Answer 8

dark, swollen, infraorbital tissue secondary to vasodilation and/pr congestion

Question 9

PE of eyes in AR

Answer 9

conjunctiva injected and edematous with clear drainage

allergic shiners

Question 10

PE of ears in AR

Answer 10

TM retraction, air fluid levels or bubbles

Question 11

PE of throat in AR

Answer 11

Pharynx is generally unremarkable

Question 12

DDX of allergic rhinitis

Answer 12

Nonallergic rhinitis syndromes

Question 13

What are some diagnostic tests for allergic rhinitis

Answer 13

• Blood (supportive but not sensitive or specific)
  i. e. Eosinophils in CBC, IgE elevation
• Nasal smears (eosinophils)
• Skin testing (immediate hypersensitivity)
• RAST (radioallergosorbent test)

Question 14

Allergic rhinitis treatment

Answer 14

• Avoidance of allergens/prevention
• pharmacologic treatment
• immunotherapy

Question 15

Examples of pharmacotherapy treatment for AR

Answer 15

• Intranasal steroids
• antihistamines
• leukotriene antagonist
• mast cell stabilizer- Cromolyn

Question 16

What are nasal polyps

Answer 16

-Pale, edematous, mucosally covered masses

Benign

Question 17

Etiology of nasal polyps

Answer 17

Unknown but thought to be from chronic inflammation

Question 18

What is acute sinusitis

Answer 18

• sinusitis of

Question 19

Diagnostic criteria for acute sinusitis

Answer 19

Moderate symptoms for > 10 days

Question 20

Cause of sinusitis

Answer 20

S. pneumonia

Question 21

Viral sinusitis

Answer 21

more common than bacterial (rhinovirus, parainfluenza virus, influenza virus)

Question 22

Bacterial sinusitis

Answer 22

Complicates only .2-2% of viral infections

• S. pneumonia and H. Influenza make up 50-60%
• Moraxella catarrhalis more common in children

Question 23

Pathophysiology of acute sinusitis

Answer 23

• initiated by viral upper respiratory infection
• mucosal edema, decreased mucus transport and obstruction of ostiomeatal complex which leads to secretions not moving
• stagnant secretions and limited function of the nose promotes bacterial or viral overgrowth

Question 24

Acute sinusitis complications

Answer 24

• orbital cellulitis
• osteomyelitis of facial bones
• subcutaneous abscesses
• CNS complications
• Potts puffy tumor

Question 25

What is Potts puffy tumor?

Answer 25

Rare, life threatening | extension of frontal sinus infection resulting in frontal bone osteomyelitis and subperiosteal abscess

Question 26

Signs/symptoms of acute sinusitis

Answer 26

- Purulent nasal discharge - facial pain/pressure/fullness - nasal obstruction - fever - halitosis (bad breath) - dental pain

Question 27

HPI acute sinusitis

Answer 27

- What are their symptoms and duration of symptoms - symptomatic OTC treatment - Ask about risk factors - others at home or work sick - prior nasal/sinus history - trauma

Question 28

Physical examination finding of acute sinusitis

Answer 28

- Fever - purulent nasal discharge/post nasal drip - nasal obstruction - palpable sinus tenderness (over sinuses/upper teeth) - swelling, erythema or edema over cheekbone or periorbital area - transilluminate sinuses - signs of extra sinus involvement

Question 29

Distinguishing acute bacterial from viral sinusitis

Answer 29

- signs/symptoms lasting greater than 10 days without evidence of clinical improvement - worsening after initial improvement - severe symptoms with fever over 102 and purulent nasal discharge over 3-4 consecutive days

Question 30

Diagnostic testing for acute sinusitis

Answer 30

- typically no imaging/further diagnostic test indicated | - sinus aspiration and culture is GOLD STANDARD for acute bacterial sinusitis

Question 31

Symptomatic treatment of acute sinusitis

Answer 31

- analgesics and antipyretics - fluids - intranasal corticosteroids - decongestants - mucolytics - intranasal saline irrigation (netipot)

Question 32

What is the drug therapy for acute sinusitis?

Answer 32

Amoxicillin | -if allergic then bactrim