HEENT - Allergic Rhinitis, Tinnitus, and Urticaria - Exam 2

Question 1

What is barotrauma?

Answer 1

Discomfort or damage due to pressure differences between the middle ear and outside world

Question 2

What are common causes of barotrauma?

Answer 2

Flying and driving

Question 3

What are symptoms of barotrauma?

Answer 3

• Pressure
• Pain
• Hearing loss
• Tinnitus

Question 4

What are typical exam findings with barotrauma?

Answer 4

• Middle ear effusion
• Hemotympanum
• TM rupture

Question 5

What is the treatment for barotrauma?

Answer 5

• Avoidance
• Oral or nasal decongestants
• Swallowing, valsalvia, chewing gum (to equalize middle ear pressure)
• Treatment of injury is usually time/patience
• If perilymphatic fistula (vertigo and senroineural hearing loss) refer to ENT

Question 6

What is Acoustic neuroma (Vestibular Schwannoma)?

Answer 6

Slow growing Schwann cell tumors that arise from the vestibular portion of CN VIII

Question 7

What are risk factors for Acoustic neuroma?

Answer 7

• Childhood exposure to radiation of the head/neck

- Neurofibromatosis Type 2

Question 8

What is the presentation of Acoustic neuroma?

Answer 8

• Unilateral sensorineural hearing loss and tinnitus (classic presentation)
• +/- gait disturbance or other CN involvement

Question 9

How is Acoustic neuroma diagnosed?

Answer 9

• Audiometry is best initial test

- MRI (diagnostic imaging of choice)

Question 10

What is the treatment for Acoustic neuroma?

Answer 10

• Surgery
• Radiation
• Observation

Question 11

What are symptoms associated with tinnitus?

Answer 11

• Perception of buzzing, ringing, hissing or other noise

- Continuous or intermittent; pulsatile or non-pulsatile

Question 12

Which type of tinnitus is most commonly vascular in etiology?

Answer 12

Pulsatile tinnitus

Question 13

Which type of tinnitus needs an ENT referral for possible imaging?

Answer 13

Pulsatile tinnitus

Question 14

What is the treatment for tinnitus?

Answer 14

• Main goal: lessen impact on quality of life
• Behavioral therapy: biofeedback, stress reduction, CBT
• Benzodiazepines - alprazolam (Xanax)
• Masking devices such as white noise machines

Question 15

What is the etiology associated with tinnitus?

Answer 15

• Ototoxic medications
• Presbycusis (SN hearing loss with aging)
• Otosclerosis
• Vestibular Schwannoma
• Chiari malformations
• Barotrauma

Question 16

What is the pathophysiology behind allergic rhinitis?

Answer 16

• Response to allergen exposure by production of IgE

Question 17

What are symptoms associated with allergic rhinitis?

Answer 17

• Rhinorrhea
• Sneezing
• Nasal congestion
• +/- Itchy eyes, itchy nose, post nasal drip, cough

Question 18

What are risk factors for allergic rhinitis?

Answer 18

• FHx of atopy (biggest factor)
• Male sex
• Birth during pollen season
• Firstborn status
• Early use of abx
• Maternal smoking exposure in 1st year of life
• Exposure to indoor allergens
• Presence of allergen-specific IgE

Question 19

How will the periorbital area appear on physical exam in individuals with allergic rhinitis?

Answer 19

• “Allergic Shiners”: bluish purple rings around both eyes

- Dennie-Morgan Lines: skin folds under eyes consistent with allergic conjunctivitis

Question 20

How will the eyes appear on physical exam in individuals with allergic rhinitis?

Answer 20

• Diffuse redness involving the bulbar and palpebral conjunctiva
• Tearing or clear watery discharge
• Chemosis
• Eyelid edema

symptoms are usually bilaterally

Question 21

How will the nose appear on physical exam in individuals with allergic rhinitis?

Answer 21

• Pale, boggy, “bluish” mucosa
• Clear nasal discharge
• Nasal crease from “allergic salute”

Question 22

How will the throat appear on physical exam in individuals with allergic rhinitis?

Answer 22

• Post-nasal drainage in posterior pharynx

- “Cobblestoning”

Question 23

How will the ears appear on physical exam in individuals with allergic rhinitis?

Answer 23

Retracted TMs and/or serous otitis media (OME)

Question 24

While allergy testing can be confirmatory, but not necessary for the initial diagnosis of allergic rhinitis, what are its benefits?

Answer 24

• Helps to identify and facilitate avoidance of allergens

- Identifies candidates for immunotherapy

Question 25

What are you looking for in a Scratch (Prick) Test? What is a risk with this testing?

Answer 25

Looking for a positive "Wheal and Flare" reaction Risk for anaphylactic reaction (should have epi available)

Question 26

What symptoms do 1st generation antihistamines help with? Which symptoms do they not help with? What are examples of 1st generation antihistamines? What are side effects?

Answer 26

Helps to alleviate sneezing, rhinorrhea, and itching; no relief of nasal congestion - Chlorpheniramine (Chlor-trimeton) - Diphenhydramine (Benadryl) Side effects: dry mouth, constipation, sedation

Question 27

When would you recommend 2nd generation antihistamines instead of 1st generation? What are examples of 2nd generation antihistamines?

Answer 27

You would recommend 2nd generation for patients that do not want sedating/drowsy side-effect of a 1st generation antihistamine - Loratadine (Claritin) QD - Fexofedadine (Allegra) QD or BID - Cetirizine (Zyrtec) QD

Question 28

What do antihistamine nasal sprays target? How are they dosed? Are they used alone or in combination with other therapies?

Answer 28

Target H1 antagonist Dosed BID May be used alone or in combination with steroid nasal spray

Question 29

Are nasal steroid sprays more or less effective than oral antihistamines? What are its side effects?

Answer 29

More effective Side effects: Epistaxis

Question 30

What is an example of a leukotriene receptor antagonist? What can these be used in conjunction with to provide more relief of symptoms?

Answer 30

Montelukast (Singulair) Used with 2nd generation oral antihistamine provides more relief then either agent alone

Question 31

When should sympathomimetics (decongestants) be used? What is its mechanism? What is an example?

Answer 31

Use if marked congestion despite antihistamine use Causes vasocontriction that will decrease edema and secretions. Pseudoephredrine (Sudafed)

Question 32

What populations should sympathomimetics (decongestants) be used with caution?

Answer 32

Patients with hypertension or cardiac disease

Question 33

What is immunotherapy (allergy shots) an effective treatment for?

Answer 33

Allergic conjunctivitis, rhinitis, and asthma

Question 34

What is the pharmacotherapy for allergic rhinitis in children less than 2 years old?

Answer 34

- Cromolyn sodium nasal spray | - 2nd generation antihistamines [Cetirizine (Zyrtec)]

Question 35

What is the pharmacotherapy for adults and children > 2 years old with mild symptoms of allergic rhinitis or episodic symptoms?

Answer 35

- 2nd generation oral antihistamines (loratadine/Claritin, cetirizine/Zyrtec, fexofenadine/Allergra) - Antihistamine nasal sprays (Azelastine/Astepro, Olopatadine/Patanase) - Glucocorticoid nasal sprays - Cromolyn nasal spray

Question 36

What is the pharmacotherapy for adults and children > 2 years old with moderate to severe symptoms of allergic rhinitis?

Answer 36

Glucocorticoid nasal sprays (1st line) - Mometasone (Nasonex) and Fluticasone furoate (Veramyst) - children 2 or older - Fluticasone proprionate - children 4 and older

Question 37

What should you prescribe for allergic rhinitis with concomitant asthma?

Answer 37

Montelukast (Singulair)

Question 38

What should you prescribe for allergic rhinitis with allergic conjunctivitis?

Answer 38

- Steroid nasal spray and ophthalmic antihistamine drops | - AVOID nasal steroid spays in patients with glaucoma or cataracts

Question 39

What are triggers for non-allergic rhinitis (AKA "Vasomotor Rhinitis"?

Answer 39

- Stress - Sexual arousal - Perfumes - Cigarettes smoke - Temperature changes

Question 40

What are typical characteristics of non-allergic rhinitis?

Answer 40

- Nasal congestion - Rhinorrhea - Postnasal drainage - No ocular/nasal itching or sneezing

Question 41

What is the typical treatment for Vasomotor Rhinitis?

Answer 41

- Avoidance of triggers - Nasal steroid sprays - Antihistamine nasal sprays - Ipratropium nasal spray (anticholinergic) if prominent symptom is rhinorrhea

Question 42

What are nasal polyps? What are symptoms associated with them?

Answer 42

Non-tender, grey soft tissue nasal growths Symptoms: nasal congestion/obstruction

Question 43

What is treatment for nasal polyps?

Answer 43

- Nasal steroid spray | - Refer to ENT

Question 44

What is Rhinitis Medicamentosa? How many days does it take to lead to rebound congestion?

Answer 44

The result of regular use of a decongestant spray such as Afrin. > 3 days leads to rebound

Question 45

What is treatment for Rhinitis Medicamentosa?

Answer 45

- Discontinue decongestant spray | - Start nasal steroid spray

Question 46

Describe urticaria.

Answer 46

- Hives/wheals - Pruritic - Pale to bright erythema - Lesions are transient

Question 47

What is the pathophysiology behind urticaria?

Answer 47

Release of histamine from mast cells of the superficial epidermis

Question 48

How can you differentiate urticarial vasculitis from urticaria?

Answer 48

Urticarial vasculitis: - Lasts longer than 24 hours - Erythematous, painful plaques with blanching halos - Leaves hyperpigmentation - Link with SLE

Question 49

What is the preferred 1st line treatment for urticaria?

Answer 49

2nd generation H1 histamine blocker: - Cetirizine (Zyrtec) - Levocetirizine (Xyzal)

Question 50

What should be given for urticaria with persistent symptoms or associated angioedema?

Answer 50

Oral glucocorticoids