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X Clin Med Exam 1 > L12 Allergic Rhinitis, Tinnitus, Urticaria > Flashcards

L12 Allergic Rhinitis, Tinnitus, Urticaria Flashcards

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1
Q

Barotrauma

A

Damage/discomfort to the ear due to pressure differences b/w middle ear and outside world

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2
Q

Symptoms of barotrauma

A

pressure, pain, hearing loss, or tinnitus, possible hemotympanum, middle ear effusion, TM rupture

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3
Q

Treatment of barotrauma

A

avoidance, oral/nasal decongestants, swallowing, valsalva, chewing gum, time
if perilymphatic fistula (sensorineural hearing loss and vertigo) refer to ENT

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4
Q

Acoustic neuroma

vestibular schwannoma

A

Schwann cell tumors, arise from vestibular portion of CN VIII, slow growing, could result in facial nerve palsies due to compression

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5
Q

clinical presentation of Acoustic neuroma

A

unilateral sensorineural hearing loss and tinnitus, may cause gait disturbance or other CN involvement

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6
Q

Dx of Acoustic neuroma

A

audiometry as initial screening test

mri

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7
Q

Treatment of Acoustic neuroma

A

surgery, radiation, observation due to slow growth

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8
Q

Tinnitus

A

perception of sound in one or both ears, occurs more in males, associated with depression/anxiety

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9
Q

Tinnitus Etiology

A

Auditory causes: ototoxic medications, presbycusis, otosclerosis, vestibular schwannoma, chiari malformations, barotrauma,
pulsatile: vascular etiology

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10
Q

Ototoxic medications

A

aminoglycosides

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11
Q

presbycusis

A

SN hearing loss w/ aging

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12
Q

otosclerosis

A

hereditary disorder where bones fuse together

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13
Q

Chiari malformations

A

cerebellar tinnitus are lower than usual

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14
Q

Pulsatile tinnitus is most commonly caused by?

A

vascular etiology

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15
Q

Dx of tinnitus

A

Hx, Physical perform a complete head and neck exam, Auscultate for bruits in patients with possible vascular tinnitus, if pulsatile, refer to ENT

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16
Q

Tinnitus Tx

A

goal is to lessen awareness and impact on quality of life

behavioral therapy, benzos, white noise

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17
Q

Allergic rhinitis

A

PAROXYSMS OF SNEEZING, RHINORRHEA, AND NASAL OBSTRUCTION, and nasal obstruction, usually accompanied by itchy eyes, nose and palate
“hay fever” aka seasonal, vs perennial which occurs year round

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18
Q

Allergic rhinitis epidemiology

A

PEAK INCIDENCE IN CHILDHOOD/ADOLESCENCE, one of the most common chronic diseases in the U.S.
Lots of money and time lost due to this

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19
Q

pathophysiology of Allergic Rhinitis

A

PRODUCTION OF IGE ANTIBODIES triggering an immune response cascade
IgE binds to mast cells carrying histamine, next time exposed to allergen, histamine is released

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20
Q

Clinical presentation of Allergic rhinitis

A

RHINORRHEA, SNEEZING, NASAL CONGESTION, itchy eyes/nose/palate, postnasal drip, cough, fatigue

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21
Q

Risk factors of allergic rhinitis

A

FH of atopy, male, atopic triad, serum IgE above 100 before age 6, first born, early use of abs, maternal smoking

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22
Q

clinical evaluation of allergic rhinitis

A

personal or FH of allergic rhinitis, asthma, or eczema? 2nd hand smoke? potential triggers? impact on pt?

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23
Q

allergic rhinitis physical exam

A

Eyes: allergic shiners and denie-morgan lines, pale palpebral conjunctiva may be pale, swollen, conjunctival injection
Nose: pale boggy “BLUISH” mucosa, clear discharge, nasal crease
Throat: post-nasal drainage in posterior pharynx, cobblestoning
Ears: serous otitis media

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24
Q

“allergic shiners”

A

bluish purple rings around both eyes

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25
Denie-morgan lines
skin folds under eyes consistent with allergic conjunctivitis
26
Diagnostic evaluation of Allergic Rhinitis
CLINICAL, allergy testing to confirmatory, but not necessary for initial dx
27
Allergy testing
skin testing: scratch or prick skin testing "wheal and flare" rxns normally occur 15-20 min, quick & cost effective, RISK FOR ANAPHYLACTIC RXN Serum testing: immunoCAP, detects allergen-specific IgE antibodies, less risk but less sensitive, more expensive
28
Allergic rhinitis therapy
avoidance of allergens, INTRANASAL GLUCOCORTICOIDS, oral or intranasal antihistamines, sympathomimetics/decongestants, leukotriene receptor antagonists, immunotherapy
29
Avoidance of allergens
allergy is often caused more by the dander, saliva, & urine than hair
30
pharmacology of Allergic rhinitis for children <2 years old
cromolyn sodium nasal spray | 2nd generation antihistamines: Zyrtec and allegra approved for children 6mo or older
31
pharmacology of allergic rhinitis for children 2 years to adults: Mild symptoms
EPISODIC SYMPTOMS 2nd generation oral antihistamines, antihistamine nasal sprays: azelastine > 5 yrs old, olopatadine (patinas) > 12 yrs, glucocorticoid nasal sprays, cromolyn nasal spray
32
pharmacology of allergic rhinitis for children 2 years to adults: Moderate-to Severe symptoms
GLUCOCORTICOID nasal sprays are considered 1st line treatment. risk for epistaxis, stay away from septum
33
special pharmacological considerations for Allergic Rhinitis
w/ asthma: montelukast (Singulair) useful additive therapy w/ allergic conjunctivitis: glucocorticoid nasal spray and ophthalmic antihistamine drops (avoid nasal sprays in its with glaucoma or cataracts
34
special pharmacological considerations for pregnant & lactating pts with allergic rhinitis
allergen avoidance use 2nd gen antihistamines (claritin or zyrtec), glucocorticoid nasal spray (rhinocort, flonase, nasonex) lactating women: budesonide or cromolyn w/ or w/o cetirizine or loratadine
35
pharmacology of allergic rhinitis for children 2 years to adults: PERSISTENT moderate-to severe symptoms
in pts who FAIL TO RESPOND to initial glucocorticoid nasal spray... antihistamine nasal spray, oral antihistamine, cromolyn nasal spray, montelukast (singular), oral antihistamine/decongestant combo
36
classifications of rhinitis
allergic, vasomotor, infectious
37
1st generation antihistamines
help alleviate sneezing, rhinorrhea, and itching no relief of nasal congestion chlorpheniramine 4mg q4-6 or 8-12mg BID diphenhydramine 25mg BID-TID side effects: dry mouth, constipation, SEDATION
38
2nd generation antihistamines
``` LESS SEDATING, same effect as gen 1, Loratadine 10 mg/d Fexofedadine 60 mg BID or 180 mg QD Cetirizine 5-10 mg/d *nasal antihistamines have the same effectiveness ```
39
sympathomimetics
decongestants, indicated for pts with marked nasal congestion despite antihistamine use Vasoconstriction will decrease edema and secretions pseudoephedrine 30-60mg q6-8h or 120 mg BID for sustained release CAUTION: PTS WITH HYPERTENSION OR CARDIAC DISEASE BC OF VASOCONSTRICTION
40
immunotherapy
allergy shots effective treatment for allergic conjunctivitis, rhinitis, and asthma gradual admin of increasing amounts of allergen requires lots of visits, treatment period lasts 3-5 years
41
pt education for allergic rhinitis
dust mine & mold avoidance clean the house humidifiers worsen sxs close windows, HEPA filter
42
When to refer if pt has allergic rhinitis
severe or refractory sxs allergic rhinitis AND asthma: consider pulm or allergist recurrent sinusitis or otitis media: refer to ENT
43
Non-allergic rhinitis etiology
aka VASOMOTOR RHINITIS abnormal AUTONOMIC responsiveness, TRIGGERED BY STRESS, SEXUAL AROUSAL, PERFUMES, CIGARETTE SMOKE, TEMPERATURE CHANGES, usually occurs later in life, >20 y/o
44
Non allergic rhinitis, symptoms
NASAL CONGESTION, RHINORRHEA, POSTNASAL DRAINAGE, USUALLY NO OCULAR OR NASAL ITCHING, nasal mucosa may appear normal, erythematous, or boggy/edematous
45
treatment of non allergic rhinitis
avoid triggers, nasal glucocorticoids, antihistamine nasal sprays, IPRATROPIUM NASAL SPRAY (USE IF RHINORRHEA IS THE PROMINENT SYMPTOM) can also use oral decongestants, 1st generation oral antihistamines (anticholingergics)
46
Nasal polyps clinical presentation
pedunculate, non tender, gray soft tissue growths,
47
Nasal polyp symptoms
nasal congestion/obstruction, seen with allergic rhinitis, vasomotor rhinitis, chronic sinusitis, and asthma
48
Samter's triad
Aspirin Exacerbated Respiratory Disease (AERD), aka Samter's Triad or Aspirin Sensitive Asthma Chronic medical condition that consists of asthma, recurrent sinus disease with nasal polyps, and a sensitivity to aspirin and other NSAIDs.
49
Treatment of nasal polyps
NASAL GLUCOCORTICOIDS | refer to ENT for obstructive symptoms
50
Rhinitis medicamentosa
regular use of OTC decongestant nasal spray (afrin) causes mucous membranes to become swollen and erythematous >3 DAYS OF USE --> REBOUND CONGESTION pts will increase freq of use and become dependent
51
Treatment of rhinitis medicamentosa
DISCONTINUE AFRIN, START NASAL GLUCOCORTICOID SPRAY
52
Urticaria
"hives", welts, wheals CIRCUMSCRIBED, RAISED, ERYTHEMATOUS PLAQUES, WITH OR WITHOUT CENTRAL PALLOR, intensely PRURITIC, raised wheals, pale to bright erythema individual LESIONS ARE TRANSIENT (disappearing within 24 hrs)
53
acute urticaria
present less than 6 weeks
54
chronic urticaria
s/s recurring most days of the week for 6 wks or greater
55
pathophysiology of urticaria
mediated by CUTANEOUS MAST CELLS in superficial epidermis, RELEASE OF HISTAMINE, vasodilatory mediators causes itching and localized swelling, might be accompanied by angioedema
56
causes of urticaria
``` infections-viral, bacterial, parasitic allergic rxns to meds, foods insect stings/bites direct mast cell activation (morphine, codeine, radio-contrast agents) nsaids ```
57
diagnosis of urticaria
clinical based on H&P review events in the hours before the rxn there might not be lesions by the time of the visit, use pictures to verify type of irriation
58
urticaria might be confused with...
urticarial vasculitis, fixed (last longer than 24 hours), erythematous, painful, urticarial plaques, with blanching halos, leaves residual hyperpigmentation or purport, linked with SLE
59
treatment of urticaria
H1 HISTAMINE BLOCKER 1st gen-diphenhydramine, chlorapheniramine, hydroxyzine 2ND GENERATION - CETRIZINE, LORATIDINE, FEXOFENADINE* preferred first line treatment b/c of less side effects can be combined with h2 histamine blocker (ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet)), or oral glucocorticoids if angioedema or persistent symptoms
60
Treatment of urticaria more specifically...
Cetirizine and levocetirizine may be more effective due to mast cell-stabilizing properties
61
if allergic etiology of urticaria is suspected
refer to allergist or may need epipen

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