Lecture 11 Smith Flashcards

Question

Answer 1

large polups visioble with anterior rhinoscopt smaller polyos require nasal endo or imaging insenate swollen nasal turbinates sometimes misten for nasal polyps

Answer 2

vasomotor rhinitis, mixedrhinitis and gustatory rhinitis

Answer 3

* Based on positive pathology of fungal invasion in affected areas * Urgent surgical evaluation for both diagnostic biopsy and debridement

Answer 4

o : CF, Sarcoidosis

Answer 5

asthma (20% pateients) or allergic rhinitis

Answer 6

ammox previously, now Augmentin, increase Hflu and Mcat coverage can be BID/TID, and high dose recommended or Doxy is good choice, less on the macrolides and perhaps FQ * **Amoxicillin** * Previously recommended 1^st line because narrow spectrum and low cost * Increasing emergence of resistance Particularly to H. flu and pneumo * Rates vary regionally: 27-43% resistance * **Augmentin** * Improved coverage for H. flu resistance as well as M. cat * BID or TID * High dose recommended * In regions with S. pneumo resistance greater than 10% * 65 years or older * Recently hospitalized * Failed abx treatment in previous month * Immunocompromised * **Doxycycline** * Reasonable alternative for first line therapy * DOC for PCN allergy * Remember to tell patient to avoid direct sunlight * **Other** * Macrolides * Would not use * Resp. FQ’s (levo or moxi) * Another option for PCN allergy * Last line if pt has failed doxy or augmentin or is really sick * Bactrim * Rarely used * 2^nd or 3^rd generation cephalosporins

Answer 7

 Children often manifest this with nose rubbing Rather than complaining of itch

Answer 8

Loratidine, Cetirizine, fexofenadine

Answer 9

#1 Topical intranasal glucocortioids: MOST EFFECTING SINGLE MAINTENANCE TX FOR ALLERGIC RHINITIS oral histamines 1st gen H1 blockers 2nd gen H1 blockers leukotriene receptor antagonists mast cells stabilizers combo of the above

Answer 10

* Purulent mucus or edema in middle meatus or ethmoid regions * Polyps in nasal cavity or middle meatus * Anterior rhinoscopy may see * Purulent mucus emanating from middle meatus * Edematous hyperemic mucosa * Polypoid mucosal changes * Frank polyposis

Answer 11

 1st generation: Significant sedation (lipophilic, BBB) • Adverse effects on intellectual and motor function o Even in absence of subjective awareness of sedation o Prohibited in many states for transportation workers

Answer 12

o Acute rhinosinusitis: Symptoms \<4 weeks  Acute Viral (AVRS)  Acute Bacterial (ABRS) o Subacute Rhinosinusitis: Symptoms 4-12 weeks o Chronic rhinosinusitis: \>12 weeks o Recurrent acute rhinosinusitis: Four or more episodes of ARS/year with interim sx resolution

Answer 13

* * **Believed to result from chronic, intense allergic inflammation directed against colonized fungi** * Patients are Immunocompromised and Show evidence of allergy to one or more fungi * **AFRS is distinguished from CRS with NP by** * **Presence of allergic mucin that contains viable fungal hyphae**

Answer 14

* Immunocompromised patient with sinus complaints, Particularly facial pain * Nasal congestion * +/- Fever * Epistaxis * Facial numbness/diplopia if CNs involved * Necrotic tissue in nares/oropharynx * Can appear as Palatal or gingival eschars or Sloughing of the nasal septum with perforation

Answer 15

amphoteracin B voriconazole

Answer 16

o Close windows and doors o Shower before bed o Change AC filters and use good ones o Mattress and pillow covers o Pest control o Avoid known triggers

Answer 17

T/P/BP/RR/O2

Answer 18

* **Treatment for all three** * Many cases cannot be cured * Goal of therapy is to reduce symptoms and improve quality of life * **CRS with NP** * Oral steroids to shrink polyps * Sometimes can shrink enough that surgery isn’t necessary * Nasal steroids to follow * Add leukotriene inhibitor for maintenance therapy * Decrease congestion * **CRS without NP** * Oral steroids * ABX for approx. 6 weeks (7 days after symptoms clear) * Follow with nasal steroids * 2^nd gen H1 antihistamines * Zyrtec * Allegra * Leukotriene inhibitors * **Allergic Fungal** * Surgery to remove inspissated mucus * Thickened mucus * Prolonged course of oral steroids

Answer 19

NON TENDER * Characterized by presence of bilateral nasal polyps * Polyps are * Translucent * Yellowish-gray to white * Glistening massed filled with gelatinous material, which may form in nasal cavity or paranasal sinuses * Gray-white color due to relatively avascular nature of the polyps * Large polyps are often visible with anterior rhinoscopy * Smaller polyps require nasal endoscopy or imaging * Insensate * Swollen nasal turbinates sometimes mistaken for nasal polyps * Similar in appearance, but these are VERY sensitive to touch

Answer 20

* 12 week duration * **4 cardinal symptoms must be present for diagnosis** * Anterior and/or posterior mucopurulent drainage * **Nasal obstruction, Bilateral** * Facial pain/pressure/fullness * Hyposmia: Decreased sense of smell * \*\*At least 2 of these symptoms must be present to consider diagnosis\*\* * \*\*In children, fourth sign is cough NOT hyposmia\*\* * Also there must be evidence of mucosal inflammation to confirm CRS * The four cardinal symptoms may be present with any subtype of CRS and do not differentiate the subtypes

Answer 21

animals, grains, chemicals, pollens, latex, carpeting

Answer 22

* **Treatment** * **Anterior** * Compression of nares continuously for 15 minsà Pt sitting/leaning forward * Short-acting topical nasal decongestants : Neosynephrine, Phenylephrine * Topical 4% cocaine applied either as a spray or on a cotton stripàAnesthetic and vasoconstrictor * Bleeding site may be cauterized with silver nitrate or electrocautery * **Posterior** * Topical sympathomimetics and various nasal tamponade methods are usually effective * In emergency, double balloon packs may facilitate rapid control with little or no mucosal trauma * NT consult for a pack to occlude the choana before placing pack anteriorly * * * ABX coverage is to avoid Toxic Shock

Answer 23

* Symptoms usually \>10 days * **Purulent discharge** * **Often unilateral, painful sinus, Worse with bending forward** * Frequently described as URI which began to improve, then worsened

Answer 24

 Acute viral rhinitis begins with viral inoculation via contact with conjunctiva or nasal mucosa • Viral replication leads to detectable levels in 8-10 hours • If symptoms develop it is usually first day after inoculation  Viral Rhinitis then spreads to sinuses by direct or indirect routes • Nose blowing propels fluid from nasal cavity to sinuses inflammation • Direct toxic effect on nasal cavity cilia causing decreased motility • Mucosal edema, thick secretions, and ciliary dyskinesia obstruct sinuses and perpetuate process

Answer 25

 Most effective single maintenance for allergic rhinitis  Work on congestions  Onset: Few hours; Maximal effect may require several days/weeks  Should be tapered to lowest effective dose once sx controlled  1st generation • 10-50% bioavailability • Beclomethasone, Flunisolide, Bedesonide  2nd generation • Less bioavailability, less systemic effects • Fluticasone propionate, Mometasone furoate, Fluticasone furoate

Answer 26

GCs more effective than H1

Answer 27

rhinosinusitis is preferred over sinusitis as inflammation of sinuses rarely occurs without concurrent inflammation of hte nasal mucosa

Answer 28

* **Diagnostics for all three types** * **Sinus CT is imaging modality of choice** * **Most common findings: Mucosal thickening Suggestive of infection/obstruction of a sinus ostum** * **Obstruction of ostiomeatal complex** * Variable degrees of sinus ostial obstruction are common in CRS * **Sinus opacification** * Complete filling of sinus with inflammatory material or fluid * May be seen with * Persistent bacterial infection * Purulent secretions, mucus * Insipissation * Polypoid mucosal thickening * Or an accumulation of allergic mucin

Answer 29

Intermittent: Symptoms occur in response to specific exposur such as cats Seasonal: Symptoms occur at certain times of year  Patients with his have associated allergic conjunctivitis in 70% of cases Itchy, red, watery eyes Persistent/Perennial: Symptoms occur year round

Answer 30

• Developed to avoid CNS effects: Lipophobic • Onset: 1 hour, Peak in 2-3 • Longer acting: Dosed once or twice daily • Reduces itching, sneezing, and rhinorrhea o Less impact on nasal congestion as steroids • Meds: Loratidine, Cetirizine, fexofenadine

Answer 31

**Asthma** **CRS with NP** **Aspirin sensitivity** * Aspirin exacerbated respiratory disease * Hypersensitivity is COX-1 basedà Blockage leads to excess of leukotrienes * AKA triad asthma * Pts with CRS with NP * 30-40% report wheezing and respiratory discomfort * 15% have aspirin associated respiratory disease * For patients whose asthma begins as an adult * The cause is not true allergy * Condition in which patients have a combo of symptoms * Such as airway problems like asthma * Nasal problems like blockage and polyps * Then develop a hypersensitivity to aspirin

Answer 32

evnironmental control (avoid allergens) pharmacotherapy immunotherapy

Answer 33

* Major symptoms * Purulent anterior/posterior nasal discharge * Nasal congestion or obstruction * Facial congestion or fullness * Hyposmia or anosmia * Fever (for acute sinusitis only) * Minor symptoms * HA * Ear pain/pressure/fullness * Halitosis * Dental pain * Fever: For subacute or chronic type * Fatigue

Answer 34

increased frequency of HA, Rhinosinusitis, Asthma

Answer 35

 Nasal congestion correlates best with leukotriene levels  Sneezing and itching correlate with histamine levels  In US, three are approved for asthma use • Only montelukast is approved for allergic rhinitis o Less effective than nasal steroids  Once daily pill

Answer 36

Inhibit mast cell release of histamine and other inflammatory mediators  Cromolyn sodium  Blocks Sx associated with intermediate and late phase nasal allergen challenge  Effective in doing so when used shortly before allergen inhalation  No serious ADRs  OTC as nasal spray  Less effective than steroids  Very safe, Safe in kids • BUT must be dosed often and is less effective o Can try if other agents aren’t tolerated well

Answer 37

o Onset at later age o Absence of nasal and ocular itching and prominent sneezing o Nasal congestion and postnasal drainage are prominent Sx o Symptoms are perennial, Year round

Answer 38

1st generation • 10-50% bioavailability Beclomethasone, Flunisolide, Bedesonide  2nd generation • Less bioavailability, less systemic effects Fluticasone propionate, Mometasone furoate, Fluticasone furoate

Answer 39

perennial allergies seasonal allergies in/outdoor air quality bugs, carpeting

Answer 40

presence of alelrgic mucin that contains visible fungal hyphae

Answer 41

* Allergy, Nasal mechanical obstruction, Tooth infection, Impaired mucociliary clearance (CF), immdef, smoker

Answer 42

* **May resolve spontaneously within first 10 days** * **Patients with \<10 days of symptoms get supportive care** * Analgesics, Intranasal steroids, Oral decongestants, Antihistamines, Mucolytics * **Patients with \>10 days of symptoms get antibiotics** * **Decision based on severity and reliability of patient for follow up** * Most often initiated empirically Assuming its S. pneumo or H. Flu * Although culture guided is optimal, obtaining suitable cultures requires endoscopy or antral puncture * Generally reserved for patients with complications

Answer 43

eczema and asthma

Answer 44

* Persistent sx with periodic exacerbations characterized by Inc. facial pain And/or inc. drainage * Fatigue * Fever is usually absent or low grade * Subset have recurrent acute rhinosinusitis symptoms: Respond well to antibiotics

Answer 45

olfaction filtration humidification (air warming) vocal resonance aesthic function

Answer 46

topical intranasal glucocorticoids MOST EFFECTING SINGLE MAINTENANCE TX FOR ALLERGIC RHINITIS

Answer 47

 Nasal congestion in last six or more weeks, Without signs of respiratory tract infection  No known allergic cause  Disappears completely within 2 weeks after delivery

Answer 48

maxillary frontal ethmoid CANT PALPATE ETHMOID

Answer 49

mixed: combo of allergic and nonalelrgic rhinitis: 45% of population

Answer 50

* Expect to see response to abx after 3-5 days * If fails to respond, or worsens after 2-3 days à high dose augmentin * Some response should be seen to this * **If pt has orbital, epidural, or brain abscess OR meningitis à prompt hospital admission**

Answer 51

**strep pneumo and H. flu (75%)** other MCAT

Answer 52

resolves in 1o days, treat for nasal obstruction and rhinorrhea fluids + OTC decongestions (3-5 days) intranasal steroids tx does not shorten clinical corse other tx: analgesics, decongestants, H1s, mucolytics, itnransal steroids, saline irragation (netipod)

Answer 53

* **Presentation** * Subtly over years * Symptoms similar to CRS with NP * Patients usually have nasal polyposis * May report semi-solid nasal crusts or rubbery gobs of dark colored mucus periodically expelled * Fever uncommon * **Occasionally presents dramatically: Complete nasal obstruction, Gross facial asymmetry And/or visual chg**

Answer 54

* Disease of immunocompromised patients * Patients with poorly controlled diabetes * Most common species: Mucor, Rhizopus, aspergillus, absidia, basidiobolus * Aspergillus Most common colonizers of sinuses

Answer 55

* Nasal Culture * **viral unnecessary, bacterial unreliable**, cant swab sinus * treat empiracally * endoscopic cx * performed by ENT **when patient not responding to empiric tx** * **XR: not indicated** in initial eval, cant distinguish viral vs bacterial * CT : can see air fluid levels, air in sinuses, mucosal abnormaity * **IMAGING OF CHOICE** for involvement of orbit, intracranial or soft tissue * **MRI: not indicated**

Answer 56

* Otoscopic exam * Findings * Diffuse mucosal edema * Narrowing of middle meatus * Inferior turbinate hypertrophy * Copious rhinorrhea or purulent discharge * Polyps or septal deviation *

Lecture 11 Smith Flashcards

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