Nasal and Sinus Disorders

Question 1

Blood test for Allergic Rhinitis

Answer 1

RAST replaced by Fluorescence Enzyme-Labeled Assay, Expensive

Question 2

Peripheral blood tests for AR

Answer 2

CBC, IgE but not descriptive

Question 3

1st Gen Intranasal Corticosteroids for AR

Answer 3

10-50% Bioavailability(more SE). Beclomethasone(4yoa), Budesoinide-(Rhinocort 6yoa), Flunisolide(6) Triamcinolone(2)

Question 4

2nd Gen Intranasal Corticosteroids for AR

Answer 4

Fluticasone propionate (<2%bioav)(4yoa), mometasone(nasonex) (<0.1%bioav) (2), Ciclesonide (Omnaris)(<0.1%bioav)(6), Fluticasone furoate(Veramyst)(<1%)(2)

Question 5

Antihistamines that cause sedating, anticholinergic(Dry mouth)

Answer 5

1st Gen, Diphenhydramine, Chlorpheniramine(6yoa), Hydroxyzine

Question 6

Antihistamines that are a lower risk for systemic effects

Answer 6

2nd and 3rd gen, Loratidine(2yrs), Cetrizine(Sedating in 10% of pts)(6mo), Fexofenadine 3rd gen (2yrs), Desloratidine (Clarinex 3rd gen (6mo)

Question 7

Azelastine(Astelin), Olopatadine(Patanse)

Answer 7

AR tx: Intranasal Antihistamines

Question 8

Combo intranasal antihistamine

Answer 8

Only Dymista (azelastine/fluticasone) shows better results than inhaled steroid alone.

Question 9

AR and oral steroids

Answer 9

won’t relieve symptoms acutely, use sparingly. but may be needed to treat r. medicamentosa, severe, AR, sinusitis with allergic component

Question 10

Oral Decongestant (AR Tx section)

Answer 10

pseudophedrine (Sudafed)

Question 11

Pseudophedrine MOA SE

Answer 11

alpha/beta agonist (Vasocon), arrhythmia, hypertension, palpitations, tachy, HA, nervousness, stimulation, anorexia, tremor, ect.

Question 12

Intranasal Cromolyn MOA and notes

Answer 12

Keeps mast cells from releasing histamines, but inferior to nasal steroids and antihistamines

Question 13

Leukotriene receptor antagonist(approved for over 6mo of age) and notes

Answer 13

Montelukast (singular) Helps most with congestion, also used in pt’s with asthma, safe, but some rare psych SE

Question 14

Phenylephrine, oxymetazoline, xylometazoline, nephazoline(Afrin, Neo-Synephrine) (risks) (aid in tx of epistaxis)

Answer 14

Nasal Decongestant Sprays. (only to be used for a day or two, otherwise risk of rebound)

Question 15

AR Tx “not to be used as monotherapy”

Answer 15

Nasal Decongestant Sprays like Phenylephrine, oxymetazoline, xylometazoline, nephazoline(Afrin, Neo-Synephrine)

Question 16

First Dose in office to observe. Grastek, O, R. (Daily through season-start 12 weeks)

Answer 16

SL Immunotherapy for AR. Oralair Ragwitek, 12 weeks before season starts

Question 17

SQ Immunotherapy for AR

Answer 17

Testing done first, tailored to allergy, effects last 7-12 years

Question 18

Expensive as hell immunotherapy for AR

Answer 18

Omalizumab (Xolair), Anti-immunoglobin E antibody, approved for use in asthma, not FDA approved for AR,

Question 19

What conditions are Nasal Polyps associated with

Answer 19

Chronic sinusitis, asthma, aspirin sensitivity

Question 20

Nasal Polyps in young children

Answer 20

Think possible CF

Question 21

Tx for Nasal Polyps

Answer 21

Intranasal Corticosteroids, treat underlying allergies, consider other AR tx’s, oral glucocorticoids in refractory cases, surgical tx often recur

Question 22

Order of sinus developement

Answer 22

MESF. F-after age 2 and last to pneumatize

Question 23

Definition of Acute Rhinosinusitis

Answer 23

Symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than 4 weeks

Question 24

What are the common viruses that cause Acute Rhinosinusitis

Answer 24

Rhinovirus, Adenovirus, Influenza virus, Parainfluenza virus

Question 25

What are the common bacteria that cause Acute Rhinosinusitis

Answer 25

Streptococcus pneumoniae, Haemophilus influenza, Moraxella Catarrhalis, Staphylococcus Aureus

Question 26

What is the signs and presentation of Viral Rhinosinusitis

Answer 26

Day 1-2 Sore throat, day 2-3 nasal symptoms, scratchy throat subsides, day 4-5 cough, nasal sx subside, lasts ~5-10 days but may last up to 2 weeks in 1/4 of pt's

Question 27

DiffDx for Viral Rhinosinusitis

Answer 27

Tonsillitis, Bacterial(Facial pain, dental pain, significant HA, facial swelling, prolonged sx, prior surgery), Influenza(Fevers, HA, Myalgia), Pertussis(Prolonged, severe cough)

Question 28

Tx Viral R

Answer 28

Sx relief. Pain, Nasal saline irrigation, Decongestants, topical vasocon(oxymetzaoline 2-3 days only), oral decongestants, anti-hist, mucolytics guaifenesin to thin secretions(no evidence), Zinc zicam risk anosmia

Question 29

Bacterial R: if sx do not improve in ___days of tx or recur within ___ of tx, then ___ needs to be considered

Answer 29

3-5 days, 2 weeks, resistant organism

Question 30

Abx for R, 1st LINE, then ____ Ped, adult, and then ___,___,___abx if allergic to ___

Answer 30

Amoxicillin x 10 -14 days, Augmentin - peds if moderate-severe illness, <2 yoa, daycare or recent tx with an antibiotic, adults if pt's not improving or hx of repeated infections or prior sinus sx. Bactrim, azithromycin and other macrolides if allergies to PCN

Question 31

Dx and signs of Chronic R (3, PND, C, NC, poss no running)

Answer 31

Sx >3mo, persistent oropharyngeal drainage, chronic cough, nasal congestion, may not have runny nose

Question 32

Refer! CR. But frequent Rhinosinusitis diffdx is

Answer 32

CF(cilia decreased), Wegener's Granulomatosis(inflammation of blood vessels, and effects kidneys, eyes and upper RT), HIV(fungus), Primary ciliary dyskinesia, neoplasm

Question 33

Wegner's Granulomatosis

Answer 33

inflammation of blood vessels, and effects kidneys, eyes and upper RT. may cause frequent R

Question 34

Pott's Puffy Tumor

Answer 34

Frontal sinus osteomyelitis reaches soft tissue and looks like a tumor

Question 35

Orbital Cellulitis risks

Answer 35

could travel into cavernous sinus and make the brain want to decrease flow there which leads to more problems

Question 36

Define time for Acute Rhinosinusitis

Answer 36

Up to 4 weeks

Question 37

Define time for Subacute Rhinosinusitis

Answer 37

at least 4 weeks but less than 12 weeks

Question 38

Define Recurrent acute Rhinosinusitis

Answer 38

Four or more episodes per year with complete resolution between episodes; each episode lasts at least 7 days

Question 39

Define time for Chronic Rhinosinusitis

Answer 39

12 weeks or longer

Question 40

First step with Epistaxis

Answer 40

Check ABCDE's, airway, breathing, circulation, disability, exposure

Question 41

Contraindications for Nasal packing ca,c,c,ft

Answer 41

Clotting abnormalities, COPD(can't interfier with airway), Known or suspected CSF leak, Facial Trauma

Question 42

Dangerous possibility with nasal fx

Answer 42

septal hematoma, if not tx could cause damage to septum

Question 43

Drugs for nasal fx with epistaxis

Answer 43

abx-cephalexin, amox, ampicillin

Question 44

Drugs and tx for nasal fx without epistaxis

Answer 44

topical nasal decongestants, analgesia and ice (ENT refer for plastic sugery)