Nose and Paranasal Sinuses

Question 1

What is the most likely culprit of URI’s?

Answer 1

Rhinoviruses

Question 2

Presentation:
Rhinitis, rhinorrhea, nasal congestion, ST, cough, laryngitis, lymphadenopathy, mild systemic sx, fever uncommon in adults but may be present in children - usually low grade

Answer 2

URI

Question 3

PE findings:
may be normal
common findings: conjunctival injection, nasal mucosal swelling, pharyngeal erythema, exudates and cobblestoning, lungs usually clear

Answer 3

URI

Question 4

treatment URI

Answer 4

symptomatic relief OTC medications
analgesics - tylenol, NSAIDS
decongestants - intranasal or oral
Antitussives - dextromethorphan or benzonatate
Cool moist humidifiers, saline nasal sprays

Question 5

URI prognosis

Answer 5

usually lasts about 3-10 days, up to 2 weeks if smoking, other comorbidities

Question 6

Rhinitis is

Answer 6

inflammation of nasal mucosa

Question 7

Most common forms of rhinitis

Answer 7

allergic
vasomotor
rhinitis medicamentosa

Question 8

Allergic Rhinitis happens when

Answer 8

climate changes resulting in increased amounts of pollen and season duration
spring - flowering shrub and tree pollens
summer - flowering plants and grasses
fall - ragweed and molds

Question 9

Allergic Rhinitis is due to (immune-mediated)

Answer 9

Ige response to airborne antigens/ allergens
ie pollen mold dander dust

Question 10

Symptoms of allergic rhinitis can develop at

Answer 10

any age, usually children or young adults

Question 11

ssx:
nasal itching, watery rhinorrhea, nasal congestion, sneezing
itchy or watery eyes
dry cough
“allergic salute” in kids

Answer 11

Allergic Rhinitis

Question 12

Allergic Rhinitis - treatment

Answer 12

antihistamines - immediate but temporary, can be used prn
Corticosteroids - intranasal, shrink nasal polyps and mucosa
Intranasal anticholinergics - ipratropium bromide spray
intranasal saline, neti pot

Question 13

Vasomotor rhinitis is

Answer 13

increased secretion from nasal mucosa precipitated by temp or humidity, odors, light, alcohol or neurovascular imbalance

symptoms clear quickly

Question 14

Treatment of vasomotor rhinitis

Answer 14

avoid irritant

Question 15

Rhinitis medicamentosa is

Answer 15

rebound congestion from overuse of nasal decongestants - discontinue afrin

Question 16

Acute sinusitis/ rhinosinusitis (ARS) is

Answer 16

inflammation in nasal cavity and para-nasal sinuses
most common etiology = viral infection

Question 17

What makes mucus green?

Answer 17

breakdown of WBC
green means infection not either bacterial or viral

Question 18

nasal/ear/facial pressure
low grade fever
sneezing, rhinitis, cough, ST
rhinorrhea may be discolored
duration 7 to 10 days

Answer 18

Viral acute sinusitis

Question 19

Viral acute sinusitis treatment

Answer 19

symptomatic treatment

Question 20

usually have preceding URI
nasal/ear/facial pressure, may be worse with bending forward, sinus tenderness
purulent discharge, nasal obstruction > 10 days after sx onset
fever fatigue malaise
duration > 10 days and worsening
facial/ eyelid swelling and/or erythema concerning for periorbital/ orbital cellulitis

Answer 20

Bacterial acute sinusitis

Question 21

Acute bacterial sinusitis workup

Answer 21

clinical dx - transillumination may be positive but not necessary
imaging usually considered in chronic sinusitis (CT scan)

Question 22

Acute bacterial sinusitis treatment

Answer 22

abx - augmentin (amoxicillin-clavulanate) for 10-14 days
if penicillin allergy - doxycycline or levaquin
include education on nasal hygiene
w/o abx pts will improve within 2 wks

Question 23

Chronic sinusitis is when

Answer 23

a single infection lasts > 12 wks

Question 24

sx of chronic sinusitis

Answer 24

persistent rhinorrhea, productive cough, foul breath, low grade fever, malaise, HA, facial or dental pain

Question 25

Complicated acute bacterial sinusitis

Answer 25

high persistent fever > 102 periorbital edema, inflammation or erythema cranial nerve palsies severe HA, altered mental status or meningeal signs

Question 26

Complicated acute bacterial sinusitis treatment

Answer 26

urgent referral to otolaryngologist for evaluation and dx image of choice - CT scan with contrast

Question 27

Nasal Obstruction - turbinate hypertrophy

Answer 27

inflammation of turbinates resulting in increased congestion and drainage URI, allergic rhinitis, vasomotor rhinitis, drugs

Question 28

Nasal Obstruction - turbinate hypertrophy treatment

Answer 28

treat the underlying condition surgery is last resort - clean out airway

Question 29

Deviated Septum - Etiology

Answer 29

Trauma connective tissue disease drugs - cocaine Postsurgical changes

Question 30

Deviated Septum - Treatment

Answer 30

nasal endoscopy surgery implants

Question 31

Adenoid Hypertrophy is the most common cause of

Answer 31

nasal obstruction in a child

Question 32

Adenoid Hypertrophy symptoms

Answer 32

mouth breathing, mucopurulent discharge, snoring, sleep apnea

Question 33

Adenoid Hypertrophy - etiology

Answer 33

chronic inflammation, allergies, chronic sinus sx

Question 34

Adenoid Hypertrophy - prolonged mouth breathing due to adenoid hypertrophy affects

Answer 34

facial and dental growth and development "adenoid facies" - open mouth, flattening and elongation of midface, retraction of upper lip, narrowing of hard palate resulting in crowing of maxillary teeth

Question 35

Adenoid Hypertrophy dx

Answer 35

clinical suspicion, endoscopic visualization

Question 36

Adenoid Hypertrophy treatment

Answer 36

adenoidectomy

Question 37

Nasal Polyps is the most common

Answer 37

tumor of the nasal cavity

Question 38

Etiology of Nasal Polyps

Answer 38

long-standing inflammation, aspirin sensitivity, environmental allergies, Cystic fibrosis

Question 39

Sx of Nasal polyps

Answer 39

mouth, breathing, sneezing, rhinorrhea, reduced smell and taste, frequent sinusitis

Question 40

PE findings of nasal polyps

Answer 40

nasal obstruction, pale mucosa, fleshy mass with superficial vessels

Question 41

Nasal Polyp treatment

Answer 41

steroids (PO, topical, intra-polyp injections), avoid aspirin, surgical excision for larger polyps, test and treat for allergies

Question 42

Foreign body - nasal locations

Answer 42

floor of nasal passage just under the inferior turbinate or superiorly in nasal cavity in front of the middle turbinate

Question 43

FB ssx

Answer 43

nasal discharge foul odor epistaxis nasal obstruction mouth breathing

Question 44

FB = button batteries warning!

Answer 44

may result in septal perforation in ~ 4 hours

Question 45

FB treatment

Answer 45

fogarty catheter Katz extractor forvents (if you can visualize object) irrigation

Question 46

Epistaxis is

Answer 46

nose bleeds!

Question 47

Epistaxis can be due to

Answer 47

trauma vs spontaneous anterior (kiesselbach plexus) vs posterior anticoagulation ETOH

Question 48

90% of bleeds are

Answer 48

anterior

Question 49

Posterior is most commonly from

Answer 49

posterolateral branches of sphenopalatine artery, can be from the carotid artery

Question 50

#1 cause of epistaxis

Answer 50

nose picking

Question 51

Other causes of epistaxis

Answer 51

dryness allergic or viral rhinitis FB Chronic intranasal drug use Blunt trauma

Question 52

Epistaxis treatment - anterior bleed

Answer 52

clear clots topical medications (afrin drops, boyette's solution) topical tranexamic acid (TXA) direct pressure for ~ 15 mins on the bulb of the nostrils identify source of bleed - check back of throat cauterize - silver nitrate sticks nasal packing as needed

Question 53

After cautery there should be no

Answer 53

blowing of nose, sneezing, coughing, bearing down sleep in a humidified environment topical abx ointment

Question 54

Treatment of posterior bleed

Answer 54

balloon catheters: tamponade posterior bleeding arterial ligation angiographic embolization

Question 55

Trigeminal Neuralgia is a

Answer 55

paroxysmal attack of usually intense, sharp, superficial or stabbing pain in distribution of one or more branches of fifth cranial nerve pain usually lasts from one to several seconds but may occur repetitively

Question 56

Treatment of trigeminal neuralgia

Answer 56

Carbamazepine (used for seizures as well)