Nose and Sinus

Question 1

Acoustic neuromaAKA Vestibular schwannomas

Etiology

Answer 1

benign

arise from the vestibular portion of the eighth cranial nerve and account for ~9% of primary brain tumors

Most are unilateral, but about 5% are associated with the hereditary syndrome neurofibromatosis type 2, in which bilateral eighth nerve tumors may be accompanied by meningiomas and other intracranial and spinal tumors.

Question 2

Acoustic neuromaAKA Vestibular schwannomas

S/Sx

Answer 2

Symptoms
The hearing loss of acoustic neuroma is unilateral and asymmetric

deterioration of speech discrimination

slowly progressive unilateral sensorineural hearing loss, tinnitus and some dizziness

Usually have continuous disequilibrium rather than episodic vertigo

Question 3

Acoustic neuroma

PE

Answer 3

vestibular examination will show a deficient response to the head impulse test when the head is rotated toward the affected side, but nystagmus will not be prominent.

Question 4

Acoustic neuroma

Dx

Answer 4

enhanced MRI (with contrast)

Question 5

Acoustic neuroma

Tx

Answer 5

Observation
microsurgical excision
stereotactic radiotherapy
All depend on such factors as patient age, underlying health, and size of the tumor.
Bevacizumab (vascular endothelial growth factor blocker) has shown promise for treatment of tumors in neurofibromatosis type 2.

Question 6

Acoustic neuroma

fun fact

Answer 6

frequently involve the facial nerve by local compression

Question 7

Vertebrobasilar Insufficiency

Etiology
Triggers

Answer 7

Poor blood flow to the brain from vertebral arteries to posterior portion of brain
Usually in elderly population with atherosclerosis
Usually triggered by change in posture or neck motion

Question 8

Vertebrobasilar Insufficiency

S/Sx & PE

Answer 8

Intermittent vertigo

Can sometimes reproduce symptoms with head and neck motion
Signs of atherosclerosis in other parts of the body

Question 9

Vertebrobasilar Insufficiency

Dx

Answer 9

MRA (magnetic resonance angiography)

Question 10

Vertebrobasilar Insufficiency

Tx

Answer 10

Vasodilators
Aspirin to prevent clotting

Question 11

Vertebrobasilar Insufficiency

Should be considered when

Answer 11

Probably have issues in other parts of the body
Consider this part of the ddx for vertigo/ dizziness in patients with known blockages elsewhere

Question 12

Nasal Cavity, Paranasal Sinuses

Functions

Answer 12

Breathing
Humidification
Warming
Smell
Voice modulation
Reduction of skull weight

Question 13

Nasal Cavity, Paranasal Sinuses

Common Sx

Answer 13

Nasal obstruction
Nasal drainage
Sneezing
Itching
Hyposmia/Anosmia
Nasal/facial pain
Nasal bleeding

Question 14

Answer 14

I.T.
Inferior turbinate
M.T.
Middle turbinate
N.S.
Nasal septum

Question 15

Deviated Nasal Septum

General/Tx/Referral

Answer 15

Very common
Usually post-traumatic
No treatment necessary if asymptomatic

Treatment
Intranasal steroids
Intranasal antihistamines

Refer
If no improvement after 1 month, or
If symptoms and exam severe

Question 16

Septal Deviation / Adhesion

Answer 16

Shown because it’s a common finding. On the right is a severe DNS, left is an adhesion, likely from prior trauma or surgery.

Septum Deviation – Adhesion
The slide on the left side shows a septum deviation with almost total obstruction of the nasal airway.
The slide on the left side shows an adhesion of the middle turbinate to the septum. These adhesions are usually of iatrogenic origin after endonasal surgery or nasal packing in the treatment of epistaxis. These adhesions induce respiratory obstruction and may promote crusting.

Question 17

Nasal obstruction

causes

Answer 17

Allergic rhinitis
Non-allergic rhinitis
Anatomic obstruction
Rhinosinusitis
Adverse drug reaction
Neoplasm
Foreign body
Pregnancy

Question 18

Rhinitis

general and Sx

Answer 18

“Inflammation of the nasal mucous membranes”

Symptoms
Nasal congestion
Rhinorrhea
Sneezing
Nasal itching

Question 19

Nonallergic rhinitis

causes

Answer 19

Vasomotor
Gustatory
Drug-induced
Infectious
Hormonal
Occupational
NARES= nonallergic rhinitis with esosinophilia syndrome

Question 20

Allergic rhinitis

general

Answer 20

Affects over 50 million Americans yearly
Most common chronic disease of childhood
Decreased quality of life
$2 to $5 billion US economic impact
Direct costs
Millions of lost work and school days annually
Decreased work/school productivity

Question 21

Allergic rhinitis

etiology

Answer 21

Adverse clinical reaction to an environmental agent (antigen/allergen) caused by an immunological reaction
Host sensitization
IgE production by host
Mast cell sensitization
Further exposure provokes symptoms
Early & late phase reactions
End-organ response

Question 22

Allergic Rhinitis

Dx

Answer 22

History most important
classic symptoms
Seasonal vs perennial
Exam often consistent
Testing

Question 23

Allergic rhinitis

Answer 23

Inferior turbinate
Pale/purple
Edematous
Cobblestone

Question 24

Allergic rhinitis

Answer 24

Dennie’s lines

Question 25

# Allergic rhinitis

Answer 25

Allergic shiners https://i4.photobucket.com/albums/y144/tooloflife/IMG_7986.jpg

Question 26

# Allergic rhinitis Treatment options 3

Answer 26

Treatment options Medicines Avoidance & environmental control Immunotherapy (desensitization)

Question 27

# Allergic rhinitis Tx - Avoidance & environmental control

Answer 27

Dust mite encasements HEPA filters Windows up in car & house during high pollen counts Masks for known high exposure Sinus irrigation & shower after high exposure Avoid indoor animals and plants, wet areas

Question 28

# Allergic rhinitis immunotherapy Tx SCIT and SLIT

Answer 28

Subcutaneous IT (SCIT)- “allergy shots” Sublingual IT (SLIT)- “allergy drops” 70-80% effective if given 3-5 years with average duration of benefit after stopping 12 years, only option with chance of cure

Question 29

# allergic rhinitis Tx - Medicines (4)

Answer 29

Oral antihistamines Cetirizine, fexofenadine, loratadine Intranasal steroid sprays (INS) Fluticasone rx, it and others OTC Intranasal antihistamine sprays (INAH) Leukotriene modifiers Singulair (montelukast)

Question 30

# Allergic Disorders/ Hypersensitivity Reactions 4 types

Answer 30

I: IgE antibody mediated reaction II: IgG or IgM antibody mediated cytotoxic reaction III: immune complex mediated reaction IV: cellular response mediated delayed reaction

Question 31

# Allergic Disorders/ Hypersensitivity Reactions general

Answer 31

Common allergens: food, venom (things that bite and things that sting), drugs/ medications, latex Anaphylaxis: allergen exposure followed by acute illness involving skin changes, respiratory compromise, hypotension, GI symptoms &/or mucosal tissue problems

Question 32

# Allergic Disorders/ Hypersensitivity Reactions Testing

Answer 32

nothing during the reaction but perform allergy testing after patient’s reaction subsides

Question 33

# Anaphylaxis Tx and supportive measures

Answer 33

IM epinephrine (epipen) ASAP; supportive measures like oxygen, IV fluid, possibly airway mgmt.; adjunct tx with antihistamines, bronchodilators and corticosteroids

Question 34

# Allergy Testing general

Answer 34

Should have moderate to severe reactions before putting patients through this Typically involves placing a small amount of common allergens on the skin and then scratching or pricking the skin to barely introduce it beneath skin; wait 15-20 minutes; observe response Performed by allergist; must avoid antihistamines and steroids prior to testing

Question 35

# Pseudo-allergic Reactions general Caused by?

Answer 35

Similar to “allergic reactions” but not IgE mediated Caused by direct mast cell activation (ex.: contrast dye for imaging, opioids and Red Man Syndrome)

Question 36

# Pseudo-allergic Reactions Red Man Syndrome

Answer 36

caused by infusing vancomycin or opioids too quickly

Question 37

# Pseudo-allergic Reactions Dye rxn prevention (3)

Answer 37

Dye: prevent with use of low-osmolality contrast preparations AND giving prednisone and diphenhydramine before dye

Question 38

# Pseudo-allergic Reactions Red man rxn Tx Prevention(2)

Answer 38

administer antihistamine (usually diphenhydramine) and slow down the infusion rate of offending medication to less than half of previous rate for current reaction; prevention is done with preadministration of diphenhydramine AND cimetidine

Question 39

# Olfactory Dysfunction (no smell AKA hyposmia or anosmia) Etiology

Answer 39

Usually due to blockage of nasal passage (swelling, polyps, mucus, foreign bodies, etc) 20% is idiopathic but often follows viral illness Common symptom of COVID (not as common with omicron) Can be caused by nerve damage to olfactory bulb(s), CN I, or olfactory cortex of the brain (tumors or trauma)

Question 40

# Olfactory Dysfunction (no smell AKA hyposmia or anosmia) Sx & PE

Answer 40

Trouble with sense of smell and sometimes taste Often can see nasal blockage Other signs of illness (other cold, COVID symptoms) University of Penn Smell Identification test (UPSIT)- scratch and sniff

Question 41

# Olfactory Dysfunction Dx Consider CT?

Answer 41

UPSIT Consider CT or MRI if there is no sign of blockage/ structural abnormality or recent viral infection

Question 42

# Olfactory Dysfunction Tx

Answer 42

Fix the blockage/ structural problem Wait out the virus Refer to ENT Mild hyposmia has better outcome than severe hyposmia or anosmia

Question 43

# Olfactory Dysfunction Pt education

Answer 43

Counsel patients to be mindful of salt use (don’t oversalt just to get taste; might cause other health problems) Patients need to be sure smoke detectors work and need to consider not using gas appliances

Question 44

# Vasomotor rhinitis general and triggers Treatment

Answer 44

Too much parasympathetic input? Triggers: Cold air, strong odors, stress, irritants Symptoms very similar to AR, but allergy test negative Treatment Intranasal anticholinergic (ipratropium) spray INS (intranasal steroid), INAH (intranasal antihistamine)

Question 45

# Drug-induced rhinitis/Rhinitis medicamentosa Causes

Answer 45

Many drugs can cause nasal mucosal edema ACE inhibitors, beta-blockers, oral contraceptives, NSAIDs, aspirin, others Rhinitis medicamentosa distinct etiology Prolonged use of nasal sympathomimetics (topical decongestant sprays): Oxymetazoline Phenylephrine

Question 46

# Rhinitis medicamentosa general

Answer 46

Alpha receptors desensitized Loss of adrenergic tone leads to chronic congestion & rhinorrhea

Question 47

# Rhinitis medicamentosa Tx

Answer 47

INS, INAH Systemic steroids Wean one nostril at a time

Question 48

# acute rhinosinusitis Acute viral rhinosinusitis Acute bacterial rhinosinusitis

Answer 48

Going to discuss both simultaneously as “acute rhinosinusitis”, because they are near impossible to clinically differentiate.

Question 49

# Acute rhinosinusitis general

Answer 49

Inflammation of lining of paranasal sinuses Almost always concurrent with rhinitis “Rhinosinusitis" Affects 35 million people annually in US 16 million office visits annually Vast majority are viral

Question 50

# Acute rhinosinusitis S/Sx

Answer 50

Symptoms **Facial pain:** cheeks, forehead, maxillary teeth Nasal drainage: rhinorrhea and/or PND Nasal congestion Hyposmia Cough Ear fullness/pressure Less common: fever, fatigue

Question 51

# General Signs/Symptoms of Sinusitis

Question 52

# Acute viral rhinosinusitis general Most common virus

Answer 52

Rhinovirus most common Also: coronavirus, flu A & B, paraflu, RSV, adenovirus, enterovirus Viral URI biggest risk factor for acute bacterial rhinosinusitis 90% of viral URI patients have sinus involvement Only 5-10% develop bacterial infection

Question 53

# Acute rhinosinusitis Viral vs bacterial

Answer 53

Think bacterial if Symptoms beyond 10 days Worsening within 10 days after initial improvement Less reliable: Severity of symptoms Color of nasal drainage

Question 54

# Acute bacterial rhinosinusitis S/Sx

Answer 54

Symptoms Nasal congestion Nasal drainage Facial pain/pressure And all others of viral rhinosinusitis, except: > 7-14 days symptoms

Question 55

# Acute bacterial rhinosinusitis Most Common Pathogens

Answer 55

**Streptococcus pneumonia Haemophilus influenzae Moraxella catarrhalis** *Staphylococcus aureus Anaerobes Fungal*

Question 56

# Normal / Acute Sinusitis

Answer 56

CT Scan of the Sinus (Normal) The picture shows coronal view of the sinuses. The scan shows normal ethmoid structures and patent osteomeatal ducts, along with a DNS to the right.

Question 57

# Orbital abscess from ethmoid sinusitis

Answer 57

Ethmoiditis Radiologic Findings The slide on the right side shows an ethmoiditis with the presence of an intraorbital abscess seen as a capsulated air/fluid level inducing displacement of the intra-orbital contents. The picture on the left shows an ethmoiditis with the presence of intraorbital subperiosteal abscess and cellulites. | (Orbital cullulitis)

Question 58

# Cavernous Sinus Thrombosis general

Answer 58

50% mortality rate even today. Cavernous Sinus Thrombosis Cavernous sinus thrombosis is usually found subsequent to ethmoiditis and/or sphenoiditis. The disease is potentially fatal and requires immediate and adequate treatment. The small picture in the lower left shows proptosis and chemosis. The slide on the right side demonstrates a transverse MRI view at the level of the sphenoid sinus and the cavernous sinus. There is evidence of right-sided sphenoiditis. At the same time there is diffuse opacification of the cavernous sinus as demonstrated around the lower portion of the white lines (circles). On the left side of the picture in the upper part we can see pre-septal and post-septal edema manifested by eyelid edema and proptosis. In the same picture small skin ulcerative lesions are seen in the nasal pyramid. These lesions were disturbed by the patient causing skin cellulitis and subsequent cavernous sinus thrombosis.

Question 59

# Cavernous sinus thrombosis Classical signs (5)

Answer 59

Classical signs of cavernous sinus thrombosis include proptosis, chemosis and ophthalmoplegia, fever, and general toxicity.

Question 60

# Cavernous sinus thrombosis Tx (3)

Answer 60

The treatment includes antibiotics, surgical drainage of the affected sinus, and anticoagulants.

Question 61

# Acute bacterial rhinosinusitis Tx | when to refer?

Answer 61

Treatment Antibiotics: amoxicillin, cefdinir, Augmentin, etc Systemic steroids INS, INAH Mucinex Saline irrigation Topical and systemic decongestants Refer, if no improvement after 1 month

Question 62

Classifying Sinusitis - Duration

Answer 62

Acute: <= 4 weeks Subacute: 5-12 weeks Chronic: > 12 weeks Recurrent Acute - > 4 episodes of acute sinusitis per year each lasting 7-10 days with symptom resolution between

Question 63

# Chronic rhinosinusitis general

Answer 63

Multifactorial inflammatory process of nose and paranasal sinuses Symptoms persist 3 months or longer Most cases are due to acute sinusitis that is either: Untreated, or Unresponsive to treatment

Question 64

# Chronic rhinosinusitis (CRS) Etiology

Answer 64

Sinus ostial obstruction Allergies Less common Polyps Immunodeficiency Dental disease Smoking a risk factor

Question 65

# Chronic rhinosinusitis (CRS) S/Sx

Answer 65

Major factors Facial pain/pressure Nasal obstruction Nasal discharge Hyp/anosmia Minor factors Headache Fever Halitosis Fatigue Dental pain Cough Ear pain/fullness

Question 66

# Chronic rhinosinusitis (CRS) Dx criteria

Answer 66

Diagnostic criteria 2 or more major factors, or 1 major factor plus 2 minor factors Plus confirmatory: Nasal endoscopy, or Radiographic findings (CT sinus)

Question 67

# Rhinosinusitis

Answer 67

Rhinosinusitis (Maxillary-Ethmoid) In acute maxillary rhinosinusitis bulging of the middle meatus and hypertrophy of the bulla ethmoidalis are frequently seen due to increased intramaxillary pressure after obstruction of the osteomeatal complex. The picture on the right side shows a bulging middle meatus; the picture on the left is a coronal CAT scan view of an acute maxillary rhinosinusitis with deforming bulging of the middle meatus.

Question 68

Answer 68

Rhinosinusitis (Maxillary-Ethmoid) The picture shows two coronal CAT scans of the sinuses. The CAT scan on the right side shows a rhinosinusitis of the right maxillary sinus with obstruction of the osteomeatal complex. In the left maxillary sinus there is mucoperiosteal thickening as well as obstruction of the osteomeatal complex. There is also thickening of the mucosa of the ethmoid sinuses. Bilateral bullous middle turbinates can be seen. The CAT scan on the left demonstrates mucoperiosteal thickening of the left ethmoid cells as seen in chronic and acute ethmoiditis.

Question 69

Answer 69

Rhinosinusitis (Sphenoid) This coronal CAT scan shows an opacified left sphenoid sinus.

Question 70

# Sinusitis Tx

Answer 70

Nasal Sprays Flonase Afrin/ Decongestant (3 days max) Pain Relief: Tylenol Motrin Sinus Rinse: NeilMed NetiPot Navage Treatment Antibiotics Systemic steroids INS, INAH Mucinex, sinus irrigation 3-4 weeks Surgery if no better | Initially Similar to acute rhinosinusitis….just longer

Question 71

# Sinusitis Bacterial Treatment

Answer 71

Amoxicillin - more helpful in children Augmentin (Amoxicillin-Clavulanate) - 1st line treatment Penicillin Allergic patients: Doxycycline Fluoroquinolones Less commonly used but sometimes helpful Azithromycin, Clarithromycin Bactrim Keflex Steroids? Helps decrease inflammation to facilitate drainage Especially useful with polyposis patients Side effects, use sparingly

Question 72

# Sinusitis Surgery Tx

Answer 72

Restore sinus ventilation, Balloon open osteomeatal complex Restructure obstructing anatomy - Septoplasty, Turbinate Reduction Debulking refractory polyps Repair bony erosion or extension of disease beyond the sinus cavities