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FA17 HEENT > Nose and Sinus Disease > Flashcards

Nose and Sinus Disease Flashcards

1
Q

hollow cavities in the skull

A

sinuses

drain unidirectionally into nose (via ostia) and mucosa of nose and sinuses (contiguous)

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2
Q

turbinates

A

make air flow more turbulent to assists in humidifying and filtering particulates from the air

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3
Q

cilia location

A

concentrated near and beat towards natural sinus ostia

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4
Q

sinus drainage depends on:

A

ciliary action

mucus viscosity

size of sinus ostia

stasis of mucous flow

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5
Q

what might cause abnormal ciliary action ?

A

infection/large inoculation of bacteria

systemic disease (causing ciliary disfunction)

local hypoxia

environmental factors

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6
Q

what might cause mucus viscosity to increase?

A

infection

autoimmune disorders

dehydration

systemic inflammatory

medications (diuretics, pseudofedarin, narcotics)

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7
Q

what can cause Ostium obstruction infection?

A

mc common cause, SWELLING

respiratory viruses, chemical irritants, physical obstruction, allergic reaction, trauma

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8
Q

inflammation of lining of sinuses

A

rhinosinusitis

classified by timing and etiology

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9
Q

epidemiology of infectious sinusitis

A

1 of 7 adults

more common from early fall to spring

more common in women

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10
Q

etiologies of infectious rhinosinusitis

A

vast majority are caused by viral infection

viral URI can also cause acute bacterial rhinosinusitis

fungal rhinosinusitis

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11
Q

Viral rhinosinusitis agents

A

mostly caused by rhinovirus (can be flu, RSV, etc)

treatment is supportive

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12
Q

bacterial sinusitis agents

A

mc cause of community rhinosinusitis are normal flora (h. influenza, strep pneumonia, M. catarrhalis, S. aureus)

nosocomial sinusitis - gram - but also poly microbial

dental disease, chronic sinusitis - anaerobes

caused by eventual colonization via sneezing, coughing, or invasion

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13
Q

acute rhinosinusitis

A

clinically diagnosed (no labs)

patient will have s/s of common cold (sneezing, congestion, runny nose)

patient appears to recover then gets worse (around day 7)

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14
Q

bacterial sinusitis s/s

A

viral URI history

facial pain over cheek (radiating to frontal region or teeth)

tenderness or pressure

purulent nasal or post nasal discharge

sinus tenderness

hyposmia

fever is RARE

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15
Q

classification of rhinosinusitis (diagnosed if)

A

these symptoms for up to 4 weeks:

  • purulent nasal discharge: cloudy, colored
  • nasal obstruction: congestion, blockage, stuffiness
  • facial pain-pressure-fullness: anterior face, headache that is diffuse

facial pressure must be accompanied w/other 2

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16
Q

acute rhinosinusitis is divided into

A

actue viral rhinosinusitis

actue bacterial rhinosinusitis

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17
Q

actue viral rhinosinusitis

A

s/s present less than 10 days and symptoms are not worsening

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18
Q

acute bacterial rhinosinusitis

A

s/s of acute rhinosinusitis fail to improve in 10 days or more beyond the onset of URI symptoms

OR s/s acute rhinosinusitis worsen within 10 days after an initial improvement

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19
Q

recurrent acute rhinosinusitis

A

4+ episodes of acute bacterial rhinosinusitis per year with sinus mucosa completely normalizing between attacks

GET BETTER between attacks

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20
Q

chronic sinusitis

A

persistence of insidious symptomatology >12 weeks, with or without exacerbations

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21
Q

chronic sinusitis symptoms

A

must HAVE 2

mucopurulent drainage
nasal congestion
facial pain/pressure/fullness
decreased sense of smell

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22
Q

chronic sinusitis signs/images

A

must have 1

purulent mucous or edema of meatus or ethmoid region

polyps in nasal vanity or middle meatus

inflammation of paranasal sinuses on radiograph

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23
Q

ENT level work up for chronic sinusitis

A

more serious diagnosis

nasal cytology
paranasal sinus biopsy
fiberoptic sinus endoscopy

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24
Q

treatment of acute rhinosinusitis

A

two fold - drain sinuses and give antimicrobial treatment

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25
drainage of sinuses (mechanisms)
1. saline lavage (can be used in patients w/o comorbidities) 2. Intranasal steroids (shortens duration in patients with allergic rhinitis, decreases inflammation of lining (2-3 weeks) ) 3. mucolytics (theoretically helpful)
26
OTC remedies for rhinosinusitis
topical (nasal spray) - CI'd bc can cause rebound congestion oral medications (OTC cold and flu remedy) can cause increased BP and tachycardia antihistamines - not used bc it thickens mucus
27
first line ABX treatment of acute rhinosinusitis
community adult patients with uncomplicated acute bacterial sinusitis 1. Amoxicillin (500 mg po/8hrs) 2. Doxy 100 mg PO bid 3. respiratory flouroquinalone
28
special situations in acute rhinosinusitis treatment
dental caries and foul discharge - ANAEROBIC coverage - metronidazole (500mg/8 hrs) -clindamycin (300mg/6-8 hrs) ICU patients - GP and GN and anaerobes - consider surgical drainage and culture - zosyn (3.75gm IV/6hrs) - Ceftriaxone (2gm IV/12 hrs)
29
how long after starting ABX should patient see improvement
2-3 days following start most of them resolve spontaneously
30
complications of rhinosinusitis local
Mucoceles | Osteomyelitis
31
mucoceles
chronic epithelial cysts in sinuses may expand concentrically causing bony erosion and extension beyond the sinus some are benign (maxillary) or severe (frontoethmoidal, etc)
32
osteomyelitis
infection of bone adjacent to sinus presents with few symptoms and may cause extensive bony destruction prior to detection mc affected is frontal sinus
33
complication of rhinosinusitis orbital (5)
orbital complications are most common ``` preseptal cellulitis orbital cellulitis subperiosteal abscess orbital abscess cavernous sinus thrombosis ```
34
s/s of orbital complication
visual acuity loss muscle eye movement loss erythema eyelid (tosis)
35
management of orbital complications
consult CT scan of facial bone with IV contrast to evaluate orbital abscess IV ABX and surgical drainage
36
intracranial sinusitis complication 2 ways
1. direct extension of the infection thru posterior frontal sinus wall to CNS 2. retrograde thromophlebitis of ophthalmic veins
37
s/s of intracranial complication
altered mental status meningitis s/s (stiff neck, light sensitivity) focal deficit visual change ataxic gait pupillary reflex
38
mc intracranial sinusitis complication
subdural abscess can cause seizure and coma managed surgically with drainage, long IV ABX
39
chronic sinusitis
sinus inflammation lasting >12 weeks most cases are caused by unresolved bacterial sinusitis
40
risk factors for chronic sinusitis
``` anatomical blockages (polyps, deviated septum) rhinitis nasotrachial or naogastric intimation ```
41
chronic rhinosinusitis results from
1. obstruction of ostia 2. stagnation of mucus 3. chronic inflammation these all lead to lower oxygen tension and lower pH within the sinus MC cause of anaerobes caused
42
chronic rhinosinusitis pathophysiology
infection by anaerobes and further damages ciliary action polymicrobial infection with GP, GN, anaerobes, and fungi
43
chronic rhinosinusitis s/s
SUBTLE presentation ``` nasal stuffiness nasal discharge postnasal drip facial fullness, discomfort and headache chronic unproductive cough sore throat ```
44
chronic rhinosinusitis work up
CT of sinuses with IV contrast have to image this bc the presentation is subtle
45
chronic rhinosinusitis treatment
reduce mucosal edema, promote sinus drainage and eradicate infections topical or oral glucocorticoids + abx and nasal irrigation
46
fungal sinusitis
invaded or non invasive disease but more likely to infuse in DM or immunocompromised
47
pathogens that cause fungal sinusitis
Apergillus and mucor species
48
spectrum of fungal disease (4)
allergic fungal sinusitis sinus mycetoma actue invasive fungal sinusitis chronic invasive fungal sinusitis
49
allergic fungal sinusitis
occurs secondary to asthma and allergic rhinitis development of allergic reaction to inhaled fungus overproduction of mucin and develop nasal polyps treatment is with sinus surgery to clear mucin and restore flow
50
sinus mycetoma
immunocompetent patients - ball of fungi blocks drainage of sinus less likely atopic disease mucupurulent/cheesy and clay like material is found at time of surgery
51
acute invasive fungal sinusitis
immunocompromised rapid hematogenous spread of fungi from sinus to CNS patients look toxic with fever cough, HA, congestion, AMS, and necrotic tissues of the septum
52
chronic invasive fungal sinusitis
invasive, slowly progressive, occurring in diabetics patients do not look acutely ill s/s of chronic fever, AMS, are ABSENT
53
fungal sinusitis dx
CT scan with IV contrast of sinus (poorly drained ostia, polyps, edema) MRI to asses spread tremens of all fungal sinusitis is surgical
54
allergic rhinitis pathophysiology
IgE mediated inflammatory response to extrinsic protein within mucous membranes
55
allergic rhinitis s/s
paroxysms of sneezing itching (nose, eyes, ears, palate) rhinorrhea (thin snot)
56
allergic rhinitis associated diseases
often associated with other igE mediated inflammatory disorders (asthma, atopic dermatitis, nasal polyps)
57
allergic rhinitis exam findings
allergic shiners allergic salute pale, boddy blys nasal mucosa thin and copious nasal discharge
58
allergic rhinitis diagnostic workup
allergic rhinitis is diagnosed clinically (no lab testing) control of allergic rhinitis will improve other allergic comorbidities
59
treatment of allergic rhinitis
1. avoidance of triggers 2. symptomatic treatment 3. immunotherapy
60
avoidance of triggers allergic rhinitis
keep windows closed, AC bar animals from bedroom and wash them frequently dehumidify air pollution exacerbates allergies
61
glucocorticoid nasal spray lists (6)
Omaris Nasonex Flonase Veramyst Rhinocort Nasacort
62
MOA glucocorticoid nasal spray
most effective maintenance therapy for allergic rhinitis + cover for nasal symptoms 1. down regulate inflammatory response of mucosal cells to allergens 2. turn on anti-inflammatory protein production in nasal mucosal cells 3. suppress local release of cytokines
63
glucocorticoid nasal spray safety concerns
concern for suppression of growth and adrenal axis they are altered to protect them can have some negative effects and lowest dose for shortest amount of time
64
glucocorticoid nasal spray ADRs
local nasal irritation aqueous preparations are less likely to have this effect trace blood in mucous or epistaxis can occur
65
glucocorticoid nasal spray directions for Aq formulation
spray and snif chin tucked (head forward)
66
glucocorticoid nasal spray directions for dry formulation
head should be tilted back no blowing nose for 15 minutes
67
2nd gen oral antihistamines drug name/list (5)
Fexofenadine (Allegra) Cetrizine (Zyrtec) Levocetirizine (Xytal) Loratidine (Claritin) Desoloratidine (Clarinex)
68
1st gen oral antihistamine drug name/list (2)
Diphenhydramine (Benadryl) Hydroxysine (Vistaril)
69
initial allergic rhinitis therapy
chronic daily symptoms are best managed with an intranasal steroid, +/- oral antihistamine drugs must take medication for several days before noting improvement
70
side effects of first generation antihistamines
cause significant sedation (cross BBB) and have powerful anticholinergic effects (dry mucous membranes, urinary retention, dilated pupils)
71
who is CI'd in first generation antihistamines
preschool children -- causes paradoxical agitation can impair school performance in school age children no role in therapy for allergic rhinitis
72
role of oral antihistamines in allergic rhinitis
decrease itching, sneezing and rhinorrhea with less impact on nasal congestion
73
oral antihistamines MOA
decrease inflammation on multiple levels decrease release of mast cells, down regulate inflammatory response, and inhibition IL-4 IL-3
74
antihistamine nasal sprays
Azelastine (Astelin) Olopatadine (patanase) administration on demand
75
rhinitis medicamentosa pathophysiology
rebound rhinitis characterized by nasal congestion without rhinorrhea or sneezing triggered by topical OTC but process is not clear they rebound congestion when try to stop nasal spray
76
what might predispose patients to suffer from rhinitis medicamentosa
rhinitis of pregnancy and CPAP machine
77
rhinitis medicamentosa treatment
discontinuation of nasal spray ASAP start intranasal steroids and wean OTC nasal spray as they take effect
78
anterior epistaxis
occur > 90% of time typically the source of these bleeds Kisselbach's Plexus
79
posterior epistaxis
usually more profuse arterial pattern greater risk of airway compromise, aspiration of blood, greater difficulty controlling bleeding
80
epistaxis etiologies
``` local trauma environmental factors Coagulopathies drugs others ```
81
epistaxis local trauma causes
picking, foreign body, facial trauma, nasal surgery
82
epistaxis workup
most are self limiting are not brought to medical attention evaluate source of bleeding, CBC, PT/INR, chemistries
83
epistaxis treatment
may be prevented with light application of petroleum jelly direct pressure 5-30 minutes pledges soaked in lidocaine or cocaine to produce vasoconstriction cauterization or packing
84
population most affected by epistaxis
children 2-5 typically in right nare
85
where are foreign objects most commonly found in nose
below inferior turbinate or immediately anterior to middle terbinate
86
foreign objects diagnosis
physical exam | foul smelling discharge, epistaxis and pain
87
foreign object treatment
typically can be removed if patient is calm can consult ENT

FA17 HEENT (8 decks)

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