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Fxns of the nose?

- olfaction
- air filtration and warming


Deficiency in ability to perceive smell?

- 2.7 million adults have some deficiency
- impaired olfaction increases with age, and impairs sense of taste


Consequences of deficiency in ability to perceive smell?

- impairs sense of taste
- leads to nutrtional deficiences
- impairs social interactions
- depression
- can be dangerous - can't smell gas


What is anosmia? Hyposmia?

- anosmia: inability to detect odors
- hyposmia: decreased ability to detect odors
-dysosmia: distorted ID of smell
parosmia: altered perception of smell in the presence of odor, usually unpleasant
phantosmia: perception of smell w/o odor present
agnosia: inability to classify or contrast odors, although able to detect odors


PP of decreased olfaction?

- in conductive defects, transmission of an odorant stimulus to olfactory neuroepithelium is disrupted
- sensorineural defects involve more central neural structures
- overall - most common cause of primary olfactory deficity are nasal and or sinus disease, prior viral URIs and head trauma


Etiologies of anosmia?

- absent smell fxn
-midline facial abnormalities - cleft palate


Etiologies of dysosmia?

distortion of smell fxn
-nasal and paranasal sinus disease (39%)
-head trauma (30%)
- meds
- exposure to toxins


Etiologies of parosmia and hyposmia?

- aging and neurodegenerative process: sense of smell decreases with normal aging, number of sensory cells in olfactory bulb decrease
- nasal obstruction
- URIs
- head trauma
- facial trauma
- central olfactory damage


air filtration and warming fxn of the nose physiology?

- removes most all particles greater than 5 micrometers and 50% of those 2-4 micrometers
- microorganisms are enclosed in droplets and inactivated by abs present in mucus
- warms and humidifies air to body temp by time it reaches nasopharynx
- respiratory cilia - beat 1000x a min and surface materials are moved 3-25 mm/min


Mucociliary movement?

- mucus blanket is double layer with superficial viscid fluid and serous layer underneath
- proper movement of mucous blanket is impt in preventing infection and other problems
- to obtain movement the cilia and mucus blanket must fxn as a unit
- cilia beat in serous inner layer and just touch the outer layer propelling the thick gel layer


What is rhinitis? Etiologies of rhinitis?

- inflammation of nasal mucosa
- 15-20% of pop
- allergic rhinitis
- infection: viral, bacterial, fungal (rare)
- vasomotor rhinitis
- mechanical obstruction
- effects of certain drugs/meds: rhinitis medicamentosa - afrin
- enviro irritants: perfume and smoke
- hormonal changes: hypothyroidism, pregnancy (increased fluids)
- chronic inflamatory disease (granulomatosis)


Rhinitis presentation?

- nasal congestion
- rhinorrhea/d/c
- epistaxis: pt on O2
- pain (nasal, sinus, pharyngeal, dental)


Common cold - inflammatory reaction can involve what tissues?

- inflammation of nasal passages commonly due to any number of respiratory - viruses
- inflammatory rxn may involve:
nasal and nasopharyngeal tissues, oropharyngeal, laryngeal tissues, down to and including the bronchial mucosae


Incidence/prevalence in USA of common cold?

- vast majority are self tx
- preschool children 6-10/year
- kindergarten 12/year
- school aged children 7/yr
- adolescents/adults 2-4/yr


Presentation of infectious rhinitis?

- pharyngitis: frequently the prodromal/first sx
- nasal congestion, rhinorrhea and/or obstruction
- sneezing
- facial and or ear pressure
- loss of smell/taste
- cough: mucus drainage, more coughing at no
- hoarseness: mucus coating larynx
- HA
- malaise (rare)
- fever over 100 (rare)


causes of common cold?

- weather: no proof
- exercise, diet, enlarged tonsils/adenoids: no proof, Vit C?
- psych stressors
- allergic disorders


VIral etiology of URIs?

- over 200 virus strains:
most cause mild illness

- rhinovirus (over 100 serotypes) - 80% of adult colds
- coronavirus - common cause in adults 10-20%
- adenoviruses (common cause in children) - 5% in adults
- no agent ID in 40% of cases


Viral etiologies of URIs that can cause more severe illness?

- orthomyxoviruses (influenza A and B) - 10-15%
- paramyxovirus (parainfluenza)
- echoviruses
- enteroviruses: polio
- coxsackieviruses: heart muscle (myocarditis)


Transmission of the cold?

- touching your skin to enviro surfaces
- inhaling drops of aerosolized mucous material containing viral particles


DDx of common cold?

- seasonal allergic rhinitis
- sinusitis: bacterial
- pharyngitis: GAS
- EBV (mono)
- mumps: pronounced swelling of parotid glands
- rubeola: rash starts at head and moves down
- influenza: systemic sxs often overshadow URI complaints and include:
fever over 101
severe HA
lower respiratory tract congestion/cough


Supportive tx of common cold?

- rest
- drink plenty of fluids - thins the mucus
- gargle with warm salt water
- use throat sprays, lozenges
- petroleum jelly for sore nose (aquaphor)
- aspirin, Ibuprofen, or acetaminophen for HAs and fevers


Warning about aspirin for fevers in children?

- never use for HAs and fevers in children and adolescents with viral infections
- Reyes syndrome: usually occurs after influenza or chicken pox, when HAs and fevers are more pronounced. ASA promotes this:
N/V, liver inflammation, progressive mental changes (delirium and confusion)


Antihistamine MOA in rhinitis management?

- these are drugs that combat histamine released during an ab-ag that would have caused release of histamine from mast cells. The drug rxn blocks the action of histamine on target tissue
- antihistamines don't stop formation of histamine nor do they stop conflict b/t IgA and IgE and ag
- cold: ag is virus
- allergy: ag is allergen


antihistamines used in rhinits?

- 1st gen only: decrease mucus production
- chlorpheniramine (CTM, Chlor-Trimeton)
- Diphenhydramine (benadryl)
- Brompheniramine (dimetapp)
- 2nd gen: zyrtec, allegra don't seem to work


Meds used to relieve fever, myalgias, and HAs?

ibuprofen (motrin, advil)
naproxen (aleve, anaprox)


MOA of decongestants in rhinitis? What do we use?

- decrease nasal congestion by causing blood vessel constriction and reduced blood flow to nasal passage
- pseudoephedrine (sudafed): oral
- phenylephrine (4 way fast acting nasal spray) and oxymetazoline (afrin) - 12 hr formulas, shouldnt be used for more than 3 consecutive days, cause rhinits medicamentosa


Unwanted SEs of decongestants?

- they may cause unwanted SEs in individuals with the following conditions:
narrow-angle glaucoma
poorly controlled HTN
coronary artery disease


dangers of cold medicines and children?

- cough and cold meds send about 7000 children to ER every year
- sxs are from unintentional overdosage: hives, drowsiness, unsteady walking
- during cold season approx 10% of children are on these meds

- always use ibuprofen for fever and pain, esp if using cold medicine that already contains tylenol


Pt education with common cold?

- reassurance: usual course is 6-10 days (up to 2 weeks)
- rest
- increase fluids
- d/c use of tobacco and ETOH
- tobacco doesnt increase risk of URI but does prolong duration of sxs


Possible complications of common cold?

- lower respiratory tract infections: bronchitis, pneumonia
- bronchial hyperreactivity: reactive airway
- exacerbation of chronic lung disease - asthma (give steroids) or chronic bronchitis/COPD
- otitis media (2% of colds): bacterial
- acute sinusitis (0.5% of colds): bacterial
- rhinitis medicamentosa


What is sinusitis?

- inflammatory or infectious processes of the air pockets on either side of and behind the nose caused by:
bacteria, viruses, fungi (rare), possibly allergies
- if longer than 7-10 days - most likely bacterial
(acute bacterial is uncommon)


Classification of sinusitis?

- acute rhino sinusitis: sxs last less than 4 wks
- subacute rhinosinusitis: sxs for 4-12 weeks
- chronic rhinosinusitis: persists greater than 12 weeks
- recurrent acute rhino sinusitis: 4 or more episodes per year. with interim sx resolution


PP of sinusitis?

- most impt element in development of sinusitis is osteomeatal complex consisting of outflow tracts of all the sinuses into nose but most impt maxillary and ethmoid sinuses
- depending on the anatomy of outflow tract (diameter, length, as well as configuration), obstruction may occur causing a sinusitis of maxillary as well as ethmoid and frontal sinuses
- ciliary fxn: ciliary dyskinesia: cystic fibrosis, or smoking


Predisposing factors of sinusitis? Recurrent sinus infections?

- 3 factors appear crucial for normal physiologic fxning of sinuses:
- patency of osteomeatal unit (OMU)
- normal mucociliary transport
- normal quantity and quality of secretions
- disruption of one or more of these factors can predispose to sinus infection

factors that predispose you to recurrent sinus infections:
- anatomical irregularities
- infections
- allergies
- polyps
- hormones
- enviro
- fbs
- CF


Microbiology of sinusitis?

- assoc with same bacteria as otitis media: acute
strep pneumo
H flu
M cat
- 35% of H flu and 75% of M cat strains produce b-lactamase making them resistant to PCN abx - use augmentin

- chronic sinusitis: assoc with staph aureus and anaerobes


sxs of sinusitis?

- facial pain or tenderness
- nasal congestion
- purulent nasal and postnasal d/c
- HA
- maxillary tooth pain
- malodorous breath
- fever
- eye swelling: diplopia, dizziness - bad: brain abscess!
- pain or pressure in cheeks and deep nasal recesses is common


Presentation of sinusitis?

- if sxs have lasted for less than7-10 days and pt is recovering, self limited viral URI is most likely cause
- however, worsening sxs or sxs that persist for more than 7 days are more likely bacterial sinusitis


Acute sinusitis may present when?

- upper resp sxs have been present for at least 7 or more days, and 2 or more of the following 4 factors are present for seven days or more after the onset of illness:
- colored nasal d/c: yellow and green color doesn't mean bacterial. Color depends upon number of cells in nasal secretion not the etiology
- poor response to decongestant
- facial or sinus pain, particularly if aggravated by postural or valsalva maneuver
- HA: frontal or under cheek bones
- a biphasic illness in which cold sxs (sore throat, rhinorrhea, nasal congestion) which subside within 7-10 days and then recur within 1-2 weeks, chances of bacterial infection are high

- triad of sinusitis: HA, sinus pain and fever (not usually present)


PE of sinusitis pt? findings?

- VS, eyes, ears, pharynx, teeth, sinus tenderness, LN, and chest
- pain localized to sinuses when pt is asked to bend forward may be more reliable than pain provoked by direct percussion
- handheld otoscope, nasal speculum
- notable findings: diffuse mucosal edema, narrowing of middle meatus, inferior turbinate hypertrophy, and copious or purulent d/c, polyps, septal deviation


Differing sxs for diff sinuses:
frontal, ethmoid, sphenoid, maxillary?

- frontal sinusitis: pain when forehead over frontal sinuses is touched, pain exacerbated by leaning forward
- ethmoid sinusitis: pain behind eyes, b/t eyes
- sphenoid sinusitis: pain behind eyes (deep pain)
- Maxillary sinusitis: MC, unilateral or bilateral, upper jaw and teeth to ache, cheeks become tender to the touch, purulent d/c in pt's nose or throat may sometimes be apparent
- nasal mucosa is often erythematous and swollen
- presence of mucoid pus in external nares or posterior pharynx is highly suggestive of sinusitis


Dx sinusitis? imaging?

- in acute, initial presentation: dx is usually made on clinical signs and sxs, severity of sxs will determin extent of testing
- imaging:
plain films are usually unnecessary b/c of cost and insensitivity (waters view)
CT: only should be used if dx remains uncertain or if orbital or intracranial complications are suspected. CT is nonspecific, very high radiatio
MRI: most useful when fungal infections or tumors are seriously considered

- sinus aspiration: invasive, only indicated for complicated sinusitis, immunocompromised pts, chronic recurrent infections that fail to respond to mult course of empiric abx therapy or severe sxs
- ENT referral at this point, cultures of nasal secretions correlate poorly with results of sinus aspiration: waste of money!


tx for mild, recent onset sinusitis?

- usually viral URI
- tx as you would viral rhinitis:
supportive therapy, lots of fluids, rest, decongestants, ibuprofen


Tx for bacterial sinusitis?

- amoxicillin: first line in pts with no allergies to PCN (10 days)
- augmentin: if B lactam restistant
- doxy (not for kids)
- z pack (if PCN allergic)


Supportive self care measures for sinusitis?

- maintain adequate hydration (drink 6-10 glasses of liquid a day to thin mucus)
- steamy shower or increase humidity in your home or personal steam vaporizer
- apply warm facial packs (warm wash cloth, hot water bottle or gel pack for 5-10 min 3 or more times/day)
- analgesics (acetaminophen, ibuprofen, aspirin as needed - don't give to kids under 18)
- decongestants: oral - pseudoephedrine hydrochloride (sudafed 60 mg q 4-6 hrs, not to exceed 4 doses/ 24 hrs)
- decongestant nasal sprays for no longer than 5 days (3 consecutive days) - afrin
- saline irrigation lavage
- saline nasal drops/spray, commercial - ocean, salinex, nasal
- adequate rest
- sleep with head elevated
- avoid cigarette smoke and extremely cool or dry air


Complications of bacterial sinusitis?

- meningitis, epidural abscess, subdural empyema, or brain abscess are characterized by high fever and CNS sxs
- orbital cellulitis and abscess are characterized by severe eye swelling and redness
- cavernous sinus thrombosis is characterized by bilateral eye swelling and edema over mastoid emissary vein, altered mentation and meningismus
- mucocele formation is complication of chronic sinusitis characterized by HA, proptosis, and diplopia. It occurs most often in frontal sinuses. Sx lesions reqr surgical intervention


Presention of allergic rhinitis? PE?

- clear rhinorrhea, sneezing, tearing, eye irritation and pruritis
- very common
- assoc sxs include cough, bronchospasm, eczematous dermatitis
- environment
- similar to viral but are persistent and may show seasonal variation
- PE: mucosa of turbinates is pale
- may have nasal polyps, cobblestoning
- tx: antihistamines, antileukotriene meds, immunotherapy


What is nasal airway obstruction?

- inability to inspire and expire through nasal passage:
- can be one or both nostrils
- partial or complete
- always, intermittent
- stable, worsening
- impaired respiration, smell, and taste
- infants are obligate nose breathers only, nasal obstruction is life threatening (put afrin on q tip if congested)


Ddx of nasal obstruction?

- polyps
- tumors
- fbs (unilateral, smelly, green mucus d/c)
- septal deviations
- trauma


What are nasal polyps and how can they block nasal passageways?

- nasal polyps represent intense inflammatory rxn of sinonasal mucosa of unknown etiology
- polyps may block OMU leading to chronic sinusitis on a mechanical basis
- eosinophilia assoc with most polyps is toxic to ciliated membranes producing a decrease in flow of mucus and this stasis could further contribute to sinusitis
- polyps can also occur w/in paranasal sinus, pressure on intrasinus membranes and bone can destroy bone
- pathology of polyps range from limited hyperplastic mucosal changes to sinonasal polyposis with bilateral and multiple sinus involvement


PE of pt with polyps?

- since polyps are devoid of sensory innervation they can be distinguished by lack of pain on manipulation


imaging for polyps?

- coronal sinus CT: imaging study of choice in eval of pts with nasal polyposis
- coronal CT of paranasal sinuses is best for delineating the underlying pathology, the extent of the disease, and possible bony destruction
- nonenhanced CT with 2-3 mm sections help to delineate the location and origin of visible polyps, eval the underlying condition of all fo the sinuses, and assess the anatomy of paranasal sinuses in event of surgial intervention
- MRI: isn't appropriate for polyps unless intracranial extension is suspected. Bony details of paranasal sinus anatomy are poorly visualized on MRI
- radiography with waters view may show opacification of sinuses


Tx of polyps?

- refer to ENT for further tx
- medical tx involves:
topical steroids - first line!
oral steroids
leukotriene inhibitors
intrapolyp steroid injections

- surgery: removal of polyp


Septal deviation etiologies?

- common
- displacement of nasal septum:
trauma, congenital (marfan, homocystinuria, ehlers-danlos syndrome)


Sxs of septal deviation?

- infections of sinus, sleep apnea, snoring, change in smell, frequent sneezing, and difficulty with breathing


Tx of septal deviation?

- decongestants, anti-histamines, nasal spray
- surgery: septoplasty


What is septal perforation?

- nasal septum dividing nostrils develops a hole or fissure
- caused by cocaine, nasal sprays, piercing
- sxs:
whistling when breathing, bloody d/c, nasal pressure, and discomfort
- tx: usually heals w/o surgery