Rhinology, Nasal obstruction and sinusitis

Question 1

Causes of rhinorrhea and post nasal drainage

Answer 1

allergic rhinitis, nonallergic rhinitis, vasomotor rhinitis, and acute and chronic rhinosinusitis

Question 2

Causes of nasal obstruction and pain

Answer 2

1. anatomic deformities (including septal and external nasal deviation, nasal valve compromise, turbinate hypertrophy, nasal polyps)
2. inflammatory changes resulting in mucosal edema

Question 3

Patients with what kinds of rhinitis present with clear rhinorrhea, no other allergic symptoms or history, and allergy tests are negative?

Answer 3

1. Vasomotor (food, temp and sudden bright light trigger it)

2. nonallergic rhinitis

Question 4

Best tx for nonallergic and vasomotor rhinitis

Answer 4

Intranasal steroid sprays

Question 5

What virus is acute viral rhinosinusitis frequently attributed to?

Answer 5

Rhinovirus (common cold)

Question 6

Which is false regarding the common cold?
A. pathophysiology involves infection, inflam, mucosal swelling and inc mucus
B. High grade fever, facial discomfort and purulent nasal drainage
C. Symptomatic tx w/antipyretics, hydration, analgesics, decongestion
D. Spontaneous resolution in 7-10days
E. Abx discouraged

Answer 6

B - low grade

Question 7

Prolonged mucosal edema can cause sinus obstruction and retention of secretions. This is called what?

Answer 7

Acute bacterial rhinosinusitis

Question 8

Which is not a major symptom of acute rhinosinusitis?
A. Ear fullness/pressure
B. Facial pressure/pain
C. Facial congestion/fullness
D. Purulent nasal discharge
E. Nasal-obstruction, anosmia

Answer 8

A. Minor symptom. Other minor include headache, fever, cough, fatigue, toothache, halitosis

Question 9

Over ___% of patients with viral URI also have an abnormal sinus CT scan?

Answer 9

80% - this means plain films or CTS do not differentiate acute bacterial rhinosinusitis from a viral URI

Question 10

How can you differentiate between a viral vs bacterial infection?

Answer 10

Viral takes 7-10 days to resolve

Symptoms >7-10 days or worsens after 5 days suggests bacterial

Question 11

organisms that cause acute otitis media?

Answer 11

S pneumonia
H influenza
Moraxella catarrhalis

Question 12

How do you break down acute, subacute and chronic rhinosinusitis?

Answer 12

Acute: less than 1 mo
Subacute: more than 1 mo but less than 3mo
Chronic: more than 3 mo(diff underlying microbiology w/inc # anaerobes)

Question 13

What is the tx of choice for acute rhinosinusitis (as well as AOM)?
What if there is resistance?

Answer 13

1. 10 day course of amoxicillin or trimethoprim/sulfamethoxazole
2. Amoxicillin/clavulanate or 2nd gen cephalosporin or macrolide or quinolone
   Must cover H influenza

Question 14

Oxymetazoline is what kind of adjuvant tx for acute rhinosinusitis?

Answer 14

Topical decongestant

Question 15

Guaifenisen is what kind of adjuvant tx for acute rhinosinusitis?

Answer 15

Mucolytic

Question 16

Which is correct about when you should call oto about acute rhinosinusitis?
A. 5-6 infections/yr
B. Infection doesn’t respond to one 3 week course of abx
C. Nasal polyps
D. Must have at least 2 complications of sinusitis

Answer 16

C.
A. 3-4
B. two 3 week courses
D. Any complications of sinusitis

Question 17

What kind of sinusitis can result in orbital cellulitis or abscess and presents with eyelid swelling, proptosis and diplopia? Tx?

Answer 17

Ethmoid sinusitis

Surgical drainage ASAP if abscess present, IV abx and decongestants if no abscess.

Question 18

What kind of sinusitis can cause ophthalmoplegia (eye mm paralysis), meningitis, and cavernous sinus thrombosis?

Answer 18

Sphenoid sinusitis

Question 19

Cavernous sinus thrombosis is a complication with even more grave implications than meningitis or brain abscess, and it carries a mortality of ~__ %. Can be caused by what?

Answer 19

50%

Sphenoid sinusitis

Question 20

Pt w/ double vision and rhinosinusitis is assumed to have what until ruled out by CT or MRI?

Answer 20

Cavernous sinus thrombosis

Question 21

Tx of sphenoid sinusitis?

Answer 21

High dose IV abx

Surgical drainage of paranasal sinuses.

Question 22

allergic disorder to fungi can result in severe symptoms of chronic sinusitis and significant inflammation in the sinonasal mucosa due to a preponderance of _____ ?

Answer 22

eosinophils

Question 23

Fungal spores can also get trapped in a sinus, where they germinate and fill the sinus with debris, forming a “fungal ball” or _____

Answer 23

mycetoma

Question 24

In what pts can certain fungal infections (e.g. mucormycosis) become invasive?

Answer 24

Immunocompromised or diabetic

ENT emergency!

Question 25

Frequent cause of nasal obstruction? | Tx?

Answer 25

Septal deviation May also snore and have obstructive sleep apnea Rhinoplasty and septoplasty

Question 26

What is this? Localized, extremely edematous nasal or sinus mucosa (microscopically full of water) Most common nasal mass

Answer 26

Nasal polyps

Question 27

__% of patients with polyps also have allergies. What else do these patients have?

Answer 27

50 | Asthma

Question 28

Tx polyps?

Answer 28

Systemic steroids, intranasal steroid sprays | Surgery if polyps recur

Question 29

Signs of polyps?

Answer 29

Grapelike swellings that protrude into lumen --> obstruction and anosmia

Question 30

What is Samter's triad?

Answer 30

Asthma Allergy to aspirin Nasal polyposis Hard to tx

Question 31

Unilateral nasal polyps may be a manifestation of what?

Answer 31

Neoplasm. Refer to oto

Question 32

Polyps in kids is uncommon and should prompt a work up for what?

Answer 32

CF

Question 33

Condition that develops when people repeatedly use decongestant nasal sprays over a long period and can cause nasal blockage.

Answer 33

Rhinitis medicamentosa

Question 34

Why does rhinitis medicamentosa occur? | Tx?

Answer 34

Mucosa becomes inflamed due to spray. May be related to cocaine abuse Stop spray use

Question 35

Why might cocaine induce ischemic necrosis in the nasal septum?

Answer 35

Vasoconstricts --> nasal septal perforation

Question 36

Why might a pt suffer from chronic rhinosinusitis even though they have a straight septum and no nasal polyposis or inflammation?

Answer 36

Blockage of sinus drainage (e.g. uncinate process is close to ethmoid bulla, forming the infundibulum where maxillary sinus drains) Swelling of the mucosa can block the sinus ostium.

Question 37

How might a nasal polyp lead to sinusitis?

Answer 37

• Obstruction of the natural ostium of the sinus will cause a backup and may lead to sinusitis.

Question 38

What are 3 intranasal masses with inflammatory etiologies?

Answer 38

1. pyogenic granuloma 2. wegner's granulomatosis 3. Sarcoidosis

Question 39

What are 5 neoplasms of the nose/sinus?

Answer 39

1. Inverting papilloma 2. juvenile nasopharyneal angiofibroma 3. Sinonasal undifferentiated carcinoma 4. adenocarcinoma 5. Esthesioneuroblastoma