W31 Nasal conditions Flashcards
(31 cards)
What is congestion?
Accompanying symptoms of congestion?
- Nasal obstruction, stuffy nose, blocked nose
- Variance of severity between patients
Accompanied by other symptoms
* Nasal discharge/runny nose/rhinorrhoea
* Postnasal drip/catarrh
* Facial pain
* Loss of sense of smell
* Sneezing
* Itching
* Crusting
Causes of congestion? (6)
- Nasal deformity
- Foreign body in the nose
- Swelling of nasal mucosa
- Inflammation of nasal mucosa
- Infection e.g. Sinusitis
- Allergy e.g. Hay fever
Treatment for congestion?
- Steam inhalation – can add menthol & eucalyptus
- Saline sprays or drops e.g. Sterimar
- Saline nasal irrigation
- Corticosteroid nasal sprays e.g. Beconase
- Oral or intranasal decongestants e.g. Pseudoephedrine, Xylometazoline
- Oral antihistamines e.g. Cetirizine, Loratadine
Define Rhinitis
What are the symptoms?
- Irritation & inflammation of mucosal membrane inside the nose
- Allergic & Non- allergic
- Sneezing
- Blocked nose/Congestion
- Runny nose (rhinorrhoea)
- Itching nose
- Postnasal drip
- Itching roof of mouth
- Cough
- Eye symptoms – itching, redness, tearing
- Mild, Moderate or Severe
Allergic Rhinitis
- IgE mediated inflammatory disorder of the nose
- Nasal mucosa exposed to allergens
-Histamine release
-Inflammatory mediator release - Seasonal – symptoms during a period each year in response to a seasonal allergen
- Perennial – Symptoms all year round - constant exposure to allergen
- Intermittent – Symptoms for less than 4 days a week or less than 4 consecutive weeks
- Persistent – Symptoms for more than 4 days a week and for more than 4 consecutive week
- Occupational – Symptoms due to allergen exposure in work
Causes of Allergic rhinitis?
- Occupational
- Genetic
- House dust mites
- Pollen
- Moulds
- Animal hair
Allergic Rhinitis
Diagnosis?
Assessment?
Differential diagnosis?
- Sneezing, itching, rhinorrhoea, congestion
- Bilateral symptoms
- Associated symptoms
- Personal or FH of Atopy
- Occur after exposure to allergen
- Type, frequency, persistence, location of symptoms
- Severity of symptoms
- Pets? Occupation?
- Hx of treatment
- Infective rhinitis
- Non-allergic rhinitis
Management of allergic rhinitis
- Nasal irrigation
-Rinse nasal cavity with Saline (NaCl 0.9%) solution
-OTC - Allergy testing
- Avoid triggers/allergen
- Pharmacological Treatments
Allergic Rhinitis - Pharmacological Treatments
- Antihistamines
- Intranasal cromones
- Intranasal decongestants
- Intranasal anticholinergics
- Oral Leukotriene receptor antagonists
- Intranasal corticosteroids
Antihistamines- Intranasal
Azelastine
- 1 spray BD
- From age 6+
- Can taste bitter
- Can irritate nasal mucosa
- Possible hypersensitivity reaction
Antihistamines- Oral
Names and dose? ? (2)
SE?
Cetirizine
* 10mg daily
* Reduce to half dose in eGFR 30-59
* Reduce to half dose & alt. days in eGFR 15-29
* Avoid in eGFR below 15
Loratadine
* 10mg daily
* Reduce to alternate days in hepatic impairment
- Side effects
- Blurred vision, dry mouth, headache, diarrhoea
- Drowsiness
- Angioedema, arrythmias, blood disorders
- Interaction with Betahistine
- Caution in Pregnancy & Breastfeeding
Intranasal Cromones:
Sodium cromoglicate
dose?
P/BF?
- 1 spray 2-4 times daily in each nostril
- No contraindications or cautions with nasal use
- Could cause bronchospasm and irritation of nasal mucosa
- No drug interactions with nasal use
- Can be used in pregnancy and breastfeeding
Intranasal Decongestants: Xylometazoline
Dose?
Cautions?
SE?
Interactions? (2)
Use in P/BF?
- Child age 6-11 = 1-2 drops 1-2 times a day PRN for max. 5 days
- Age 12+ = 2-3 drops, 2-3 times a day PRN for max. 7 days
-Spray 1-3 times daily - Cautions – Diabetes, Hypertension, Hyperthyroidism, CVD, Angle-closure Glaucoma, BPH/Prostate enlargement
- Side Effects – rebound congestion, hypertrophy of mucosa, headache, nausea, irritation, dryness, hallucination, restlessness, sleep disturbance
- Drug Interactions – Rasagiline, Selegiline
- Avoid in Pregnancy & Breastfeeding
Intranasal Anticholinergics
Ipratropium Bromide
* Age 12-17 – 2 sprays, 2-3 times daily in each nostril
* Adult – 2 sprays, 2-3 times daily in each nostril
* Avoid spraying near the eyes
* Cautions – Cystic Fibrosis, bladder obstruction, Benign Prostatic Hyperplasia (BPH), prostate enlargement
* Side Effects – Epistaxis, dryness, irritation, headache, nausea, GI motility disorders, palpitations, urinary
retention
* Drug Interactions – Antimuscarinics, bronchodilators
* Avoid in pregnancy & breastfeeding
Leukotriene Receptor Antagonists
SE?
Interactions?
Avoid in..?
Montelukast:
* Age 15+ - 10mg in the Evening
* Side Effects – Abdo pain, headache, hyperkinesia, thirst, eosinophilia, vasculitic rash, abnormal dreams, aggression/agitation, anxiety, antimuscarinic effects, peripheral neuropathy, cardiac complications
* Drug Interactions – carbamazepine, clopidogrel, leflunomide, phenobarbital, phenytoin, primidone, rifampicin
* Avoid in Pregnancy & Breastfeeding
Non-Allergic Rhinitis
What are the causes?
- Change in temperature/humidity
- Common cold
- Exercise
- Irritants - Smoke, perfume, paint fumes
- Alcohol, spicy food
- Drugs – Alpha blockers, ACE inhibitors, B-Blockers, Chlorpromazine, aspirin, NSAIDs, Cocaine
- Rebound congestion – decongestant overuse
- Hormonal – Pregnancy, HRT, Contraception, Hypothyroidism
- Non-allergic rhinitis with eosinophilia syndromes (NARES)
- Systemic & Structural defects
What is Sinusitis?
3 categories?
- Inflammation of the paranasal sinuses and nasal cavity
- A.k.a. Rhinosinusitis
- Acute – Resolves within 12 weeks
- Recurrent Acute – 4+ episodes of acute sinusitis/year
- Chronic – Symptoms last for over 12 weeks
Sinusitis
Sinusitis- Causes?
- Viral URTI
- Bacterial infection
- Asthma
- Allergic rhinitis
- Seasonal
- Smoking
- Nasal defects – Polyps, deviated septum, trauma, foreign body, impaired ciliary motilility
- Aspirin sensitivity
- Immunocompromised
- Genetic
- Sinus surgery
Sinusitis- Complications
- Orbital -Orbital cellulitis, abscess, cavernous sinus thrombosis
- Intracranial – meningitis, encephalitis, abscess, venous thrombosis
- Osteomyelitis
- Progression to chronic sinusitis
- Sleep problems, fatigue, depression
- QoL – Reduced social life, absence from work, ability at work
Sinusitis - Diagnosis
Acute:
* Usually after a cold
* Worsening symptoms after 5 days, persisting for over 10 days but less than 12 weeks
* Nasal congestion or discharge
* Facial pain or pressure
* Reduced sense of smell
* Nasal voice
* Tenderness, swelling, inflammation
over cheekbone and periorbital
areas
* Cough
Chronic
* Nasal congestion or discharge
* Facial pain or pressure
* Reduced sense of smell
* Lasts for longer than 12 weeks
* Pain/swelling/ tender maxiofacial area
* Inflamed and swollen nasal mucosa
* Possible nasal polyps or anatomical defects
Sinusitis – Differential Diagnosis
- Upper RTI
- Common cold
- Allergic rhinitis
- Foreign body in nose
- Adenoiditis/tonsillitis
- Tumour
- Turbinate hypertrophy
- Migraine
- Giant cell arteritis
- Temporomandibular disorder
- Trigeminal neuralgia
- Dental pain
Acute Sinusitis - Management
- Admit to hospital if systemically unwell or have orbital or intracranial complications
- Do not offer antibiotic treatment if symptoms present for less than 10 days
- Likely viral cause
- Resolve in 2-3 weeks
- Self manage fever
- Lack of evidence for saline, decongestants, antihistamines, steam inhalation, mucolytic
Intranasal Corticosteroids
- Available as drops and sprays
- Greater risk of systemic effects with drops
- Use from age 12+
- Beclometasone (Beconase)
- Mometasone (Nasonex)
- Fluticasone (Flixonase, Avamys, Dymista)
Contraindications
* Untreated fungal, bacterial or viral nasal infection
* Recent nasal surgery/trauma
* Pulmonary TB
* Can be used in pregnancy & breastfeeding
* Local adverse effects – Nasal dryness & irritation, nosebleeds, throat dryness & irritation, skin redness,
rash & itching, headache, disturbed smell & taste
* Systemic adverse effects – Less likely than with oral corticosteroids but risk with high doses and extended
treatment, lower risk with spray than drops
Phenoxymethylpenicillin
What is its drug class and moA?
C/I?
Caution?
Interactions?
Adverse effects?
- Β-lactam antibiotic
- Interrupts bacterial cell wall synthesis
- Narrow spectrum
- Contraindications – Penicillin allergy, cephalosporin allergy
- Caution – Renal impairment
- Drug interactions – MTX, oral anticoagulants
Adverse effects:
* GI – Nausea, diarrhoea, vomiting, stomatitis, glossitis. Rarely cause abx associated colitis
* Skin – Rash, urticaria, pruritis
* Anaphylaxis
