CMS I: EXAM #1 (NOSE & SINUS DISORDERS LEC)

What are the types of sinusitis?

Acute rhinosinusitis, chronic sinusitis & ASA triad

What is sinusitis & rhinosinusitis?

Inflammation in the nasal cavity & parasnasal sinuses

How long does acute rhinosinusitius last?

Sxs last for less than 4 weeks

How long does subacute rhinosinusitis last?

Sxs for 4-12 weeks

How long does chronic rhinosinusitis last?

Sxs persist greater than 12 weeks

How long does recurrent acute rhinosinusitis last?

4 or more episodes of ARS per year, with interim symptom resolution

What is the pathophysiology of acute rhinosinusitis?

Swelling of nasal mucous membrane, impaired mucociliary clearance, obstruction of osteomeatal complex & accumulation of mucous

What sinus is most affected?

Maxillary sinus

Are the majority of acute rhinosinsutis cases viral or bacterial?

Viral

What are the most common viruses that cause acute viral rhinosinusitis?

Rhinovirus, influenza virus, & parainfluenza

What % of acute rhinosinusitis is of bacterial etiology?

0.5-2%

When does acute bacterial rhinosinusitis usually occur?

As a complication of viral infection, but can be associated with rhinitis or conditions that obstruct the nose or impair local or systemic immune fxn

What are the most common bacteria associated acute rhinosinusitis?

Strep. Pneumoniae, Haemophilus influenzae & Moraxella catarrhalis

What sxs is not usually seen in acute viral rhinosinusitis?

Fever

What color will nasal discharge be in acute viral rhinosinusitis?

Clear, watery

What color will nasal discharge be in acute bacterial rhinosinusitis?

Green-yellow

What are some rhinosinusitis PE findings?

Altered speech due to nasal obstruction

Erythema or edema over the involved cheek bone or periorbital area

Purple to drainage in the nose or posterior pharynx

Exacerbation of facial pain or pressure w/ percussion of the sinuses

Transillumination of the sinuses may show opacity

How do you dx acute rhinosinusitis?

Clinical - based upon s&s

Plain Sinus XR - Water's view

What is the gold standard to dx acute rhinosinusitis?

CT scan - most diagnostic "air fluid levels & mucosal edema" but not routinely used & not specific

What is the tx for acute viral rhinosinusitis?

Supportive care

Analgesics & antipyretic - NSAIDs & acetaminophen

Saline irrigation

Intranasal glucocorticosteroids

Oral decongestants (3-5 days)

Intranasal decongestants (Afrin, 3-5 days) - no evidence to support

Antihistamines - no studies for efficacy

Mucolytics

What is the classical presentation for acute bacterial rhinosinusitis?

Triad: HA, facial pain & fever

Other sxs: nasal congestion, purulent rhinorrhea

How to distinguish between bacterial and viral acute rhinosinusitis? Acute bacterial rhinosinusitis...

Persistent sxs > 10 days w/o improvement

Onset of severe sxs: fever > 102 degrees F, purulent nasal dc or facial pain for at least 3-4 days at the beginning of illness

"Double-sickening" pattern - new HA, fever or increase in rhinorrhea after 5-6 days after improving

What is 1st line tx for acute bacterial rhinosinusitis?

Augmentin (adults: 5-7 days, kids: 10-14 days)

What should pt take to treat acute bacterial sinusitis if they are PCN allergic?

Doxycycline or FQ (moxifloxacin, levofloxican)

What abx should you avoid when treating acute bacterial rhinosinsusitis? Why?

Macrolides, trimethoprim-sulfamethoxazole (Bactrim) & 3rd generation cephalosporins due to high rates of resistance

What should you do if you have recurrent or persistent bacterial sinusitis?

Consider changing abx

Specialist referral

Culture

CT scan

What should you refer a pt with acute bacterial rhinosinusitis to ENT?

Failure to resolve after course of abx

Sxs that persist > 4-12 weeks

Suspected extension of dz outside the sinuses (vision changes, periorbital edema/erythema, abscess or AMS)

What is considered chronic sinusitis?

Sxs > 3 months

What pathogens cause chronic sinusitis?

Gram negatives

S. Aureus

Anaerobes

How do you tx chronic sinusitis?

Longer course of abx (3-6 weeks): Augemntin, cefuroxime, gemifloxacin, moxifloxacin, clindamycin

Culture-directed therapy recommended

Surgery if refractory to medical rx

What is chronic sinusitis?

Sinus mucosa is chronically inflamed

Persistent low grade infection w/ periodic flare ups

Repeated sinus infections ( > 3 in 6 months)

Chronic infection with little or no infection

Definition to dx chronic sinusitis:

12 weeks or longer of 2 or more of the following:

Anterior or posterior mucopurulent drainage

Nasal obstruction

Facial pain-pressure-fullness

Decreased sense of smell

Define recurrent acute sinusitis:

4 or more episodes per year of acute bacterial rhinosinusitis, w/o s&s of rhinosinusitis between episodes

What are complications of sinusitis?

Chronic nasal obstruction

Sleep apnea

Amos is

Chronic sore throats

Orbital cellulitis

Cavernous sinus thrombosis

Brain abscess

Osteomyelitis

Meningitis & septicemia

General malaise & chronic HA

What does ASA (Samter's) Triad present as?

Chronic rhinosinusitis

What conditions follow ASA (Samter's) Triad?

Severe bronchial asthma or rash

Nasal polyps

Aspirin sensitivity

What is the tx for ASA (Samter's) Triad?

ASA desensitization

Oral or topical nasal steroids

Nasal polypectomy PRN

What are the types of Rhinitis?

Allergic Rhinitis

Viral Rhinitis

Vasomotor Rhinitis

Rhinitis Medicamentosa

Nasal Polyps

What is allergic rhinitis?

"Hay fever"

Allergic rhinitis sxs are similar to?

Viral rhinitis

Allergic rhinitis has an association with what?

Asthma

What is the etiology of allergic rhinitis?

Allergens like pollens, flowering plants & grasses, ragweed, molds, dust & household mites

What are sxs of allergic rhinitis?

Sneezing, rhinorrhea, nasal obstruction, postnasal drainage & itching of the eyes, nose & palate

What are the insidious effects of allergic rhinitis?

Fatigue, irritability, reduced performance at school & work & depression

What are clinical findings of allergic rhinitis?

Rhinorrhea

Eye irritation (pruritus, erythema, tearing)

Pale or violaceous mucosa

When during the year is allergic rhinitis the worst?

Spring or fall

Usually follows a seasonal pattern

What cells are found in the nasal dc or serum in allergic rhinitis?

Eosinophils

What is the tx for allergic rhinitis?

Oral antihistamines (brompheniramine, allegra, xyzal, clarinex)

Antihistamine sprays (Astelin)

Intranasal corticosteroids (Flonase, beclomethasone, flunisolide)

What are other txs for allergic rhinitis?

Leukotriene receptor antagonists (montelukast, singular)

Intranasal ipratropium bromide

Nasal saline irrigation

How long do intranasal corticosteroids take to work & what do they do?

Takes 2 or more weeks to work & shrinks nasal polyps

What allergic rhinitis tx can you develop tolerance to?

Antihistamines; will have to change which one you are taking after a while

What is viral rhinitis?

The "common cold"

Benign & self-limited

What conditions can viral rhinitis cause?

Bacterial sinusitis

Acute OM

Asthma

Bronchitis

CF exacerbation

What are sxs of viral rhinitis?

Clear rhinorrhea, nasal congestion, decrease in sense of smell, sneezing, general malaise, throat discomfort & HA

What is the pathophysiology of viral rhinitis?

Infection, inflammation, mucosal swelling & increased mucous production

What are PE findings of viral rhinitis?

Edematous, erythematous nasal mucosa

Watery dc

Is there a curative tx for viral rhinitis?

No, Rx is symptomatic

What is the tx for viral rhinitis?

Pseudoephedrine, afrin nasal spray

Tylenol, ibuprofen

Intranasal ipatropium bromide (Atrovent)

Abx use discouraged

What are some complications of viral rhinitis?

Middle ear effusion, Eustachian tube dysfunction

Secondary bacterial infection leading to OM

What is vasomotor rhinitis?

Non-allergic & chronic in nature

Dx of exclusion

What is the etiology of vasomotor rhinitis?

Increased sensitivity of vidian n. in the pterygoid canal b/c of warm or cold air, odors or scents, light or particulate matter

What is the most common cause of clear rhinorrhea in the elderly?

Vasomotor rhinitis

What is the tx for vasomotor rhinitis?

Intranasal steroid sprays are the best (flucticasone)

Nasal anticholinergics (atrovent & astelin)

Tx is difficult

What is rhinitis medicamentosa?

Chronic inflammatory condition

What are the clinical manifestations of rhinitis medicamentosa?

Hx of chronic decongestant nasal spray use or cocaine use

Presents w/ c/o nasal obstruction

What are PE findings of rhinitis medicamentosa?

Erythema, edema & clear rhinorrhea

What is the tx for rhinitis medicamentosa?

D/c topical nasal decongestant

Nml saline nasal gtts QID

Nasal steroid spray BID

PO corticosteroids

What are nasal polyps?

Pale, edematous masses covered with mucosa

What pts commonly have nasal polyps?

Pts with allergic rhinitis & CF

What are clinical manifestations of nasal polyps?

Nasal obstruction, diminished sense of smell & pale, blue edematous masses

What is the tx for nasal polyps?

Nasal steroids (1-3 months)

Oral steroids (short course of prednisone)

Surgical removal if failed medical management or larger polyps

Avoid ASA b/c can lead to ASA triad

What are the types of epistaxis?

Anterior nose bleed

Posterior nose bleed

What is epistaxis & the etiology/predisposing factors?

"Nose bleed"; caused by digital manipulation, nasal trauma, rhinitis, low humidity, HTN, nasal cocaine use or EtOH

What is the common site of nose bleeds?

Kiesselbach plexus (anterior)

Only 5% from sphenopalatine artery (posterior)

What is the tx for anterior epistaxis?

Lean forward & direct pressure to area x 15 minutes

Topical nasal decongestants (Phenylephrine - anesthetic & vasoconstrictor, Afrin - topical decongestant and anesthetic)

Topical cocaine 4%

What are other tx options for anterior epistaxis?

Cautery w/ silver nitrate, diathermy or electrocautery

Anterior packing or nasal tamponade (rhino rocket, Meroe last tampon - f/u in 24 hrs)

Posterior packing (but more difficult)

Treat HTN

What is the most common site of posterior epistaxis?

Posterior to the inferior turbinate from the sphenopalatine artery

What is posterior epistaxis frequently associated w/?

HTN & pts on blood thinners

Who does posterior epistaxis usually occur in?

Elderly

What is the tx for posterior epistaxis?

Posterior nasal packing and usually hospital admission for monitoring

What are some uncommon nasal disorders?

Vestibulitis & rhino mucormycosis

What is vestibulitis?

Inflammation/infection of the nasal vestibule

What is the etiology of vestibulitis?

Staph aureus from folliculitis

What is the tx for vestibulitis?

Mupirocin (Bactroban)

Systemic abx (dicloxicillin 500 mg QID, Bactrim DS BID, Rifampin 600 mg once a day)

I&D furuncle if present

What is the tx of choice for vestibulitis?

I&D

What is a complication of vestibulitis if not treated appropriately?

Retrograde infection via cavernous sinus into the cranium

What is rhinocerebral mucormycosis?

Rare but serious opportunistic infection of the sinuses & brain

What is the etiology of rhinocerebral mucormycosis?

Saprophytic fungi

What pts usually have rhinocerebral mucormycosis?

Immunocompromised pts (DM, ESRD, BM transplant, AIDS)

Sxs of rhinocerebral mucormycosis is similar to what?

Bacterial sinusitis

What are the sxs of rhinocerebral mucormycosis ?

Facial pain more severe

Palate/nasal mucosa w/ black, necrotic eschar

Cranial neuropathies

How do you dx rhinocerebral mucormycosis?

Nasal or sinus biopsy

What is the tx for rhinocerebral mucormycosis?

Medical & surgical emergency

Debridement & Amphotericin B (anti-fungal)

What is the mortality rate for rhinocerebral mucormycosis?

20% or above

What are clinical features of a nasal fx?

Hx of trauma

Pain

Epistaxis

Nasal obstruction

Periorbital ecchymosis

Edema

What are PE findings of a nasal fx?

Must visualize nasal septum to r/o septal hematoma (immediate ENT referral if present b/c can lead to tissue necrosis)

Assess nasal deformity

Do not overlook other injuries

How do you dx a nasal fx?

Nasal XRs

CT of the face to r/o Le Fort Fx

What is the tx for a nasal fx?

Manage hemorrhage 1st

Topical vasoconstrictors

Reduction

Plastics or OMF referral

What are the complications of a nasal fx?

Septal hematoma

Saddle nose deformity from hematoma

Unmanageable/uncontrollable hemorrhage

What are some nasal tumors & granulomatous dz's?

Malignant nasopharyngeal & paranasal sinus tumor

Inverted papilloma

Wegener's granulomatosis