Nasopharynx - pathophysiology and treatment

What is the most common type of acute sinusitis?

Acute maxillary sinusitis

How does acute maxillary sinusitis occur?

Mucosa of sinuses swells and leads to blockage of drainage foramen

What can inflammation of sinuses be due to?

Common cold, flu or allergic rhinitis

What can stasis of mucous in sinuses lead to?

Secondary bacterial infections

What are the symptoms of the acute maxillary sinusitis?

Discomfort or pain around base of eye and discomfort with teeth, particularly when chewing

What are symptoms of acute maxillary sinusitis often related to?

Relationship with other structures within the skull - sinus forms base of eye socket and floor of sinus connects to roots of second premolar tooth and first two molar teeth

What is the second most common form of sinusitits?

Sinusitis due to obstruction of drainage of frontal and ethmoid sinuses

How does obstruction of drainage of frontal and ethmoid sinuses occur?

Mucous secretions accumulate and form a mucocele

What are the symptoms of sinusitis associated with obstruction of drainage of frontal and ethnoid sinuses?

Pain above the eyes (frontal sinuses) and/or around the nose (ethnoid sinuses), skin over skull may be tender under light pressure and if pain when leaning forward (frontal sinuses)

What is the nature of acute sinusitis?

Self-limiting condition - takes 2-3 weeks to resolve

What is often needed for acute sinusitis due to it being an uncomfortable condition?

Symptomatic relief

What can the headache associated with acute sinusitis be treated with?

Simple analgesics - paracetamol, aspirin or ibuprofen

What can be used to treat nasal congestion in sinusitis?

Systemic decongestant pseudoephedrine or topical decongestants e.g., ephedrine, oxymetazoline and xylometazoline

What is a problematic side effect of topical sympathomimetic nasal decongestants?

Rebound congestion upon withdrawal if used for more than 7 days and tolerance can develop

What is an example of a topical sympathomimetic nasal decongestant?

Xylometazoline

What patients should topical sympathomimetics be used in caution with?

Diabetics, hypertension, hyperthyroidism, ischaemic heart disease, closed angle glaucoma and prostatic hypertrophy

What is a downside of pseudoephedrine?

Not as effective as topical decongestants

What is a benefit of pseudoephedrine?

NO rebound nasal congestion on withdrawal of therapy

What are the cautions of pseudoephedrine?

Weak sympathomimetic agent so same cautions as topical nasal decongestants

What are patients treated with for acute bacterial sinusitis if they have had the symptoms for less than 10 days under pharmacy first?

Self-care measures and pain relief

What are patients treated with for acute bacterial sinusitis if they have had symptoms for 10 or more days and are not getting better under Pharmacy first?

High dose nasal corticosteroid for 14 days - fluticasone or mometasone

What should be prescribed if a high dose nasal corticosteroid is unsuitable for acute bacterial sinusitis under Pharmacy first?

Antibiotics prescribed e.g., phenoxymethylpenicillin or clarithromycin if pen. allergic

What can chronic sinusitis be caused by?

Nasal polyps or chronic inhalation of irritants

What are nasal polyps?

Overgrowths which are lined with respiratory epithelium and contain seromucous glands, goblet cells and inflammatory cells

What are chronic inhalation of irritants as a cause of chronic sinusitis?

Initial toxic allergic reaction to inhalant becomes chronic, thickens mucous membrane

What should happen for patients with suspected chronic sinusitis - repeated or untreated bouts of acute sinusitis?

Referral to specialist in nasopharynx for long term treatment

What is another name for nose bleeds?

Epistaxis

What are the main causes of nose bleeds?

Trauma from nose picking, blow to the nose or acute rhinitis

What is the usual site that nose bleeds occur from?

Anterior septum (Little’s area)

How can nose bleeds be managed?

Pt leaning forward, pinching fleshy part of the nose and allowing blood to clot - avoid blowing nose for a few afters after

What conditions may require nasal packing or cautery of bleeding blood vessel in nose bleeds?

Pts with bleeding disorders e.g., haemophilia and those taking anticoagulants - both can prolong bleeding

When should patients be referred for nose bleeds?

If nose bleed doesn’t settle within 10 mins or so of beginning - go to A&E

What are the most common type of nasal tumours?

Sinonasal papillomas - benign

What age group are sinonasal papillomas most common in?

Men over 60

How are sinonasal papillomas treated?

Total excision

What can inverted papillomas turn into if left untreated?

Frank carcinoma

What is the common cold caused by?

Rhinoviruses, adenoviruses, coronaviruses, respiratory syncytal virus (RSV), parainfluenza

What are the clinical signs of a cold?

Rhinorrhoea (runny nose), nasal obstruction, sneezing, pyrexia, myalgia

What is the pathogenesis of a common cold?

• Nasal mucosa becomes thickened, oedematous and reddened

• Nasal cavities narrowed and conchae becomes enlarged

• Mucous contains dead epithelial cells in first 2-3 days that contains viral inclusions - necrosis of these leads to fluid exudation and mucous

How are colds treated?

Symptomatic relief using analgesics for headache, pyrexia and myalgia and congestion by topical or systemic decongestants

What is sneezing associated with in colds?

Shedding of dead epithelial cells, will lessen as cold progresses

What are the common symptoms of allergic rhinitis?

Sneezing, itchy nose and palate, running nose, nasal congestion, red, watery itchy eyes that are bilateral, disturbed sleep and tiredness and listlessness

What do symptoms of allergic rhinitis that last less than 4 weeks or 4 days indicate?

Intermittent/seasonal allergy e.g., hayfever

What are the different hayfever seasons?

• Tree pollens from February onwards

• Grass pollen appears from April/May-end of summer

• Seeds from weeds that flower appear later in summer

When may hayfever symptoms be asymptomatic?

Days where there is little wind or wet days

What do symptoms of allergic rhinitis lasting longer than 4 weeks or for more than 4 days indicate?

Perennial allergy - dust mites, mite faeces and pet dander

What is a very effective non-pharmacological treatment of allergic rhinitis?

Avoiding the allergen!

What are the non-pharmacological methods of treatment for hayfever?

• Remain indoors if possible when pollen counts are high

• Keep doors and windows closed

• Avoid obvious areas where pollen may be present e.g., parks, fields especially after grass cut

• Wear sunglasses when outside and wash face and hands when indoors

• If pets go outdoor wipe down their fur when they come back in the house

What is some non-pharmacological advice for perennial allergic rhinitis?

Some polyethylene bedding may give some protection but must be robust enough to stand repeated washing, bedrooms/bedding = buildup the most, not enough evidence to support usefulness of measures to avoid allergens

What oral treatments can be recommended for allergic rhinitis?

Oral antihistamines can relieve itchiness, sneezing and rhinorrhoea of allergic rhinitis

What are oral antihistamines not effective for?

Nasal congestion

What can be a side effect of first generation antihistamines e.g., chlorphenamine?

Cause excessive sedation but can be helpful for patients suffering from poor sleep

What oral antihistamines are less likely to cause sedation?

Loratidine, cetirizine, acrivastine

What antihistamine administered as a nasal spray is available to treat allergic rhinitis?

Azelastine

How is azelastine used for seasonal allergic rhinitis?

Begin at least 2-3 weeks before allergen season begins and is quicker to act than oral antihistamines

What can azelastine be used alongside to relieve congestion?

Intranasal decongestants

What are intranasal steroids useful for?

Relieving the sneezing, rhinorrhoea and congestion - less effective against nasal itchiness and should begin 2-3 weeks before allergy season

What corticosteroids are available as intranasal formulations OTC for over 18s?

Beclometasone, budesonide and triamcinolone

What corticosteroids are available as intranasal formulations on prescription?

Flunisolide, fluticasone, mometasone