cdp 3- nose and sinus disorders

Anterior vs Posterior Epistaxis origin

Anterior:

-Originates from Kiesselbach plexus

Posterior:

-Originates from posterolateral branches of sphenopalatine artery in the region of Woodruff's Plexus

Anterior vs Posterior Epistaxis S/Sx

Anterior:

-small volume

-typically unilateral

Posterior:

-large volume

-may be bilateral

Epistaxis tx

1. Pinch nose & lean forward for up to 15 min

2. Use of Oxymetazoline (Afrin) nasal spray x 2

3. Use of chemical cautery (ex: Silver Nitrate)

4. Use of electrocautery (ex: Bovie)

5. Packing (ex: tampon, gauze, or balloon)

-Start unilateral, then add second packing to other nostril if not resolved after 30 min

6. Send to ER for possible surgical management

-Sphenopalatine artery ligation or selective embolization of the affected arteries

Samster's triad is associated with what condition

Nasal polyps

-Samster's Triad: Aspririn sensitivity + Asthma + Nasal Polyp

Nasal Polyps S/Sx

S/Sx:

-Bilateral edematous swellings of nasal mucosa

-Yellow, white, or pink grape-like massess

-Could cause: airway congestion or blockage & Anosmia

Imaging of choice for refractory or unilateral Nasal Polyps

CT

Nasal Polyps tx

1. Intranasal corticosteroids

Ex: Fluticasone Propionate (Flonase)

2. Oral Steroids

Short-term option for severe symptoms only

3. Mepolizumab (Nucala)

Sub Q injectable monoclonal antibody indicated for use in patients with chronic rhinosinusitis and nasal polyps with inadequate response to nasal corticosteroids

4. Surgical excision

May be done earlier for very large polyps

Allergic Rhinitis risk factors

Eczema

asthma

Type 1 Hypersensitivity rxn to allergens

Allergic Rhinitis S/Sx & PE

S/Sx:

--Nasal congestion

-Rhinorrhea

-Post-nasal drip

-Nasal Itching

-Sneezing

-Fatigue

PE:

-Pale or violaceous nasal mucosa

-Cobblestoning of posterior pharynx

-Allergic Salute

-Allergic Shiners

-Dennie-Morgan lines

Allergic Rhinitis Tx

Tx:

-Avoid allergens

-Intranasal corticosteroids/antihistamines

-Oral antihistamines

-Decongestants

Non-allergic Rhinitis is due to

Due to an increase in blood flow to the nasal mucosa due to irritants (but not allergens)

-Rhinitis Medicamentosa (rebound from decongestant drops overuse)

-Drug induced

-Pregnancy

-Gustatory (hot/spicy foods)

-Vasomotor (cold/dry air)

Non-allergic Rhinitis S/Sx & PE

S/Sx:

-Nasal Congestion

-Rhinorrhea

-Post-nasal drip

PE:

-Normal nasal mucosa

-Boggy nasal turbinates

Non-allergic Rhinitis Tx

Tx:

-Correct underlying cause

-Intranasal corticosteroids/antihistamine/anticholinergic

Viral Rhinitis is more common in

children with 6-8 URIs per season

Adults with 2-4 URIs per season

Most common cause: Rhinovirus

Viral Rhinitis S/Sx & PE

S/Sx:

-Nasal congestion

-Rhinorrhea (clear, yellow, or green)

-Sore throat

-Fever

-Sneezing

-Cough

-Headache

PE:

-Fever

-Erythematous nasal mucosa

-Anterior cervical lymphadenopathy

Viral Rhinitis Tx

Tx:

-Supportive

-Tylenol, NSAIDs

Acute Rhinosinusitis definition & most common causes

Inflammation of the nose and sinuses lasting < 4 weeks

-Most commonly a viral cause: Rhinovirus, Influenza, Parainfluenza virus

-If bacterial, most common occurs after a viral infection: S. pneumoniae, H. influenzae, & M. catarrhalis

Acute Rhinosinusitis S/Sx

S/Sx:

-Nasal Congestion

-Purulent nasal discharge

-Facial pain or pressure (worse w palpation & bending forward)

-Fever

-Hyposmia or Anosmia

Acute Rhinosinusitis viral vs bacterial dx

Clinical diagnosis

-Acute Viral: <10 days & sx NOT worsening

-Acute Bacterial: >10 days w biphasic pattern or no improvement

Acute Rhinosinusitis viral vs bacterial tx

Tx:

-Acute Viral: Sx management

-Acute Bacterial: Sx management + abx 5-10 days

-Amoxicillin-clavulanic acid (Augmentin)

Chronic Rhinosinusitis definition and most common causes

Inflammation of the nose and sinuses for > 12 weeks

-Most common pathogens in immunocompetent patients are S. aureus and P. aeruginosa

-Most common pathogens in immunocompromised patients are Aspergillus, Fusarium, Mucorales, and diatomaceous molds

Chronic Rhinosinusitis S/Sx

S/Sx: (same as acute condition)

-Nasal Congestion

-Purulent nasal discharge

-Facial pain or pressure (worse w palpation & bending forward)

-Fever

-Hyposmia or Anosmia

Chronic Rhinosinusitis diagnostic criteria

Must have at least 2 of the 4 cardinal symptoms for at least 12 consecutive weeks:

-Nasal congestion

-Purulent nasal drainage

-Facial pain/pressure

-Hyposmia/anosmia

Plus, objective evidence on physical examination or CT of the paranasal sinuses

-Mucopurulent drainage

-Edema of the nasal mucosa

-Polyps in the middle meatus

-Mucosal thickening within the sinus

Chronic Rhinosinusitis tx

Tx:

-Reduce modifiable risk factors

-Intranasal corticosteroids (fluticasone) & nasal saline irrigation 1-3mo

-Endoscopic sinus surgery if failed tx