How long does untreated viral rhinitis last vs treated with antibiotics?
7 days for both
Common presentation of viral rhinitis
CLEAR rhinorrhea, nasal congestion, cough, malaise, and headache
physical findings: erythematous, engorged nasal mucose with no purulent nasal secretions
PURULENT yellow green nasal discharge, facial pressure -
Acute bacterial rhinosinusitis
What presents with associated symptoms of a productive cough and post nasal drip that usually comes from the drainage of the posterior ethmoids
Acute bacterial rhinosinusitis
To check for infection or fluid in the sphenoid sinus, what view on plane films would show this the best?
LATERAL view is good to view frontal and sphenoid sinuses.
What view on plane films is best to check for posterior ethmoid sinusitis?
What view on plane films is best to view anterior ethmoids, maxillary sinuses, and the turbinates of the noes?
most common causative organisms of acute bacterial rhinosinusitis
strep pneumoniae, H flu, S aureus, M catarrhalis
Treatment for acute bacterial rhinosinusitis
1st line: Amoxicillin 1GM tid 7-10 days
If allergic to PNC: Timethoprim - sulfamethoxazole
If allergic to life: Doxycycline
If patient has been on ABx in the past 3 weeks: Levaquin
Why would you normally need to keep someone on Abx for more than the reccomended 7-10 days for an acute bacterial rhinosinusitis?
Sinuses have poor perfusion so it is difficult to get good penetration of the medication
what is the goal of the symptomatic treatment of acute bacterial rhinosonusitis while waiting for abx?
To break up and thin out the mucous
If patient presents with diplopia and CNS side effects with a history of chronic bacterial rhinosinusitis, what should you consider?
Treatment for nasal vestibulitis
can treat the infected hair follicle with bactroban or dicloxacillin - usually from s aureus. tell patient to stop picking their nose.
What should you see upon inspection of the nose in a patient with epistasis due to some type of trauma?
Kiesselbach's plexus (very prominent blood vessels that are anterior and superficial) - these are usually the source of epistasis
What should you consider before using a cotton ball for packing an anterior nose bleed?
only for mild and low pressure epistasis, should saturate in neosynephrine to provide vaso constriction, and patients age (if a child, increased risk of aspiration)
What is important to consider if you use a nasal tampon for packing epistasis?
MUST give oral Abx- pt is suseptable to sinus (maxillary) infection because they are blocked from being drained. Give 2nd generation cephalosporin.
*LEAVE IN FOR 5 DAYS
- patient need some narcotics and anti-anxiety meds
How would you know if a patient with epistasis was caused by a posterior bleed?
- higher pressure bleed
- probably an underlying cause - can not be packed with typical cotton balls and should be admitted before placing the epistat
what would should you explain to a patient who has experienced a nasal trauma involving their nasal bone and cartilage?
- surgery usually only for function (affect on breathing) or style - but should be done within 10 days of the injury
Clot that has formed in the septum between the cartilage and mucosa of the septum and a saddle deformity of the nose is noted
Septal Hematoma - when a hematoma is not evacuated, the pressure put on that aspect of the septum dies and becomes sunken in (creating the saddle shape)
Treatment for septal hematoma
Incision and drain! Need to get the clot out
What is at the top of your DDx if a patient complains of loss of smell
What is the gold standard for the diagnosis of nasal polyps?
CT of sinuses after visually inspecting the nasal cavity
What approach should be taken in the treatment of nasal polyps resulting from allergies?
Try to control the patients allergic reaction - treat with nasal/oral steroids. Even if surgery is performed to remove them, they will reoccur if allergies are not controlled
How would an inverted papilloma present and what are many of them associated with?
Unilateral obstruction and bleeding - associated with squamous cell carcinoma (so considered a pre-cancerous lesion).
What causes an inverted papilloma and how would you approach treatment?
HPV on the lateral wall of the nose. Lateral maxillectomy (but still very high rate of re-occurrence)
On physical exam, how could you distinguish between an allergic nasal polyp and an inverted papilloma?
Polyps are usually translucent and have a smooth service and have no associated bleeding. Inverted papillomas have a "warty" appearance and are associated with a lot of bleeding.
14 yo boy with severe epistasis for the 3rd time in 1 month. What should you consider?
Juvenile angiofibroma - highly vascular tumor arising from the nasopharynx. Benign but should be resected due to their potential to be very large which can lead to compression and necrosis of the surrounding tissue.
How might nasal malignancies present?
Often manifest as unilateral serous otitis media. See decreased Eustachian tube function, congestion, swelling, and proptosis. Most commonly SCC (very aggressive - tx varies but with stage 4= palliative care)