What is viral rhinitis?

common cold

non-specific illness

• varied pt presentation
• Nasal mucosea will be erythemic & occasionally edematous
• Watery nasal discharge – lack of yellow/green (purulent) discharge

no curative Tx = maily supportive à no value for antiviral chemotherapy

- Edu pts that they do not need an antibiotic -will only develop resistance

- Decongestants – psudoephedrine 30-60 mg q 4-6º prn (or 120 mg BID)

- Nasal prep (careful not to abuse --- no more than 3 days)

     Oxymetazoline (Afrin, Vicks, Sinex); Phenylephrine (Neo-Synephrine

- Fluids, analgesic and anti-inflamm. Meds

bacterial sinusitis;

acute otitis media,

acute exacerbations: asthma, COPD-related,

immunocompromized

What is "Hyposmia"?

(olfactory dysfunction)

– most commonly occurs w/common cold

-          Blockage of the olfaction sensory receptors:  

20% idiopathic

Other causes:

CNS neoplasms, endocrine, Parkinson’s & Alzheimer’s, multiple meds

(T/F)

sinusitis can be referred as rhinitis

(T/F)

Acute sinusistis

is less common than the common cold

-          Follows respiratory illness:

1. Viral or allergic rhinitis
2.  2’ to impaired mucocilliary clearance & obstruction of the osteomeatal complex

• toothacke type pain in maxillary region
• pain and pressure over the cheeks
• less symptoms with frontal and ethmoid/sphenoid sinuses
• change in secretion from watery to purulent  (green or thick yellow) or mucoid discharge

Maxillary sinus

it is an emergency!!!

• Maxillary sinus effected the most
• Dental infections can be the original site of infection
• If ethmoid is infected, will usually also have maxillary infection
•  2’ cellulitis can result
• Sphenoid sinusitis most commonly present in pansinusitis

• S. pnemoniae
• H. influenzae
• less common: S. aureus and M. catarrhalis

Note: 25% of healthy people harbor these bacteria in the sinuses!!!

• imaging not routinely performed
• based on PE and S/Sx
• if needed, coronal CT best viewed
• if suspected malignancy, MRI with galoinium preferred

• 2/3 of untreated pts resolve w/o Tx in ~14 days
• Antibiotics à reduce incidence of clinical failure by 50% for clinically lasting symptoms > 10-14 days
• Symptomatic Tx w/nasal preps & decongestants (oxymetazoline “Afrin”, pseudoephedrine “PSE”)
• ABX duration for 10-14 days: Amoxicillin 500mg PO 3×day; Augmentin 875 mg 2×day
• Penicillin allergy: Trimethoprim-sulfamethoxazole (Bactrim) 160/800 or  Doxycycline 100mg ×2 a day
• Quinolones: Cipro, Levaquin, Avelox, Zegam
• Macrolides: Azithromycin (Zithromax), Clarithromycin (Biaxin)

Recurrent symptoms of acute sinusitis:

• recurrent symptoms do not generally respond well to antibiotics
• Referral to ENT is warranted for recurrent Dz or poor response to appropriate Tx

-          orbital  cellulitis

-    osteomyelitis of the frontal bone from chronic sinusitis

• Intracranial complications are rare: IV cavernous sinus thrombosis, meningitis, intraparenchymal brain abscess

• results from folliculitits of the nasal region:
  • nasal manipilation
  • trimming of nasal hairs

What is a causative agent of nasal vestibulitis?

• Dicloxacillin 250 mg QID × 7-10 days;
• topical mupirocin (Bactroban)

• very rare condition !!!
• Fungus spreads rapidly thru the mucosa and vascular channels:
  • lethal if not treated
  • Immuno-compromised or post bone marrow transplant pts are more susceptible
• Medical and surgical emergency :
• presents a lot like rhinitis and sinusitis à black eschar on middle turbinate
• maintain a high degree of suspicion knowing there is a low likelihood
• Tx with Amphotericin B IV following surgical debridment

• same symptoms as viral rhinitis but last longer and can be seasonal depending on allergic (IgE) sensitivities
  • pollens (spring)
  • grass (summer)
  • ragweed  (fall)
• pale mucosa on nasal turbinates -- yellowish
• nasal polyps

• same nasal symptoms as in viral rhinitis

+

• pale mucosa on nasal turbinates - yellow, boggy, nasal polyps
• eye irritation, tearing, itchy throat, itchy ears and buzzing

• OTC antihistamins:
  • brompheniramine (Dimetapp)
  • chlorpheniramine "Actifed" - PO
  • clemastine "Tavist" - PO
• H1 receptor antagonists:
  • Cetirizine "Zyrtec" - PO
  • Fexofenadine "Allegra" - PO
  • Loratadine "Claritin" - PO
• Nasal spray
  • Levocabastine "Livostin"
  • Azelastine "Astelin"
• Intranasal corticosteroids (mainstay Tx of AR):
  • beclomethasone "Beconase"
  • flunisolide "AeroBid"
  • mometasone furoate "Nasonex"
  • fluticasone propionate "Flonase"
• leukotriene inhibitors
  • montelukast "Singulair"
• mast cell stabilizers
  • cromolyn sodium
• maintain allergy free environment

• pale, edematous, mucosal covered masses
• seen in pt with allergic rhinitis

• Anterior portion of the nose
• Kiesselbach's plexus

• nasal trauma: nose picking, forceful nose blowing or sneezing
• rhinitis
• dry mucosa
• deviated septum
• anticoagulant use

1. anterior ethmoidal (ophtalmic)
2. posterior ethmoid (opthalmic) -- NOT in Kiesselbach's  plexus
3. sphenopalatine (maxillary)
4. greater palatine (maxillary)
5. branch of superior labial (facial)

• determine site: anterior or posterior...
• if cannot see any site of bleeding, inspect the oropharynx (pt should be sitting upright)

• 1st onset - apply direct pressure to the nares (pt in sitting position, head leaning fwrd to prevent aspiration)
• topical nasal preps:
  • Phenylephrine (Neo-Synephrine)
• Vasoconstriction agent:
  • Cocaine 4% (topical, cotton ball/gauze) or oxymetazoline (Afrin)

• pack with sponge product MeroCel or balloon of ther products
• control anterior sites with cautery (electrocatery or chemical catery-Silver Nitrate Sticks)
• if pt has HTN, get BP under control!

refer to ENT

- some sites need to be cauterized or ligated to prevent further bleeding -

epistaxis, pain, soft tissue hematoma

Note: septal hematoma can cause erosion of septal cartilage - saddle-nose deformity

• maintain airway for patency for long term
• closed reduction w/i 1 week of injury
• usually best to wait for swelling reduction
• if suspected septal hematoma, quick referral to ENT for definitive management (I&D, drain)
• plastic surrgery, cosmetic repair

• inverted papilloma - HPV etiology
• juvenile angiofibroma - consider in adolescent males with recurrent epistaxis

• Initially present as allergic / viral rhinitis
• late diagnosis = poor prognosis

• Wegner's Granulomatous - necrotizing granulomatous vasculitis of the upper and lower respiratory tract, glomerulonephritis, and a varialbe degree of small0vessel vasculitis
• NK Cell & T Cell EBV-Positive lymphoma - rare but present in young, most commonly
  Asian pts with non-Hodgkin Lymphoma
• Sarcoidosis - microscopic, inflammatory granules that can occur in tissues and organs anywhere in the body