Chapter 25 Dains Nasal Symptoms and Sinus Congestion

What color is your nasal drainage?

Acute rhinitis-watery, profuse, early then becomes more mucoid and purulent. Primary viral or secondary bacterial infection-purulent discharge Color is not diagnostic.

Is the symptom on one side or both?

Bilateral-infectious rhinitis and allergic rhinitis Unilateral-anatomical cause (polyps, deviation, choanal atresia, FB).

Key questions: What symptoms will help me narrow the possibilities?

Can you describe your symptoms? Do you have pain? Where? How long have symptoms been present? Do they occur any particular time of year? History of nasal problems? Family history of allergies or asthma? Acute sinusitis-abrupt onset of infection of one or more paranasal sinuses; occurs when sinus ostia obstructed usually after URI. Sore throat, postnasal drip, facial/tooth pain, HA over sinus, morning periorbital swelling, fever, malaise. Acute sx of rhinitis or sinus congestion-lasts 48-7hrs. Caused by edematous mucosa obstructing sinus ostia. Systemic sx-fever, myalgias, chills and acute infectious rhinitis usually caused by rhinoviruses or parainfluenza virus. Acute epistaxis-trauma, temp change or humidity change, rhinosinusitis infection Chronic sx-caused by prolonged obsturction of osteomeatal complex leading to ciliary dysfunction and movement of mucus. Local factors of obstruction-adenoid hypertrophy, conchae bullosa, polyps, FB, nasal deviations. Adults w/sx >3weeks-have upper molar pain or HA, post nasal drip, nausea. Chronic rhinitis is rarely infections. In children-chronic >30 days Adults sx-prolonged nasal congestion and fcial pain. Children rarely complain of HA or facial pain. Ethmoid sinusitis-referred pain to vertex, forehead, occipital/temporal. Sphenoid-pain to top of head. Suspect allergic rhinitis-season nasal symptoms, sneezing, itching burning eyes.

Is there systemic disease present? Have you noticed other body symptoms? Do you have chronic health problems?

Decreased mucociliary clearance-CF, ciliary dyskinesia, immunoglobulin deficiency. Increased risk of sinusitis with DM, leukemia, AIDS, CF Nasal symptoms-horner syndrome, neoplasm, granulomatosis disorder

Differential Diagnosis: Rhinitis medicamentosa

Drug induced rebound congestion from long term use of nasal decongestants. Abolished after admin of reserpine.

Focused physical exam: transilluminate sinuses

Frontal-place light below supraorbital rim. Maxillary-over infraorbital rim and block light with hand. Light passes through air filled sinuses. Normal results of frontal sinuses rules out fronal sinusitis 90%.

Do you smoke? Are you exposed to smoke? Recent head or facial trauma? Have you been diving or swimming? Exposure to infections in day care, school, or work? Are you pregnant?

Increased sinusitis risk with smoking-more tenacious mucus and temporary ciliary paralysis. Secondary exposure-increased risk of upper and lower resp tract infections. Trauma-80% of head injuries involve paranasal sinuses. Diving/swimming-secondary to barotrauma, infection from contaminated water, allergic response to chlorine. Viral infections increased when children exposed to other children. Droplets or contaminated objects. Normal pregnancy changes-nasal congestion.

Key questions: Do your symptoms change with position? Do you have a history of sinus problems?

Maxillary sinusitis-worse with bending/leaning forward. cough worse when lying down from postnasal drainage

Focused physical exam: condition of nasal mucosa and turbinates

May need topical vasoconstrictive to see middle meatus. Infants and children-nares open forward. Tilt nose up with thumb to inspect. Allergic rhinitis-pale, swollen, wet turbinates. May produce violet colored mucous membrane. Acute coryza (acute rhinitis) or hay fever-inflamed mucous membranes. Ulceration with drug use.

Focused physical exam: Inspect for masses

Polyps-skinned grapes, bilateral, hang from middle turbinate into lumen. Septal deviation-predispose to infection; obstruction. Squamous cell carcinoma usually unilat. Meningocele-masses that increase in size and pulsate w/valsava.

Is the patient using drugs that would cause nasal congestion? Are you using nasal sprays or drops? Cocaine/other illicit drugs? What other medications are you taking?

Rebound nasal congestion or vasodilation if sympathomimetic sprays or drops >1 week. Inhaled drugs-conjunctivitis and irritation of eyes. Rebound nasal congestion with cocaine use. Oral contraceptives, phenothiazines, ACE inhibs, B-blockers cause nasal congestion.

Do you have other acute symptoms-cough, fever, muscle aches? Do you have other chronic symptoms-eye pain, bad breath, fatigue?

Seropurulent drainage-acute bacterial infection of nasal and sinus mucosa. Acute rhinitis-bacterial or viral; systemic symptoms-fever, myalgia, chills. Allergic rhinitis-sneezing, nasal congestion, clear and profuse rhinorrhea, pruritis of nose, palate, pharynx, middle ear. Eye-conjunctival irritation, itching, erythema, tearing. Ear-fullness with popping. Sinus-pressure/pain of cheeks, forehead, behind eyes. Acute sinusitis in children-presence of sx for <30 days, persistent cough, fever >102.2 > 3 days, malodorous breath.

Most common organism in bacterial sinusitis in adults and children:

Streptococcus pneumoniae H. Influenzae

Differential Diagnosis: Infectious rhinitis

acute condition usually w/history of URI. Definitive sign-yellow or green purulent discharge and red nasal mucosa

Focused physical exam: VS

afebrile/low grade fever-acute viral rhinitis or acute sinusitis Allergic rhinitis-afebrile

Labs and Diagnostics: nasal endoscopy

allows direct view of nasal passages, larynx, pharynx, and surrounding tissue.

Focused physical exam: examine lungs

assess breath sounds

Focused physical exam: neuro testing if indicated

assess if severely ill. Cavernous sinus thrombosis-rare but severe complication of sinusitis; located at base of skull and drain venous blood from facial veins. CN affected-III, IV, V, VI.

Differential Diagnosis: nonallergic rhinitis

associated with eosinophilia on nasal smear. diagnosis based on nasal cytology and symptoms similiar to allergic rhinitis w/o identifiable allergen. History shows ASA or NSAID intolerance and rhinorrhea.

Differential Diagnosis: nasal or sinus obstruction

associated with history of ASA intolerance of asthma w/polyps. acute suggest edema from infection, allergic response, irritant exposure, FB (children).

Focused physical exam: presence and color of discharge

bacterial sinusitis-pus in ostium of middle turbinate CSF drainage-increases in forward position. Test for glucose and protein. Sinusitis of dental origin-foul smelling Foreign body-foul smelling unilateral purulent drainage

Differential Diagnosis: chronic sinusitis

can be caused by incompletely treated acute sinusitis. peristent symptoms of lowgrade infection and intermittent acute exacerbations of typical acute sinusitis. recurrent and not controlled OTC/nonpharm. Most common organism-moraxella catarrhalis, H. influenzae, S. pnuemoniae. Dx requires CT w/mucosal thickening of 5mm or greater.

Focused physical exam: Mouth and teeth

check for abscesses in 1st and 2nd maxillary molars especially. TEnderness w/tapping on maxillary teeth with tongue blade-dental root infection or maxillary sinusitis. Lymphoid hyperplasia-"cobblestoning"; posterior pharynx w/chronic allergies. Children w/acute viral rhinitis-mild erythema of tonsils and posterior pharynx.

Differential Diagnosis: osteomyelitis of frontal bone

complication of sinusitis. children and young adults following head trauma or scuba diving. Staphylococcus pyogenes or anaerobic streptococci. Severely ill and edema of upper eyelid, puffy swelling over frontal bone. Dx-radiography and blood culture.

Labs and Diagnostics: allergy skin testing

confirm antigens responsible for allergic rhinitis.

Differential Diagnosis: allergic rhinitis

distinguished by-recurrent rhinitis with clear, watery mucus, sneezing, pruritis. Pale and swollen nasal turbinates. family history of allergies. Seasonal allergies-short burst of intense exposure consistent with histamine-mediated response. Critical in diagnosis-history or pattern of symptoms.

Focused physical exam: Regional exam of head/neck

eyes (including acuity), ears, cervicofacial nodes Complications of severe fulminant sinusitis-rare; caused by direct infection spread, secondary to destruction of wall between sinuses and orbit. Sx-sudden increase in pain, edema of eyelids, periorbital edema and erythema, decreased visual acuity, diplopia, displacement of eye laterally. Coryza(acute rhinitis) ear and eye drainage Erythematous TM w/acute viral rhinitis

Paranasal sinuses:

frontal ethmoid maxillary sphenoid

Focused physical exam: palpate and percuss frontal and maxillary sinuses for tenderness

frontal sinus-pressure over eyebrow or slightly upward under brow. Direct percussion for tenderness over affected sinus.

Focused physical exam: general inspection

general appearance mental status immediate referral-severe, unremitting new onset HA, vomiting, altered LOC

Early summer:

grass pollen

Rhinitis:

inflammation of mucous membranes; caused by bacterial or viral infection, response to allergens, meds, or extreme temperatures.

Chronic sinusitis:

long episodes of inflammation or repeated infections. Non relieved. Cold that doesn't go away, eye pain, halitosis, chronic cough, fatigue, anorexia, and malaise.

Labs and Diagnostics: Nasal smear

looks for eosinophils for allergic rhinitis.

Most common sinus cavity in children:

maxillary and ethmoid

Epistaxis:

most before age 10 and between 45-65 years. causes: trauma, mucosal changes from fluctuations in temp and humidity, anticoag therapy.

Differential Diagnosis: nasal polyposis

multiple causative factors-asthma and ASA intolerance. translucent, grapelike. mobile, rarely bleed, and prolapse. biopsy if suspicious.

Labs and Diagnostics: Sinus radiographs

not routine; done with severe symptoms and treatment failure. Can cause orbital cellulitis, brain abscess, osteomyelitis, cavernous sinus thrombosis. 4 views-anteroposterior (caldwell) of ethmoid, (Chamberlain) of frontal, lateral of sphenoid and frontal, occipitomental (waters) of maxillary

Labs and Diagnostics: sinus aspiration

only way to confirm bacterial;

Nasal turbinates:

promote turbulent airflow that allows matter to fall to mucosa then swept away by ciliated cells to nasopharynx.

Differential Diagnosis: acute sinusitis

purulent nasal discharge, postnasal drip, localized facial pain over sinus involved. Follows viral URI. Children-halitosis, reduced smell, morning cough w/o pain. Pain w/palpation and w/forward bending. Purulent discharge. Ciliary function impaired with infection and not restored for 2-6 weeks. Dx in children requires 2/3 major critera (cough, purulent nasal discharge, purulent pharyngeal discharge, drainage) or 1 major/1 minor (sore throat, wheezing, foul breath, facial pain, periorbital edema, HA, earache, fever, toothache)

Labs and Diagnostics: CT

shows air, bone, and soft tissue. Done with chronic sinusitis.

Rare sinus cavity:

sphenoid

Focused physical exam: test for smell

test each nare separately. Severe nasal congestion or ethmoid sinusitis-anosmia (loss of smell)

Early spring allergies:

tree pollen

Labs and Diagnostics: MRI

used for soft tissue of face and neck especially with neoplasms.

Early fall:

weed pollen

Focused physical exam: test for facial fullness and pressure

worse when bending from waist or w/valsalva maneuver