Common nasal and sinus problems topics

nasal and tumor polyps DD

(1) benign or malignant polyps (2) granulomatosis with polyangiitis (GPA) (Wegener granulomatosis) Systemic vasculitis of unknown cause Glomerulonephritis + granulomas of nose and lung (lymphomas and carcinomas) Can also effect skin, eyes, heart, GI, nervous system, MSK Prognosis 1 year after dx unless identified and treated early saddle nose deformity** (3) mucoceles (4) granulomas without systemic involvement.

Management of congestion

-management depends on cause -benign viral: -bulb syringe cleanses passagway in infant -neti pot -alternative: acupuncture -intranasal zinc: associated with loss of smell -prevention: -oral zinc BUT causes nausea -probiotics prevent URI (evidence inconsistent) -ginseng, garlic, vit C, echinacea -no benefit -handwashing**

Common causes of nasal congestion

-presentation depends on etiology -virus most common -rhinovirus, coronavirus, RSV -children can have 6-8 (up to 12) URI/ common cold a year -avoid unnecessary use of abx - have good abx stewardship

idiopathic rhinitis complications

-sleep distrubance -diminished QOL

Anatomy of nose and sinuses

-smokers: dysfunctional cilia -CF, allergies, ASA sensitivity, asthma -genetics -pregnancy and hormonal state -infectious, immune or environmental factors

AIT

AIT • AIT is a treatment option for allergic disease including food allergy. In patients with life-threatening reactions to foods or severe allergic asthma, treatment with AIT may negate the need for epinephrine and improve the quality of life for these patients • Generally considered in AR if symptoms present for >6 mos with severe symptoms not responsive to traditional treatments • AIT includes subcutaneous immunotherapy (SCIT), oral immunotherapy (OIT), epicutaneous immunotherapy (EPIT), and sublingual immunotherapy (SLIT). • SQ injections administered weekly at progressively increasing doses until maintenance dose achieved; then given monthly •OIT has most AE but has best results with food allergens • goal of AIT is to induce immune tolerance and cause a change in the immune response to specific antigens and also produce longer-lasting benefits without the need for daily medication. •The mechanism of action for immunotherapy is centered on modulating the immune response, changing IgE that is allergen specific to IgG4, and to decrease basophil action to allergen cross-linking, causing an increase in regulatory T cells. Desensitization occurs after months of AIT. •AIT can induce adverse reactions that can be local, such as tingling following sublingual therapy, to systemic reactions that are life-threatening; monitor for 30 mins post and ensure carries EpiPen •Omalizumab in patients older than 12 years old with inadequately controlled and significant AR noted significant symptom relief and improved quality of life

idiopathic rhinitis

Aka nonallergic or vasomotor rhinitis

disorders of smell

Anosmia: loss of sense of smell Parosmia: smell distortion Hyposmia: diminished sense of smell

Epistaxis

Anterior (95%): From littles area where Kiesselbachs plexus is The blood supply of the Kiesselbach area comes from branches of the internal carotid, which break up into the facial and internal maxillary arteries, which supply most of the face. Two of the six branches of the internal maxillary artery, the palatine and sphenopalatine arteries, supply 80% of the blood supply with an additional 20% coming from the facial artery This plexus in vulnerable and easily injured Posterior (5%): Posterior branches of the sphenopalatine artery

epistaxis presentation

Anterior: unilateral with continuous moderate bleeding +/ small clots Posterior: bilateral, severe bleeding with bleeding into pharynx

Idiopathic rhinitis treatment

Avoidance of triggers Saline irrigations Oral decongestants (avoid regular use of topical due to rebound congestion) Immunotherapy and antihistamines ineffective Refer to allergist or immunologist PRN

Pharmacological NAR

BB, ACEI, chlorpromazine, estrogen, OCP Tx: DC med

Bacterial infectious rhinitis

Bacterial: Originates from allergic or viral swelling of the nasal mucosa inhibiting drainage from the sinuses Traps microorganisms in warm, dark, moist environment Hard to distinguish viral from bacterial; bacterial usually only recognized after secondary sinusitis develops

CRS

CRS inflamed mucosal lining of the nasal passages and paranasal sinuses occurring for 12 weeks or more.

nasal trauma DI

CT: extensive head trauma X-ray: nasal bone only HOWEVER rarely provide more than physical exam alone and not recommended unless suspect extensive trauma beyond simple nasal fracture Deferring initial X-ray examination of nasal bones is appropriate and will not influence the plan of care if: tenderness and swelling are isolated to the nasal bridge both nares are patent there is no significant deformity or angulation seen no septal hematoma is present. US highly sensitive and specific but less available

Nasal FB

Can be noticed by caregiver, or be undetected until symptoms arise Classic symptom: unilateral, purulent, foul-smelling nasal discharge If embedded in tissue or mucosa, may look like nasal mass Other symptoms: Mouth breathing, epistaxis, nasal obstruction DD: polyps, purluent rhinitis, adenoiditis, rhinosinusitis, nasal tumors

rhinitis medicamentosa

Chronic administration of sympatholytic drugs, NSAIDs or decongestants (topical) Most common is decongestants: rebound engorgement after use for 1-2 weeks Discontinuing of the offending drug curative Can use 1-2 week course of INCS or systemic steroids during withdrawl period

nasal tumors and polyps complications

Chronic nasal obstruction Olfactory dysfunction Recurrence of polyp or tumor GPA: inability to create remission; fatal if not suspected early (once proteinuria and hematuria develops, progression to renal failure is rapid) Note: morbidity can be from disease or toxicity of treatment

AR classification

Classification: Intermittent if it persists for only 4 weeks or less Persistent if it is present for longer than 4 weeks. Mild: does not impair any of the following four: daily activities, sleep, school or work activities, and the child is not troubled by the symptoms. Moderate to severe, there are changes in one or more of these four items

nasal trauma clinical presentation/ PE

Clinical Presentation/ PE: discern between isolated nasal injury and other conditions (i.e. facial or orbital injury, C-spine injury) loss of consciousness, headache, nausea and vomiting, diplopia, visual changes, facial numbness, prior nasal injury or surgery, and malocclusion or other dental injury periorbital ecchymosis, edema, abrasions or lacerations, epistaxis, or CSF leakage (clear or blood-tinged liquid); trauma to the teeth, neck, or chest; and any obvious deformity Use frontal, worms eye and birds eye view for inspection Assessing patency of airflow through the nostrils can help determine the presence of potential obstruction caused by deviation of a fractured septum, soft tissue edema, or a potential septal hematoma. Palpate dorsum (bridge) of the nose: Deformity, instability, crepitus, and point tenderness. Palpable infraorbital rim for step-off;this indicates a zygomatic complex fracture If orbital involvement is suspected: EOM and diplopia on upward gaze (entrapment of inferior rectus seen with blow out fracture) facial anesthesia (infraorbital nerve injury) Stability of the teeth and palate Intranasal examination with adequate lighting and use of a nasal speculum Septal hematomas will appear as a rounded bluish or purplish mass against the nasal septum and CSF: clear fluid in nasal passage

CRS presentation

Clinical Presentation: Above, also cough, dental pain, fatigue, fever, halitosis, headache

idiopathic rhinitis clinical presentation/ PE

Clinical presentation: Perennial nasal congestion Usually no discharge (if present, is watery, not purluent)** Obstructive symptoms (instead of itching, sneezing and other irritative symptoms that occurs with AR) PE: Erythematous nasal mucosa (instead of pale with AR)

Nasal tumors and polyps presentation

Clinical presentation: Malignant tumors: Asymptomatic until late in course Early: Nonspecific and mimic rhinitis or sinusitis Unilateral nasal obstruction and discharge, pain, recurrent hemorrhage, visual or olfactory changes Benign: Nasal obstruction, discharge, facial swelling Bleed easily and cause recurrent epistaxis Polyps: Nasal obstruction, hyposomnia, anosmia Recurrent sinusitis, headache, postnasal drip Developing: tear drop shaped Mature: peeled seedless grape

disorders of taste/ smell presentation/ PE

Clinical presentation: Most common: loss of taste or smell s/p URI PE: CN I with coffee, isopropyl alcohol, toothpaste CN IX for posterior 1/3 taste, VII for anterior 2/3 taste with sweet, salty, sour and bitter Then focused HEENT and neuro assessment

infectious rhinitis

Coexistent infection present with rhinitis; rhinitis disappears when infection resolved

disorders of taste/ smell complications

Complications: Permanent loss of taste or smell Impacted QOL; depression Loss of appetite and weight loss Decreased sensitivity to harmful substances

CRS complications

Complications: Ulcerations, infections, septal perforation. Nasal inhalation of cocaine is associated with nasal bleeding, nasal congestion, rhinitis, and deviated or perforated septum.

URI complications

Complications: secondary OM, pneumonia, sinusitis, wheezing

AR complications

Complications: sinusitis, eustachian tube dysfunction, malocclusion from allergic facies, chronic cough and post-nasal drip, asthma, pulmonary disease, sleep apnea • note: worse in adolescence to adulthood • note: if move, usually improvement for 1-3 years but will return once becomes sensitized to allergen again

Acute rhinosinusitis

Definition: inflamed mucosal lining of the nasal passages and paranasal sinuses.

Anatomic NAR

Deviated septum, nasal polyps and nasal tumors Older adults: suspect neoplasm Polyps: usually incidental finding in those with asthma or ASA sensitivity Treat cause

ARS diagnosis

Diagnosis: clinical; transillumination or percussion not recommended; imaging (enhanced contrast CT brain) only done if suspecting complications Symptoms worse in am and when bending forward Pain referred through trigeminal nerve (traverse floor of sinus)

AR DI

Diagnostic testing is not needed Nasal cytology (wright stain): Nasal smear via swab or anterior rhinoscopy to looks for eosinophils can help substantiate the diagnosis but is a nonspecific, non-universal finding. The presence of nasal eosinophilia often predicts a positive response to nasal corticosteroid sprays. Serum RAST for food specific allergies Serum ELISA for common allergens Allergen-specific IgE testing done by skin prick testing (SPT) The American Academy of Allergy recently recommended against ordering large panels of allergen testing and stressed the importance of only doing testing for specific allergens by history. Allergy panel can lead to the diagnosis of an allergy that the child does not have and can result in unnecessary avoidance. It can also result in false reassurance in the face of a negative test, when in fact the child's history is positive for an offending trigger.

URI DI

Diagnostics: None (unless presenting with sore throat and no other URI symptoms; do culture to r/o strep)

CRS risks

Dysfunctional cilia as seen in smokers and those with cystic fibrosis Preceding viral, bacterial or fungal infection Allergy, asthma, aspirin sensitivity Genetic factors Immunodeficiency Pregnancy Anatomic problems, including septal deviation, nasal polyps, trauma, FB, or abnormality of the osteomata complex; GERD

disorders of taste/ smell education

Education: Take special care to avoid eating harmful substances CO detector Electric instead of gas appliances

nasal trauma education and age considerations

Education: do not remove dressings or get wet; no swimming; no nose blowing; use face shields and protective head gear for sports Children: not as common as nasal bone composed of cartilage and generally involved in lower risk activities; include abuse in differential Geriatric: Fall risk; investigate co-morbid conditions related to fall; note that ICH can occur without obvious focal neuro signs; any nasal trauma should be referred to ED for further imaging

nasal tumors and polyps DI

Endoscopic evaluation and biopsy gold standard

Episodic AR

Episodic AR occurs with intermittent exposure to an allergen with a resultant rhinitis and is related to a distinct event, such as visiting a house where a cat lives.

ARS complication

Ethmoid: preseptal cellulitis, orbital cellulitis, subperiosteal and orbital abscess, cavernous sinus thrombosis Frontal: intracranial complications including Pott's puffy tumor, epidural abscess, subperiosteal abscess, brain abscess, venous thrombosis, meningitis

Food or drink related NAR

Exact cause unknown; may be cholinergic reaction If allergy, also have GI, derm and systemic involvement Tx: avoidance of trigger food

nasal trauma Tx

Fracture without deformity or hematoma: Ice Elevate HOB Analgesia (Tylenol) Otolaryngology FU in 3-5 days Note: ideally reduced initially, however specialists may prefer to reduce after swelling has subsided in 3-5 days; children should be done in first few days as heal quicker Antibiotics: severe facial and nasal trauma Tetanus if associated wound

nasal tumor and polyps treatment

Glucocorticoids: Nasal topical steroids If not helpful, short course of oral Antihistamines: can be useful for symptom management, but have no effect on the polyp itself Topical intranasal capsaicin - more studies needed Refer to otorhinolaryngologist for surgical removal Note: polyps usually return Malignant tumors need excision Chemo and rad prn Benign can be removed endoscopically GPA: rheumatologist

Nasal tumors and polyps PE

HEENT exam, lymph node exam Nasal speculum exam +/- phenylephrine to improve visualization Note: polyps usually seen bilaterally - if unilateral, further work up needed to r/o neoplasm

disorders of taste/ smell lifespan considerations

Lifespan: Children: sinonasal disorders Teens: head trauma Older adult: normal aging, Alzheimer's or Parkinson's, polypharmacy, nutritional deficiencies

disorders of taste patho

Loss of taste buds with aging Damage to taste receptors from heavy smoking, viruses, medications, chemical exposure, environmental exposure, iatrogenic exposure, radiation Ageusia: disease of chorda tympani or gustatory fibers (rare) Lesions involving sensory pathways to taste centers of brain, or lesions of the taste center in the brain

tumors and polyps of the nose

Malignant tumors: nose, nasopharynx and paranasal sinuses Carcinomas, lymphomas, sarcomas and melanoma Most common: squamous cell carcinoma Benign tumors: inverted papilloma (from common wall between nose and maxillary sinus) Juvenile angiofibroma (highly vascular tumor) Polyps: Inflammatory disorder of nose and paranasal sinuses Pale, edematous masses

ARS management

Management To avoid over diagnosis and to aid in decision-making about when to treat, the AAP developed clinical guidelines for the treatment of ARS based upon three different clinical presentations in children A URI with persistent nasal discharge or daytime cough lasting for more than 10 days without clinical improvement A URI that worsens or there is a new onset of fever, nasal discharge, or daytime cough after initial improvement A fever higher than 102.2°F (39°C) with purulent nasal discharge for at least 3 days in a child who also has sinusitis Watchful waiting for 3 days with analgesics, NSAIDS, oral or topical decongestants, topical nasal steroids, nasal saline; RA after 72 hrs Amoxicillin at a standard dose of 45 mg/kg/day divided in two doses is the first-line treatment in communities with low incidence of non-susceptible S. pneumoniae. In communities with more than 10% of resistant S. pneumonia, amoxicillin should be used at 80 to 90 mg/kg/day divided every 12 hours (maximum dose: 1000 mg/dose). In patients younger than 2 years old, day care attendees, recent antimicrobial use, or in patients with moderate to severe illness, amoxicillin-clavulanate at 80 to 90 mg/day of amoxicillin component divided every 12 hours and only use the 600 mg/5 mL formulation. In children with vomiting, a single dose of 50 mg/kg of ceftriaxone can be given either IV or IM. In patients with allergy to amoxicillin, the type of allergic reaction determines the antibiotic: If the child has a serious type 1 immediate or accelerated reaction, the cephalosporins cannot be used. If they have a non-type 1 hypersensitivity reaction, they can safely be treated with be treated with one of the third-generation, cephalosporin antibiotics—cefdinir, cefpodoxime, or cefuroxime.

Nasal FB management

Management: Properly restrain the child in order to avoid movement during the examination Use a head light or overhead light when possible to free up your hands for examination. Elevate the child's head suction out blood and secretions. Removal of the nasal FB depends on its location, its composition, and the skill of the practitioner. A curette, alligator forceps, suction with narrow tips, and cotton-tipped applicators with collodion with or without topical vasoconstrictor drugs (to reduce swelling) can be used. If the object is small and 5-French catheter with a balloon can be advanced past the FB, the balloon can be inflated and gently withdrawn with the object. A Katz Extractor Otolaryngology referral is merited for young children who cannot cooperate or when the FB is extremely difficult or dangerous to remove, such as paper clips or staples . On a cautionary note, an FB can be forced deeper into the nose if the practitioner is inexperienced at nasal FB removal.

AR Management

Management: Saline irrigation with 100-150mL and positive pressure (+/- magnesium and potassium to promote cellular repair, limit inflammation and reduce apoptosis of respiratory cells) Episodic symptoms: oral or nasal H 1 antihistamines with oral or nasal decongestants if needed Seasonal or perennial rhinitis with mild symptoms: there is no significant difference between inhaled nasal corticosteroids (INCS), oral or nasal H 1 antihistamine, or LTRA Seasonal or perennial rhinitis with moderate to severe symptoms: INCS are the first-line agents with an alternative of oral H 1 antihistamine plus LTRA for patients who do not tolerate the side effects of INCS or who do not want to use the drug. Seasonal: Pharmacologic agents should be started 1 to 2 weeks before pollen season Perennial AR: Start with the maximum recommended dose and then taper to the minimum dose needed to control symptoms.

URI management

Management: Supportive! The following pharmacologic agents may be needed to treat symptoms of respiratory illnesses: • Analgesics and antipyretics: Acetaminophen and ibuprofen may be prescribed for relief of pain or fever. • Decongestant, antihistamines, and cough medicine: The use of decongestants, antihistamines, and cough medicine does not shorten the course of a disease. Due to the risk of overdose, unsupervised ingestions, potential for harm, and little evidence of efficacy, the use of decongestants and/or cough medication is no longer recommended for children younger than 6 years. FDA issued warnings not to prescribe any cold medications containing codeine or hydrocodone to pediatric patients under 18 years of age due to serious side effects, deaths, and addiction potential • Expectorants: Water is one of the most effective expectorants. OTC agents provide some symptomatic relief, but do not shorten the course of respiratory illnesses. Although expectorants like guaifenesin are approved for use in children over 2 years of age, they are not recommended for use in children less than 6 years old- common side effects include gastrointestinal upset, dizziness, and headache • Cough medication: There is lack of evidence to recommend any OTC cough medication for children. The use of honey over the age of 2 years has been suggested by some authors. Recent guidelines on chronic cough of greater than 4 weeks requires further evaluation. Antihistamines and cough and cold medications are not recommended for persistent cough • Zinc and vitamin C: The use of zinc is not recommended in children due to potential side effects and questionable efficacy. Similarly, studies investigating the effect of large dosages of vitamin C in either the prevention or treatment of the common cold have demonstrated little to no benefit • Probiotics: The use of probiotics is being explored as a possible option for prevention of common cold illnesses in young

idiopathic rhinitis patho

NOT immune mediated In response to triggers: Cold air Strong smells Irritants Changes in weather Meds: ACEI, BB Stress Exercise Foods Changes in hormone levels (pregnancy, OCP) Postulated neurogenic cause: parasympathetic control favored over sympathetic control of nasal mucous membranes; underlying cause unknown

URI patho

Once the virus is deposited on the nasal mucosa, it attaches to cell receptors and enters the cells. Potent cytokines including interleukin (IL)-8 attract large number of neutrophil cells by 6 hours after infection. As a result, vascular permeability increases, causing the leak of plasma proteins into nasal secretions. Bradykinins cause the pharyngitis and rhinitis. The presence of polymorphonuclear leukocytes (PMN), rather than bacterial colonization, changes the color of nasal mucus, with yellow to green mucus due to PMN enzymatic activity and yellow mucus caused simply by PMN presence. The presence of neutrophils attracts interleukins 1 and 6, tumor necrosis factor, and chemoattractant ultimately leading to cell death. Adenovirus and influenza have a significant destructive effect on the respiratory epithelium

Oral antihistamines

Oral Antihistamines Oral antihistamines are divided into classes based on the four different types of histamine receptors, each with a varying ability to mediate an allergic response. H 1 and H 2 receptors are found in a variety of cells and cause the early and late phase of allergic response. H 3 and H 4 receptors cause pruritus as well as a proinflammatory immune response. Different classes of drugs may be more effective for different children Second generation antihistamines are particularly effective in relieving symptoms of AR (nasal itching, sneezing, and rhinorrhea) Only required OD dosing Quick relief with 1-2 hr onset Less sedating (except cetirizine) 1st generation have less H selectivity and therefore also have muscarinic effects (constipation, blurred vision, urinary retention) Sedating an can interfere with daytime activities Require dosing several times/ day Reserve for nighttime symptoms Drug dosage may need to be increased until there is relief of symptoms or side effects are experienced. Tolerance to a particular antihistamine can develop necessitating the need to rotate drugs. If side effects with one antihistamine are experienced, prescribe another antihistamine in a different class or one in the same class but with different actions. Note: Although effective at relieving symptoms of AR, not as effective at relieving nasal congestion (especially second generation); can get combo with decongestants (Allegra or Claritin have pseudoephedrine in them) CI HTN, prostate enlargement or narrow angle glaucoma

CRS PE

PE: Each nostril should be carefully inspected with an otoscope and wide speculum while applying gentle pressure to the tip of the nose with the examiner's thumb to widen the nostrils, and then inserting the lighted otoscope. The nasal mucous membranes are inspected for erythema, pallor, atrophy, edema, crusting, and discharge. The mucosa of the turbinate's is often more erythematous in patients with chronic nasal congestion compared with the pale bluish hue or pallor seen in patients with allergic rhinitis.

Epistaxis patho

Patho: Anterior: Irritated mucous membranes or trauma Posterior: idiopathic or vascular disease (not HTN)

disorder of taste

Patho: Hypogeusia: diminished taste Aliageusia: unpleasant taste Dysgeusia: persistent taste Ageusia: absent taste (less common)

ARS patho

Patho: Complication of viral URI due to inflammation of the sinus mucosa obstructing the sinus ostia, nasal polyps, allergic rhinitis, and underlying conditions such as ciliary dyskinesia, CF, and immunodeficiency. Ethmoiditis: after 6 mos (most common) Largest sinus Ostium into the nose superiorly placed so cannot take advantage of gravity Frontal sinusitis: after 10 years old Bacterial: Streptococcus pneumoniae, non- typeable (30%), Haemophilus influenza (20% to 30%), Moraxella catarrhalis (10% to 20%), and rarely by Staphylococcus aureus

Nasal trauma patho and risks

Patho: Due to prominence of the nose on the face and the relative fragility of the nasal bones compared with other facial bone structures. Risk: Blow to the face: MVC, sports injuries, falls, altercations

CRS patho

Patho: Nasal congestion is primarily the result of vascular changes and chronic inflammation in the nasal mucosa induced by a combination of immunologic, infectious, and/or environmental factors. Persistent inflammation impairs sinus drainage.

Allergic rhinitis patho

Patho: There are two phases of the nasal response: The immediate phase occurs 15 to 30 minutes after an exposure to an allergen and is due to mast cell mediator release. In about 60% to 70% of individuals, there is a late-phase response that occurs 6 to 12 hours after exposure and is due to inflammatory cells (i.e., T lymphocytes, basophils, eosinophils) infiltrating the nasal mucosa.

Perennial AR

Perennial AR has year-round signs and symptoms that may be more severe in the winter. Onset can occur before the second year of life, and offending substances tend to be indoor allergens, including house-dust mites, cockroaches, feathers, allergens or dander of household pets, and indoor mold spores and seasonal pollens.

Other NAR

Pregnancy and hypothyroidism Cocaine and atrophic drugs Tx: treat underlying medical problem

ARS presentation

Presents in three ways: (1) onset of severe upper respiratory symptoms, (2) onset of upper respiratory symptoms with persistent symptoms, and (3) a "double sickening" with initial improvement followed by onset of severe disease

ARS prevention

Prevention: allergy and GERD management, flu shot, relief of airway obstruction

Posterior epistaxis management

Refer to ED if not subsided in 15 minutes - extensive packing may be required in ED, OR or specialist office Epistat: Posterior packs with a balloon catheter provide bidirectional pressure to control the bleeding until the patient can be brought to surgery. Arterial ligation or vascular embolization definitive

viral infectious rhinitis

Rhinovirus most common Transmission through direct contact with secretions (usually hand to hand) virus attaches to a variety of cellular receptors Replication causes an infiltration of neutrophils, lymphocytes, and other inflammatory cells cause the mucus-secreting glands within the submucosa to become hyperactive the turbinate's become engorged, and several mediators, including prostaglandins, histamine, interleukins, and tumor necrosis factor, are released Causes rhinorrhea (usually purulent) Coronavirus: Specifically infect the ciliated epithelial cells in the nasopharynx through aminopeptidase N or sialic acid receptors Damage the ciliated cells when the virus replicates, releasing same cascade of mediators as rhinovirus

disorders of smell risks

Risk factors: Aging Tobacco Toxins Medications malignant neoplasms nasal inflammation Infection Malnutrition head or facial trauma Parkinson disease, Alzheimer disease multiple sclerosis Diabetes inflammatory autoimmune conditions

disorders of taste risk factors

Risk factors: Same as smell, but also endocrine dysfunction, anesthesia, malignant neoplasms, head and neck irradiation, procedures, iatrogenic causes, kidney or gastric dysfunction, metabolic or hepatic disorders, environmental exposure, substance use disorder, psychiatric disorders

URI risk

Risk increases with daycare and school attendance (Children have 2-10/year; daycare increases to 14)

epistaxis risks

Risk: <10 or >40 Local predisposing factors: Nasal trauma, rhinitis, drying of the nasal mucosa from low humidity, nasal septum deviation, polyps, hemangiomas, FB alcohol use, and chemical irritants Systemic conditions: Genetic or acquired coagulation disorders, hematologic cancers Medications: nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, chronic use of topical nasal sprays containing corticosteroids or antihistamine decongestants, and topical cocaine abuse Herbal supplements can inhibit platelet aggregation, causing adverse effects with other prescribed medications.

Seasonal AR

Seasonal AR (hay fever or seasonal pollenosis) results from sensitization to airborne allergens, such as tree, grass, and weed pollen (e.g., ragweed) and outdoor molds. There can be geographic variations in seasonal AR depending on climate and when allergens are released into the environment.

nasal trauma complication

Septal hematoma: separates septal cartilage from adherent mucoperichondrial (supplies septum nutrition) Septal cartilage necrosis Saddle nose deformity Septal perforation Septal abscess Requires urgent surgical I&D and packing by ED or otolaryngologist Septal deviation: sinusitis and epistaxis due to blockage of mucociliary clearance Septal ulcers and perforations after repeated trauma

Anterior epistaxis management

Sit up straight, tilt the head forward, and apply firm, continuous pressure for 15 minutes to the anterior aspect of the affected nostril If doesn't work, packing: Merocel: nasal polyhydroxylated polyvinyl tampon that expands when moistened. Rapid Rhino: Coated inflatable balloon to increase the pressure and is effective as a platelet aggregator. There should be minimal packing visible at the nares The packing strings or balloon should be taped to the face to avoid displacement Packing is not removed for 24 to 48 hours. If the bleeding continues, the opposite nostril should be packed in a similar fashion to increase nasal pressure. Observe x 30 mins to ensure no posterior bleeding Vasoconstrictors: Short acting topical nasal decongestants (i.e. oxymetazoline 1-2 sprays; NOT phenylephrine) Topical TXA being researched Topical agents such as BleedCease, WoundSeal, or NasalCease are hydrophilic polymers that form an artificial scab when in contact with blood Cautery: chemical cautery (silver nitrate); high failure rate and can cause atrophy electrocautery After the bleeding has stopped, a small amount of petroleum is applied in the nares Patient is observed for 30 minutes. Antibiotics: There are not any studies to support the use of antibiotics to prevent infection and many providers opt not to treat anterior nasal bleeds with a prophylactic antibiotic Nasal packing: prophylactic antibiotics such as cephalexin (250 mg) 4 times daily or amoxicillin-clavulanate (875 mg/125 mg every 12 hours)

disorders of smell patho

Smelling: odorant molecules taking in through the nose Pass through nasal cavity to cribriform area Soluble in mucous that lies over the dendrites of olfactory receptor cells (CN I) Inability of molecules to reach CN I most common cause Reception barriers: physical barriers (polyps, septal deformities, rhinitis, nasal tumors) or epithelial cell changes (from aging, trauma, chemical or iatrogenic exposure)

AR education: Nasal spray

Specific recommendations for nasal spray application are to: (1) gently blow nose or use saline irrigation to remove excess secretions; (2) have patient lean head forward and look at the floor with the nasal spray aiming nearly vertical; (3) then using the hand opposite the nostril being treated, aim the nozzle slightly up and outward (lateral and cephalad) away from the septum; (4) and spray without sniffing or while sniffing very gently, keeping the medication in the nares, to prevent sucking the medication back into the throat. The medication will not help if in the throat so the patient should understand to gargle and rinse the mouth and throat if that occurs.

tumors and polyps of the nose patho

Squamous cell carcinoma: from keratinocytes of the epithelium From normal skin, preexisting actinic keratosis or leukoplakia Risks: Men, smoking, alcohol, sun exposure Inverted cell papilloma's: From squamous cells in which the epithelium is invaginated into the vascular connective tissue stroma Invasive locally Can involve invasion of orbit or cranial vault Juvenile or nasopharyngeal angiofibroma's: Vascular and may hemorrhage Associated with familial adenomatous polyps Risk: adolescent males with red hair and fair skin Locally invasive to nasal cavity, sphenoid, Para sinuses, extradural Polyps: From MM linings of maxillary sinuses and prolapse into nasal cavity Four types: Antrochoanal: non eosinophilic, unilateral mass Idiopathic: unilateral or bilateral eosinophilic without lower airway involvement Eosinophilic: asthma or ASA sensitivity Polyps with underlying disease: CF, Churg-Strauss syndrome, Kartagener syndrome

CRS DI

The clinical practice guideline for diagnosis of CRS indicates: (1) the necessity of specialist consultation in diagnosing CRS (2) the importance of distinguishing recurrent acute rhinosinusitis from CRS (3) aids in preventing over diagnosis and inappropriate treatment Diagnostics requirements-symptoms are present 12 weeks or more and that two of the following symptoms are present: A diminished sense of smell Facial pain Nasal congestion Mucopurulent drainage. Additional requirements for diagnosis of CRS include (1) confirmation of presence of edema or purulent mucous discharge in anterior ethmoid region or middle meatus (2) nasal cavity or middle meatus polyps, and/or (3) radiographic documentation of paranasal sinuses inflammation. three variants of CRS: CRS with nasal polyposis, CRS without nasal polyposis, and allergic fungal rhinosinusitis. CRP, ESR, Skin and allergic IgE test, serum IgA, IgG and IgM, ELISA, ANA, ACE if looking for underlying cause

URI course

The typical course of these illnesses is an initial low-grade fever with a sore throat that progresses to rhinorrhea, cough, and congestion The average duration is 7 to 9 days the peak is generally on the third day when purulent discharge may be noted. There is a slow resolution with clear nasal discharge by day 10. Most contagious in first 3 days, can shed for 2 weeks Sleep disturbances may occur N/V/D uncommon

CRS types

There are main three variants of CRS: CRS with nasal polyposis CRS without nasal polyposis Allergic fungal rhinosinusitis.

Topical Nasal Antihistamines

Topical Nasal Antihistamines • Azelastine is a nasal antihistamine spray approved for use in seasonal AR in children ≥6 months of age. Azelastine acts by competing with histamine for H 1 receptor sites; it has a bitter taste and is associated with sedation. It is available as a combination with fluticasone propionate and approved for children over 12 years. • Olopatadine is a nasal spray approved for use in children ≥6 years of age. Like nasal azelastine, it is effective in reducing itching, sneezing, rhinorrhea, and congestion

URI transmission

Transmission: hand contact of infected surface to nose or conjunctiva, inhalation of small airborne particles, or deposition of large particles that land directly on conjunctiva or nasal mucosa

CRS treatment

Treatment: CRS w/o polyps: Daily saline irrigations and intranasal corticosteroids Note: topical steroids may be less effective in patients who have CRS without nasal polyps CRS with polyps: sinus surgery to remove polyps Note: recurrent polyps are possible. Immunotherapy and leukotriene modulators: possible considerations, though more research is needed to assess benefit. Oral steroids: used in some situations, but long-term use is concerning because of the associated risks Acute on chronic bacterial sinusitis: "watchful waiting" before treating with antibiotic therapy is advised, as symptoms can resolve within a few days; Antibiotics may be a consideration Referral to an otolaryngologist is necessary for patients with severe congestion refractory to treatment. Allergic fungal rhinosinusitis: surgically and with steroids by the otolaryngology specialists Nasal congestion associated with pregnancy: resolve after delivery Use of saline lavage for symptomatic relief is recommended Intranasal corticosteroid use during pregnancy is labeled Category C. Patients with rebound nasal congestion related to topical decongestant use: will have resolution 2 to 3 weeks after the offending medication is stopped. Children can receive adenoidectomy (reservoir for bacteria) Analgesics: Comfort measures include the use of acetaminophen and ibuprofen for severe pain. Decongestants and antihistamines: There is no randomized controlled trial (RCT) to support the use of topical decongestants. Similarly, there are no data to support the use of either topical or oral antihistamines as an adjuvant therapy Adequate hydration is important. Diving is contraindicated with rhinosinusitis. Educate that steroids take 4-6 weeks to work.

disorders of taste/ smell treatment

Treatment: underlying cause; TCA for burning mouth syndrome Refer to otolaryngology for suspected nasal obstruction or persistent dysgeusia after controlling for GERD or persistent burning mouth syndrome with TCA Neurology is CNS lesion suspected Allergy if rhinitis suspected Dental prn Rheumatology if Sjorgen suspected Endocrine prn Smell and taste specialist for impaired QOL

disorders of taste DI/ smell DI

University of Pennsylvania smell identification test Sniffin sticks If unavailable, refer for specific smell and taste dysfunction Additional as indicated: CBC, CMP, LFT, TSH ANA, ESR Sjorgen: Ro/SSAA and La/SSB Metal and vitamin levels MRI/ CT

URI/ common cold

Upper Respiratory Tract Infection (Common Cold): 50% Viral: Rhinovirus, parainfluenza, RSV, adenovirus, coronavirus, human bocavirus and human metapneumovirus

URI presentation

Virus-specific findings include: Mild conjunctival injection; red nasal mucosa with secretions of varying colors depending on the degree of nasal mucosa destruction and PMN activity; mild erythema of the pharynx Anterior cervical lymphadenopathy with freely movable nodes less than 2 cm Chest clear to auscultation and without adventitious sounds

Epistaxis PE

Vital signs and airway safety** Internal examination may be deferred until the blood flow has subsided If the bleeding does not readily subside or nasal compression causes postnasal bleeding, the nose should be examined with a nasal speculum clear with suction or nose blowing to identify the site of bleeding 1 : 1000 epinephrine or 4% cocaine, applied either as a spray or on a cotton pledget, serves as both an anesthetic and a vasoconstricting agent PRN If the site cannot be identified, the posterior pharynx is inspected for any bleeding. Rinsing the oropharynx first with water will clear the area to permit identification of any new bleeding.

epistaxis education

avoid vigorous exercise and aspirin-containing medications for several days or weeks follow-up evaluation within 48 to 72 hours to ensure healing of the lesion. Avoidance of tobacco and hot, spicy foods (causes vasodilation) Lubrication of the mucous membranes with petroleum jelly, nasal saline, or bacitracin ointment may relieve nasal discomfort and reduce the need to manipulate the nasal passages Home humidification

Environmental control

most important** • Outdoor harder than indoor as allergens are smaller and lighter, and remain in air longer • Control house dust, paying special attention to the child's bedroom. • Use dust mite-proof mattress and pillow covers (allergen-impermeable encasement). • Wash bed linens in hot water (>130°F [54.4°C]) weekly. • Minimize (if possible, eliminate) stuffed toys in child's bedroom. • Use vertical blinds instead of horizontal blinds or curtains. Curtains should be cotton • Remove carpeting from bedroom; if present should be synthetic and short napped fibered Rugs should be washable; loose or old rugs removed • Use plastic or wood furniture instead of cloth or upholstered furniture • Keep closet doors shut • Eliminate smoking from the child's environment; if household members still smoke despite education, emphasize smoking outside the house and never in the car. • Consider hairless pets; pet hair collects urine, dander, and saliva; the protein in pet saliva causes the reactivity Keep pet out of bedroom Keep pet outdoors as much as possible Wash pet and bed weekly • Reduce mold; avoid damp basements and other sources of moisture in the home environment. • Indoor humidity should be less than 50%; avoid vaporizers. • Use dehumidifiers, air conditioners with efficient filters, and air-cleaning devices with an electronic precipitator or with a high-efficiency particulate air (HEPA) filter; frost free fridge • Eliminate any offending substances; vector control for cockroach elimination • keep windows closed between 10p and 5a, when windy outside • reduce house plants and books • bathing and changing clothes when immediately when entering home • wear long sleeves and masks outside

AR risks

pediatric AR include: a positive family history, male gender, first-born child, early use of systemic antibiotics, maternal smoking, and exposure to allergens.

epistaxis complications

respiratory function can be compromised, and patients may become hypotensive or anemic if bleeding is severe. necrosis, abscess formation, septal perforation, and sinus infection toxic shock syndrome has also been reported as a complication of nasal packing Posterior packing can cause a vagal response undergo embolization are at higher risk for a stroke compared with a nasal packing procedure.

Nasal cromolyn

• Cromolyn is an intranasal mast cell stabilizer used for seasonal or perennial AR. It is less effective than INCS, and frequent dosing is needed (>4x/day). It is safe for children 2 years and older.

decongestants

• Decongestants may help relieve nasal congestion; there is no evidence supporting the use of oral phenylephrine as a decongestant • Topical decongestants can cause rebound rhinorrhea (rhinitis medicamentosa) if used for more than 3 to 5 days; errors in administration can cause systemic absorption and side effects of irritability, nervousness, and insomnia among others. • Children younger than 4 years old should not be given decongestants.

LTRA

• Montelukast is the only approved LTRA for use in seasonal and perennial AR. It is approved from 6 months to 5 years at a 4 mg packet (granules) once daily. It has a moderate effect when used alone. If patient has AR, administer dose in morning or evening; if patient also has asthma, give dose in evening. Guidelines suggest the use of INCS for AR as LTRA are not as effective as nasal steroids

Intranasal corticosteroids

• These agents are effective in reducing local cytokines and mediator release factors produced by mast cells, basophils, eosinophils, monocytes, and macrophages that lead to inflammation and subsequent nasal obstruction • INCS are considered one of the most effective treatments to manage AR and have been safely used in long-term management of AR to relieve symptoms of nasal congestion, rhinorrhea, itching, and sneezing. • provide targeted dose of steroid allowing for maximum effiacy and limited systemic side effects • May notice effectiveness in 6-8 hrs; can take up 2- 4 weeks before maximum clinical benefit is observed. • Side effects include local burning, irritation, sneezing, or soreness (<10% experience these symptoms). Epistaxis is related to improper technique—spraying the nasal septum. examples: Flonase, budesonide