Nose/Sinus Disorders

Nose/Sinus Disorders-

-Acute/Chronic Sinusitis-

-Acute Sinusitis is symptomatic inflammation of the nasal cavity and nasal passages lasting less than 4 weeks
-Acute sinusitis is viral etiology and is only complicated by a bacterial etiology about 2 percent of the time
-Usually resolves itself within 7-10 days, even bacterial etiology may be self limiting
-Bacterial sinusitis should be suspected for symptoms lasting longer than 10 days, fever greater than 102 and purulent discharge or facial pain for at least 3 days, and the onset with worsening symptoms following viral URI that last 5-6 days and was improving
-major organisms are S. Pneumoniae, H. Influenza, and M. Cat.
-treatment includes analgesics, saline irrigation, and nasal steroids
-topical decongestants such as afrin should only be used for 72 hours
-antihistamines and mucolytics can provide some symptomatic relief
-Amoxicillin is considered first line in adults
-Augmentin is considered first line in children
-Doxcycline or Levaquin or Avelox are considered appropriate for penicillin allergic patients in adults
-Macrolides and cephalsporins are not acceptable for empiric therapy because of high rates of S. Pneumoniae and H. Influenzae resistance


-Chronic Sinusitis-
-defined as a inflammatory condition involving the paranasal sinuses  is persistent for more than 12 weeks
-4 signs of chronic sinusitis are: anterior or posterior purulent discharge, nasal obstruction, facial pain, and decreased sense of smell
-treatment is directed at controlling symptoms and drainage.  Nasal saline irrigation, topical nasal steroids, and decongestants
-the uses of antibiotics as monotherapy is limited.  The goal of therapy has shifted towards controlling the inflammation
-Leukotriene inhibitors have shown some benefit when used as adjuncts with nasal steroids
-Antihistamines can be helpful
-Surgery is sometimes needed to help clear passages as well as get cultures.  Antifungal treatment is reserved to after cultures obtained




-Allergic Rhinitis-

-Allergic Rhinitis is characterized by paroxysmal sneezing, rhinorrhea, post nasal drip, and nasal obstruction
-there can be concomitant allergic rhinitis
-usually caused by tree pollen, grasses and weeds
-may also be caused by indoor allergens such as dust mites, mold, and animal dander
-on nasal exam may be visible pale bluish hue or pallor along with turbinate edema
-incidence of concomitant sinusitis and allergic conjunctivitis
-50% of children with asthma have allergic rhinitis
-Atopic Dermatitis is another associated condition
-the best treatment is avoidance of allergens
-intranasal steroids are the most effective single maintenance therapy
-For patients with symptoms refractory to intranasal steroids, singulair may be helpful
-antihistamines and combination decongestants can be used
-any underlying infection should be treated for sinusitis




-Epistaxis-

-most of the bleeds are anterior and resolve spontaneously
-90 percent of the nose bleeds occur in the watershed area of the septum called Kiesselbach's plexus
-posterior bleeds result in significant hemorrhage.  These usually require nasal packing, and ENT referral.  Some posterior nose bleeds may need admitted to hospital
-patients who are on warfarin in a therapeutic range, and hemostasis have been obtained are instructed to resume the warfarin
-recurrent posterior nose bleeds may be due to aneurysm of the carotid artery
-epistaxis may be a symptom of nasal neoplasm
-ASA has not been identified as a risk factor for epistaxis
-alcohol may increase the incidence of epistaxis
-airway intervention, fluid resuscitation, and emergent ENT consult may be necessary in a severe nose bleed
-to tamponade the epistaxis the patient blows nose to remove clots and then nares are sprayed with neosynephrine spray or afrin nasal spray.  Then pinch clamp across alae of nose
-the nose can be packed with merocel or rhino-rocket
-bilateral packing may be necessary if does not quit bleeding or bleeds on the other side
-Cautery is the first line for sources that are mild and can be visualized
-you administer prophylactic antibiotics usually keflex or amoxicillin for patients with nasal packing to prevent infection
-Follow up within 48-72 hours with ENT is necessary to remove packing



-Foreign Body (Nasal)-

-Two types of FB can cause damage to nasal structures:  button batteries and paired disc magnets
-Button batteries cause electrolysis at the negative battery pole and generates hydrogen ions that cause an alkaline environment and tissue necrosis
-Paired disc magnets in each nostril can cause prolonged attachment and perforation from chronic compression of the nasal septum
-Most nasal foreign bodies are most commonly located on the floor of the nasal passage just under the inferior turbinate
-Most present without symptoms.  Some will have foul odor, nasal drainage, epistaxis, or nasal obstruction
-Diagnosis is made by direct visualization, most of the time with an otoscope. Rarely need fiberoptic endoscopy
-ENT referral is necessary when there is posterior foreign body, chronic or impacted foreign bodies, penetrating or hooked FB, or any foreign body that cannot be removed during initial attempt
-most foreign bodies are removed with positive pressure techniques or direct instrumentation
-most common complication is bleeding but injury to nasal tissue or perforation possible




-Nasal Polyps-

-nasal polyps are growths inside of the nose and sinuses
-polyps usually occur on both sides of the nose
-nasal steroids are the mainstay of treatment
-patients that fail medical treatment should be considered for surgery if they are symptomatic