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Nonallergic Rhinitis and Acute and Chronic Sinusitis PowerPoint Presentation

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Published on : Jul 12, 2021 | Views : 2018 | Downloads : 0

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Nonallergic Rhinitis (Ch.46) Acute and Chronic Sinusitis (Ch. 47) Marilene B. Wang, MD, FACS Professor UCLA Department of Head Neck Surgery Chief of Otolaryngology VA Greater Los Angeles Healthcare System
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1. Nonallergic rhinitis Is more common in males Incidence increases with age May occur in conjunction with allergic rhinitis B and c All of the above
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2. Innervation of the nasal mucosa Parasympathetic nerves are the primary component of the efferent nasal reflex arc. Parasympathetic nerves release vasoactive intestinal peptide Parasympathetic nerves cause nasal decongestion C fibers are efferent nerves that react to pain, changes in temperature, osmolarity and irritants. All of the above
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3. Nasal provocation testing Can differentiate between allergic and non-allergic rhinitis Done with histamine is specifically for allergic rhinitis Done with capsaicin is specifically for nonallergic rhinitis Done with histamine causes decreased vascular permeability, sneezing, and nasal obstruction Done with methacholine leads to increased rhinorhea
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4. Nonallergic rhinitis with eosinophilia Occurs in response to common allergens such as dust, pollen, mold Symptoms are exacerbated by weather changes Occurs in over half of patients with nonallergic rhinitis Involves mast cells and Ig-A positive cells in the nasal mucosa Does not occur with nasal polyps
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5. Rhinitis of pregnancy Occurs more frequently in pregnant women who smoke Affects the majority of pregnant women Occurs in response to estrogen-induced vascular smooth muscle relaxation Severity of symptoms parallels blood progesterone levels All of the above
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6. Medication-induced rhinitis can be found from use of the following medications: Aspirin Oral contraceptives Amitryptiline Hydralazine All of the above
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7. Atrophic rhinitis Is most commonly associated with infection from Klebsiella pneumoniae Can occur after aggressive nasal surgery Is most common in young adults Results in changes in nasal mucosa from squamous epithelium to ciliated respiratory epithelium Can be treated effectively with antibiotics
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8. Idiopathic rhinitis Is also known as vasomotor rhinitis Occurs rarely Involves autonomic nervous system dysfunction A and c All of the above
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9. Diagnosing nonallergic rhinitis Requires a thorough history Requires acoustic rhinomatry Requires a sinus CT scan All of the above None of the above
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10. Treatment of nonallergic rhinitis a. May include nasal steroids, antihistamines, and anticholinergics b. Septoplasty and/or turbinate reduction may be of benefit c. Vidian neurectomy can provide relief of rhinorrhea d. A and c e. All of the above
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Acute and Chronic Sinusitis 12
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Major Healthcare Problem Problem One of most common healthcare problems in U.S. Over 31 million Americans affected annually 18-22 million physician office visits annually
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Definition of rhinosinusitis Group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses Acute, subacute, chronic
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Paranasal Sinus Function Lining – pseudostratified ciliated columnar epithelium Mucous and serosanguinous glands Parasympathetic and sympathetic innervation
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Paranasal Sinus Function Mucous blanket renewed every 10-15 minutes Warm and humidify air Secrete immunoglobulins, interferons, inflammatory cells
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Paranasal Sinus Function Cilia beat 10-15 times/second Cilia function varies with environment, allergies, etc. Mucociliary system—cleanse sinus, immunoprotective Move mucous to natural ostia of sinuses
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Rhinosinusitis-Major factors Facial pain/pressure Nasal obstruction/blockage Nasal discharge/purulence/discolored postnasal drip
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Rhinosinusitis-Major factors Hyposmia/anosmia Purulence in nasal cavity on examination Fever (acute rhinosinusitis only)
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Rhinosinusitis-Minor factors Headache Fever Halitosis Fatigue
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Rhinosinusitis-Minor factors Dental pain Cough Ear pain/pressure/fullness
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Categories of Rhinosinusitis Acute Subacute Chronic Recurrent, acute Acute exacerbations of chronic
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Acute Rhinosinusitis Duration up to 4 weeks > 2 major factors 1 major factor + 2 minor factors Nasal purulence on exam
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Subacute Rhinosinusitis Duration 4-12 weeks >2 major factors 1 major factor + 2 minor factors, or nasal purulence on exam Complete resolution after effective medical therapy
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Chronic Rhinosinusitis Duration > 12 weeks History same as for subacute Facial pain does not constitute suggestive history in absence of other nasal symptoms or signs
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Recurrent acute >4 episodes/year + each episode last >7-10 days. Absence of intervening signs of chronic rhinosinusitis
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Acute exacerbations of chronic Sudden worsening of chronic rhinosinusitis Return to baseline after treatment
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Factors Associated with Chronic Rhinosinusitis Allergies Immunodeficiency Genetic/congenital
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Factors Associated with Chronic Rhinosinusitis Endocrine Neural
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Factors Associated with Chronic Rhinosinusitis Anatomic Neoplastic Acquired mucociliary dysfunction
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Associated Factors Microorganisms—viral, bacterial, fungal Noxious chemicals, pollutants, smoke Medications Trauma Surgery
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Microbiology of acute sinusitis (adults) S. pneum (20-43%) H. influenzae (22-35%) Strep spp. (3-9%) Anaerobes (0-9%) M. catarrhalis (2-10%) S. aureus (0-8%) Other (4%)
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Microbiology of acute sinusitis (children) S. pneum (25-30%) H. influenzae (15-20%) M. catarrhalis (15-20%) S. pyogenes (2-5%) Anaerobes (2-5%) Sterile (20-35%)
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Recommended abx for adults with acute bacterial rhinosinusitis Mild disease with no recent antimicrobial use Augmentin, Amoxicillin Vantin Ceclor Omnicef
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Switch if no improvement after 72 hours Tequin, Levaquin, Avelox Augmentin Combination (Amox or clinda + Suprax)
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Abx for acute sinusitis if PCN-allergic Bactrim Doxycycline Zithromax, Biaxin, Erythromycin Switch to quinolone if no improvement in 72 hours
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If recent abx use Quinolone Augmentin Clindamcin + rifampin Consider IV abx
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Abx for acute sinusitis in children Augmentin, Amoxicillin Vantin Ceclor Omnicef Switch if no improvement after 72 hours
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If PCN-allergic Bactrim Macrolide
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If recent abx use (children) Augmentin Rocephin Bactrim, macrolide Consider IV abx if no improvement
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Other symptomatic therapies Afrin for 3 days Normal saline sprays Decongestants Antihistamines ?Steroids
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Complications of sinusitis Periorbital cellulitis Preseptal cellulitis/abscess Orbital cellulitis Orbital abscess Cavernous sinus thrombosis
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Chronic rhinosinusitis Antibiotics Antihistamines Nasal steroids Normal saline irrigations Allergy evaluation +/- immunotherapy
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Chronic rhinosinusitis Sinus CT scan Consider anatomic factors—septal deviation, nasal polyps, concha bullosa, ostio-meatal blockage
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Indications for sinus surgery Nasal polyposis Anatomic blockage—deviated septum, enlarged turbinate, concha bullosa Mucocele Orbital abscess
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Indications for sinus surgery Fungal sinusitis—allergic vs. invasive (mucor) Tumor of nasal cavity or sinus
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Indications for sinus surgery Chronic, recurrent sinusitis Failure to respond to maximal medical therapy Obtain cultures
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Long-term management May be a lifelong disease Allergy control—antiihistamines, nasal steroids, immunotherapy Oral steroids—judiciously Antibiotics for acute exacerbations
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Long-term management Environmental control—avoid carpet, damp, mold, older homes, smog Saline irrigations
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Long-term management Alternative therapies—acupuncture, stress management, herbal remedies Pain management Multi-disciplinary effort—work with allergy, infectious disease, neurology/pain management services