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The Nose and Sinuses

The Nose and Sinuses. Tintinalli Chap. 116. Rhinosinusitis. Common predisposing factor is viral URI Most common in infants 12-23 months (day care) Acute Complete resolution < 30 days Subacute Resolution in 30-90 days Chronic Lasts > 90 days. Anatomy. Ethmoid and maxillary sinuses

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The Nose and Sinuses

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  1. The Nose and Sinuses Tintinalli Chap. 116

  2. Rhinosinusitis • Common predisposing factor is viral URI • Most common in infants 12-23 months (day care) • Acute • Complete resolution < 30 days • Subacute • Resolution in 30-90 days • Chronic • Lasts > 90 days

  3. Anatomy • Ethmoid and maxillary sinuses • Present at birth • Sphenoid sinuses • Form at 3-5 years of age • Frontal sinuses • Appear at 7-8 years of age

  4. Predisposing Factors • Viral rhinosinusitis (80%) • Allergic inflammation (20%) • Nonallergic rhinitis • Cystic fibrosis • Immunodeficiency • Ciliary dyskinesia • Anatomic abnormalities

  5. Common Pathogens • Acute Sinusitis • Strep. pneumo • Nontypeable H. influenzae • Moraxella • Chronic Sinusitis • Same as acute • Staph. Aureus • Anaerobes • Fungus

  6. Acute Bacterial Sinusitis • Clinical Features • High fever • Purulent nasal discharge • Headache (behind the eye) • Facial pain • Swollen erythematous turbinates • Tenderness to percussion/direct pressure • Periorbital edema • Diagnosis • Imaging studies are routinely not needed • Head CT recommended for suspected complications or surgical candidates

  7. Acute Bacterial Sinusitis • Treatment • Mild symptoms • Observe for 7-10 days • Persistent or severe symptoms • Antibiotics to speed recovery, prevent complications, and minimize asthma exacerbations • High-dose amoxicillin (80 mg/kg/day) for 10-14 days • Oral 2nd- or 3rd-generation cephalosporin • Clarithromycin or azithromycin • Intranasal steroids • Fluticasone or beclomethasone

  8. Acute Bacterial Sinusitis • Complications • Preseptal/postseptal cellulitis • Subperiosteal abscess • Cavernous sinus thrombosis • Osteomyelitis of the frontal bone (Pott puffy tumor) • Subdural empyema • Epidural/brain abscess • Meningitis

  9. Chronic Bacterial Sinusitis • Treatment • Nasal saline washes • Augmentin or newer quinolones (Avelox) for 4 weeks • ENT referral • Special Populations • Immunodeficiency • Recurrent or refractory sinusitis • Cystic fibrosis • Nasal polyps, chronic sinusitis, failure to thrive, and chronic cough

  10. Allergic Rhinitis • IgE-mediated • Usually children over 2 • 80% of patients with asthma • Seasonal (hay fever) • Allergy to pollen • Perennial • Allergy to dust mites, animal dander, or mold

  11. Allergic Rhinitis • Clinical Features • Clear rhinorrhea • Nasal pruritus • Sneezing • Conjunctival hyperemia/pruritus • Sleep disturbance • Poor school performance

  12. Allergic Rhinitis • Management • Environmental Controls • Avoid allergens • Avoid pollutants (cigarette smoke) • Nasal saline irrigation • Antihistamines • Loratadine • Cetirizine • Intranasal steroids • Montelukast • Disodium cromoglycate

  13. Nasal Foreign Bodies • Common objects • Beads • Paper • Rocks • Toy parts • Organic material (peas, corn, seeds, nuts, legumes) • Clinical Features • Most are asymptomatic • Unilateral, foul-smelling nasal discharge • Pain • Epistaxis

  14. Nasal Foreign Bodies • Management • Immobilization (20% require ketamine) • Topical lidocaine/phenylephrine • Removal • Alligator forceps • Foley catheter technique • Positive pressure • Suction catheter • Complications • Failure • Epistaxis • Laceration • Septal perforation

  15. Nasal Foreign Bodies • Button batteries • Plain radiograph • Extensive mucosal edema and mucopurulent discharge • Can cause severe alkali burn and liquefactive necrosis resulting in septal perforation w/i 7 hours • Live insects (cockroaches, mosquitos, beetles) • First kill w/ 2% lidocaine or mineral oil

  16. Epistaxis • Usually in children 2-10 years old • Most originate from Kiesselbach plexus • Causes • Nose picking • Rhinitis sicca • Facial trauma • Foreign body • Sinusitis • Excessive coughing

  17. Epistaxis • Management • Pinch nostrils for 5-10 minutes • Ice or phenylephrine • Cotton gauze under upper lip • Cautery (heat, silver nitrate) • Nasal packing • Dispo • Don’t pick your nose! • Petroleum jelly at night

  18. Epistaxis • Recurrent, severe • Coagulopathy • Usually von Willebrand type 1 • Refer to hematology • Neoplasm • CT • Refer to ENT

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