Rhinitis/CRS

Question 1

Environmental changes that have contributed to pollen allergy?

Answer 1

1. Increased PM.2.5 increases asthma exacerbations and lung injury
2. longer summers lead to longer pollination of oak and hickory.
3. longer periods of warmth increase fungal pollination
4. Increase in humidity may increase asthma exacerbations
5. increase in CO2 leads to longer pollination seasons

Question 2

Which dust mite is seen in tropical countries?

Answer 2

Blomia tropicalis

Question 3

What are the dust mite allergens?

Answer 3

Cysteine proteases: Der p 1 and Der f 1

Serine proteases: Der p 3, 6, 9

Question 4

What is the % of cross reaction between dust mite and crustacean?

Answer 4

5-15%

Question 5

What is the cross reactive component in dust mite?

Answer 5

Tropomyosin (Der p 10)

Question 6

What is the most important factor needed for dust mite growth?

Answer 6

humidity.

mites requite RH higher than 65% to prevent water loss and to thrive. Once humidity is <50% mite proliferation decreased and survival is decreased.

Question 7

Dust mite belongs to which Taxonomic category?

Answer 7

Arachnids that below to taxonomic order called Acari

Question 8

Allergen in dust mite - cysteine proteinases

Answer 8

Der f 1, der p 1

Question 9

Allergen in dust mite - Lipid binding proteins

Answer 9

Der f 2, Der p 2

Question 10

Dust mite allergen which is peritrophin (chitin binding)

Answer 10

Der p 23

Question 11

dust mite allergen which cross reacts with shrimp and cockroach

Answer 11

Der f 10, Der p 10

Tropomyosins

Question 12

Major cat allergen

Answer 12

Fel d 1

Question 13

Minor cat allergens

Answer 13

Fel d 2 (albumin) , Fel d 3 (cystatin) and Fel d 4 (lipocalin)

Question 14

Major dog allergen

Answer 14

Can f 1
Lipocalin cysteine protease inhibitor
found in hair, dander and saliva

Question 15

Minor dog allergens

Answer 15

Can f 2 (lipocalin), Can f 3 (albumin), Can f 4 (dog dander)

Question 16

Where is mouse allergen found?

Answer 16

In mouse urine - MUP - mouse urine protein

Mus m 1 - pre albumin

Question 17

Cockroach allergen

Answer 17

Bla g 1 and Bla g 2

Question 18

What is chitin

Answer 18

2nd most abundant polysaccharide in the world.

Present in insects, crustaceans, parasites and fungi

Question 19

Define ABRS (Canadian Guidelines)

Answer 19

ABRS requires the presence of

1. nasal obstruction or purulence/drainage AND
2. 2 of PODS
   - pain
   - obstruction
   - discharge
   - anosmia
3. Timing: > 7 days, <4 weeks

Question 20

Define recurrent ABRS

Answer 20

4+ episodes of ABRS a year

Question 21

Gold standard for diagnosis of ABRS

Answer 21

sinus aspirates, however not recommended in a clinical setting bc invasive

Question 22

CDC diagnostic criteria for ABRS

Answer 22

1. Symptoms lasting at least 7 days ANS
2. purulent nasal secretions AND
3. 1 of the following
   - maxillary pain
   - tenderness in the face (esp. unilateral)
   - tenderness of the teeth (esp. unilateral)

Question 23

ABRS diagnosis requires the presence of at least 2 major symptoms:

Answer 23

P - pain (facial)
O - nasal Obstruction 
D - nasal Discharge 
S - Hyposmia/anosmia (smell) 
one of which must be O or D, and symptom duration of > 7 days without improvement

Question 24

Red flags for urgent referral in ABRS

Answer 24

1. Alt. mental status
2. HA
3. Systemic toxicity
4. swelling of the orbit, or changes in visual acuity
5. neurological findings
6. Intracranial complications
   - meningitis
   - intracranial abscesses
   - CV thrombosis
7. Involvement of associated structures
   - periorbital cellulitis
   - pots puffy tumour

Question 25

First line antibiotics in ABRS

Answer 25

Amoxicillin for beta lactam allergic ppl: TMP/SMX 2nd line: Flouroquinolones or amoxi-clav

Question 26

Berg prediction rule for CRS based on signs and symptoms

Answer 26

1. Purulent rhinorrhea with unilateral predominance - 50% PPV 2. Local pain with unilateral predominance - 41% PPV 3. Pus in nasal cavity - 17% PPV 4. Bilateral purulent rhinorrhea - 15% PPV

Question 27

William prediction rule based on signs and symptoms of ABRS

Answer 27

1. Maxillary toothache LR 2.5 2. Poor response to AH/ decongestants LR 2.1 3. Purulent nasal secretions LR 2.1 4. Abnormal transillumination LR 1.6 5. Coloured nasal discharge LR 1.5 Presence of >/= 4 symptoms has a positive LR of 6.4

Question 28

What are the 2 main causative infective bacteria implemented in ABRS (AAAAI) What are the main bugs in CRS

Answer 28

1. Strep pneumonia 2. H. influenza Other - M. catarrhalis, s. aureus, gram neg bacilli, and oral anerobes CRS 1. S.aureus, enterobacter, pseudomonas

Question 29

Adjunct therapy for ABRS

Answer 29

1. Topical INCS 2. Analgesics 3. Oral decongestants 4. Topical decongestants 5. Saline irrigation

Question 30

Diagnosis of CRS

Answer 30

2 or more major symptoms are present for at least 8- 12 weeks along with documented inflammation of the paranasal sinuses or nasal mucosa (classified as CRSwNP or CRSsNP) (ie. 1 objective finding on CT or endoscopy)

Question 31

CRSsNP diagnosis requires the presence of what?

Answer 31

1. At least 2 symptoms (CPODS) and 2. Inflammation documented by endoscopy 3. Absence of NPs in the middle meatus (by endoscopy) and/or demonstration of purulence originating from the osteomeatal complex on endoscopy or rhinosinusitis confirmed by CT imaging

Question 32

Diagnosis of CRSwNP requires:

Answer 32

1. At least 2 symptoms (CPODS) and 2. The presence of bilateral polyps in the middle meatus confirmed by endoscopy and 3. Bilateral mucosal disease confirmed by CT imaging

Question 33

origins and contributors to CRS

Answer 33

CRS is an inflammatory disease of unclear origin, contributors includes: 1. bacterial colonization 2. bacterial biofilms 3. eosinophilic, neutrophilic, and lymphocytic infiltrations 4. Upregulation of numerous th2 assoc. cytokines 5. tissue remodeling 6. atopy determines allergic versus non allergic classification

Question 34

CRS bacteria are different from ABRS

Answer 34

1. s. aureus 2. enterobacter spp. 3. pseudomonas spp. Less common - s. pneumoniae - h. influenza - b hemolytic step - CONs

Question 35

Prevention of acute exacerbations in CRS | as per CSACI

Answer 35

1. Avoid predisposing allergic triggering factors 2. Use proper hand hygiene 3. Avoid smoking 4. Perform saline nasal irrigation

Question 36

Indications for sinus surgery

Answer 36

1. restoration of sinus ventilation 2. Debulking of severe polyposis 3. Failure of intensive medical therapy 4. Bony erosion or extension of disease beyond the sinus cavities

Question 37

What is functional endoscopic sinus surgery?

Answer 37

FESS - telescopes with a variety of viewing angles illuminates the inside of the nose and sinus - helps with identifying and restoring proper drainage and ventilation of the nose - 98% of patients at 18 months reported improvement in symptoms

Question 38

What is balloon ostial dilation (BOD)?

Answer 38

- the frontal, sphenoid or maxillary sinus ostium is dilated or ethmoid cells are pushed aside using a balloon catheter - efficacy compared to FESS is unclear

Question 39

Adenoidectomy for CRS?

Answer 39

suggested in young children with CRS and adenoid hypertrophy but high level evidence is lacking endorsed by 2014 consensus statement on ped CRS in those not responding to medical management

Question 40

Name 2 medical adjuncts to sinus surgery

Answer 40

1. Steroid impregnated nasal dressings - insert into middle meatus 2. Steroid eluting stent - placed in ethmoid cavity following surgery

Question 41

Management of allergic fungal rhinosinusitis

Answer 41

- endoscopic intervention for dx and mgmt - removal of polyps, mucin, debris - sinuses opened up as widely as can be

Question 42

Etiology of rhinosinusitis

Answer 42

``` Obstruction of the various ostia Increased visocosity of secretions Impaired immunity Mucus accumulates Decrease in oxygenation in the sinuses Bacterial overgrowth ```

Question 43

Factors associated with ARS

Answer 43

ICAM1 – receptor for rhinovirus is up-regulated in ARS Smoking – affects ciliary function Pollution Anatomic variants – Haller cells, concha bullosa, septal deviation Dental infections ?Allergic Rhinitis

Question 44

Steroid management of CRS (AAAAI 2014)

Answer 44

- Consider a short course of oral steroids for treatment of CRSsNP and CRSwNP because it decreases polyp size and alleviates symptoms - Treatment usually results in clinical improvement & transient improvement in sense of smell, although the duration of clinical benefit is variable & may decrease w/ repeated courses (expert opinion)

Question 45

Complications of acute sinusitis

Answer 45

Orbital extension – dipolopia, proptosis, periorbital erythema, swelling Bone – periosteal abscess Brain – intracranial abscess or frontal/sphenoid sinusitis can cause meningitis Orbital phlegmona – can lead to cavernous sinus thrombosis and loss of vision

Question 46

Management of ABRS

Answer 46

1. Antibiotics are not useful in mild or uncomplicated ARS 2. Amoxicillin is first line for moderate or severe ABRS 3. Nasal steroids 4. Nasal irrigation 5. Supportive treatment/pain control 6. Hydration 7. Treatment should be reassessed after 72 hours and changed in no improvement (add or change antibiotics)

Question 47

Contributors too high risk of antibiotic resistance

Answer 47

Abx in last 3 months Symptoms >3 weeks Parents of children in daycare

Question 48

Pathophysiology of CRSsNP

Answer 48

- Likely begins with obstruction of sinus ostium leading to ABRS - If it fails to resolve, it sets up a chronic inflammatory process - Presence of bacterial biofilm in 45-80% of cases Or may become intracellular between exacerbations - Primarily a Th1 response – IL-3 driven

Question 49

Pathophysiology of CRSwNP

Answer 49

- Polyp tissue contains high levels of Th2 cells, IL-5, IL-13, and histamine - May be localized IgE to S. aureus – sIgE to staph enterotoxins (superantigens) have been isolated - May also have decreased Treg function – low IL-10 - tight junction proteins are reduced 80% of nasal polyps are eosinophilic CF is neutrophilic in 50% Asian polyps are Th1/Th17 in 50% - again neutrophilic`

Question 50

Management of CRSsNP

Answer 50

Antibiotics - If possible, choice should be made based on cultures obtained from middle meatus/ostia - Macrolides are generally not effective - Clavulin or moxifloxacin are reasonable empiric choices - Given for at least 3 weeks but can be extended for up to 10 in refractory cases Steroids - Nasal steroids are definitely useful; unclear about risk vs. benefit of oral steroids - Topical steroid instillations rather than sprays may be more effective - Recommendation in guidelines is Prednisone 40 mg for 8 to 10 days concurrently with antibiotics Nasal saline rinses

Question 51

Management of CRSwNP

Answer 51

Nasal steroids - Steroid rinses are again more effective - First line therapy - Mometasone 200 mcg BID used in studies (improves congestion by day 3 and smell by day 13) Oral steroids - Oral steroid plus topical steroid therapy is more effective over 6 months than just topical steroid therapy in decreasing polyp size and improving olfaction Antibiotics Saline irrigation Surgery for medical failures or complications Biologics - Omalizumab – reduced polyp size and improved symptoms in allergic and non-allergic CRSwNP and comorbid asthma - Anti-IL5 - Mepolizumab – 50% response - Reslizumab – 50% response – particularly those with elevated IL-5 in nasal secretions

Question 52

Complications of CRS

Answer 52

Mucocele – epithelial lined sac full of mucus – fills the paranasal sinus and capable of expansion - Usually unilateral (90% of the time) - Most commonly affects the fronto-ethmoid region - Treatment is with surgery CSF leak – due to trauma (90%), surgery, or idiopathic - Presents as clear fluid or salty PND - Beta 2 transferrin in nasal secretions - Need head imaging to localize leak - Endoscopic surgery to repair

Question 53

Name 3 sinusitis syndromes

Answer 53

1. CF 2. PCD 3. Fungal rhinosinusitis (ABPA)

Question 54

What is paradoxical vocal fold motion?

Answer 54

inappropriate motion of the true vocal cords

Question 55

AAAAI first line treatment for CRSsNP

Answer 55

Topical steroids, nasal saline irrigation, consider antibiotic PO culture based if possible

Question 56

Comorbidities associated with VCP

Answer 56

1. asthma 2. post extubation 3. irritants 4. neurological injury 5. larygopharyngeal reflux 6. psychosocial disorders

Question 57

evaluation and diagnosis of VCP

Answer 57

- Laryngoscopy is the gold standard for diagnosis - PFT and imaging may be performed prior depending on the clinical presentation - PFT usually show normal expiratory phase in PVFM – some may show restrictive pattern - Inspiratory phase may show flattening FEF50:FIF50 may be >1 (normal is <1)

Question 58

Management of VCP

Answer 58

Acute Management - Reassurance and supportive care until episode resolves – panting may help abort the episode - CPAP may be helpful; heliox also reported as having some benefit - Intubation/tracheostomy are not needed and considered only if at risk for airway obstruction for another cause Long-Term Management - Requires a multi-disciplinary approach - Behavioural speech/voice therapy - SLP can assist in retraining and education - Evidence for breathing, voice, and neck relaxation exercises - Biofeedback with video laryngoscopy can be helpful - Psychological counseling and avoidance of irritants - ?Atrovent prior to exercise in patients with exercise-associated PVFM may be helpful

Question 59

What is the concha bullosa?

Answer 59

Pneumotization of the middle turbinate often associated with deviated septum No association to sinus disease, unless very large and blocking the maxillary sinus

Question 60

What are Haller cells?

Answer 60

They are ethmoidal air cells that extend on the medial floor of the orbit and can increase risk of acute sinusitis

Question 61

First line treatment of acute bacterial rhinosinusitis (ABRS)

Answer 61

1. Intranasal corticosteroids in mild/moderate disease 2. consider adding antibiotics in severe disease adjunct therapies: saline rinses

Question 62

histopathology of nasal polyps

Answer 62

edema, thickened BM, fibrotic stromal tissue, infiltrating eosinophils

Question 63

Nose is lined by 3 epithelium:

Answer 63

1. stratified squamous epithelium 2. pseudo stratified columnar epithelium 3. specialized olfactory epithelium

Question 64

How to steroids work?

Answer 64

Blocks T cell derived and APC derived cytokine expression and release 1. reduced inflammatory cells in the nasal mucosa 2. reduced inflammatory cytokine release

Question 65

cyclosporin MOA | Tacrolimus MOA

Answer 65

forms complexes with cyclophilin to inhibit calcineurin | tacrolimus binds FKBP12 and forms complexes to also inhibit calcineurin

Question 66

mycophenolate MOA

Answer 66

inhibits ionosine monophosphate dehydrogenase SE: diarrhea, n/v, anemia, leukopenia, thrombocytopenia

Question 67

how do you classify AR?

Answer 67

1. intermitten 2. persistent > 4 days a week (ARIA) seasonal vs. perennial (US)

Question 68

RFs for AR

Answer 68

1. fam hx of atopy 2. sIgE > 100 before age 6 3. maternal smoking 4. high SES 5. positive SPT 6. particulate air pollution

Question 69

mechanism of gustatory rhinitis

Answer 69

stimulation of C fibres | treat with ipratriopium (anti cholinergic)

Question 70

mgmt of rhinitis of pregnancy

Answer 70

- nasal decongestant - nasal strips - nasal lavage - ICNS do not work!

Question 71

meds that can causes rhinitis

Answer 71

1. anti htns 2. psychotropics like risperidone, chlorpromazine, and hydralazine 3. PDE-5 inhibitor like sildenafil 4. NSAIDs 5. Others - OCP and gabapentin

Question 72

what is chitin

Answer 72

2nd most abundant polysaccaride in the world comes from insencts, fungi, parasites, crustaceans size dependant lung inflammation