What are the risk factors for chronic RS?
- Deviated septum and other anatomical variations
- Tooth infection
- GERD
- Vitamin D deficiency
- Aspirin usage
What are the cardinal clues for rhinosinusitis (RS)?
◦ Nasal discharge OR nasal obstruction/congestion AND
◦ Facial pain/pressure/fullness OR reduction/loss of smell
Use the Mnemonic PODS
- Pain/face Pressure
- nasal Obstruction
- discolored Discharge
- loss of Smell
What are other additional symptoms that may be present with RS?
Local ENT sx such as sore throat, hoarseness, foul breath (fetor oris), nasal speech. Fullness in the ears, maxillary toothache. Periorbital edema. Drainage may cause wheezing or coughing. Fever, malaise, fatigue, etc. Change in ability to smell.
What physical exam procedures should be done on a patient with RS? And which one is most predictive of this condition?
Observe Temperature & other vitals Percuss/transilluminate sinuses** 90% sensitivity for frontal sinuses Rhinoscopic exam Examine pharynx Tap maxillary teeth Palpate lymph nodes Examine cervical muscles and joints Screen TMJ Perform otoscopic exam (kids) Lung auscultation Cranial nerves II - VI
How do you differentiate simple rhinitis from acute RS vs chronic RS?
Also how do you DDX bacterial vs viral?
Duration is key:
Rhinitis <7 days
Acute RS is >7days and <4 weeks
Chronic >4 weeks
Bacterial >10 days and ~5 days double sickening
Viral Sx peak 2-3 days after onset and improve
What would a basic conservative care plan look like for acute RS?
What about chronic RS?
- Watchful waiting OR prescribe initial antibiotic therapy for adults w/ uncomplicated acute bacterial RX.
- Manual therapy: spinal manipulation, sinus percussion, lymph drainage.
- First line Tx: Saline irrigation. Intranasal corticosteroid sprays. Analgesics.
CHRONIC:
• Nasal specific (contraindicated with nasal polyp) or argyrol application
• If no improvement 4-6 weeks: CT/endoscopy, short term oral corticosteroids
• First line Tx: all the same if NO nasal polyps.
What in office interventions are most likely to promote drainage in chronic RS?
- Nasal specific is likely to be the most effective modality for Tx of chronic sinusitis. But it is uncomfortable and so
- Argyrol nasal application may be preferred.
- Nasal lavage, in office and at home, is useful
- Eustachian tube manipulation is useful for ear complications e.g. sinusitis
What home care interventions are most likely to promote drainage in chronic RS?
Nasal lavage is a home care intervention. “Nasal saline irrigation is effective as sole treatment for CRS or as an adjunct to topical nasal steroids, but compared directly with topical nasal steroids, the benefits of saline irrigation are less pronounced.” (Rosenfeld 2015)
Which OTCs are most likely to be effective for RS (decongestants, steroid sprays, acetaminophen cough syrups)?
• Acetaminophen or OTC NSAIDS may help relieve P or fever in ARS or C viral RS.
Which of the following interventions have the most evidence: steam inhalation, auto inflation for the ear, nasal lavage, and lymphatic massage?
Good question. Fill in the blank
What are the ancillary studies are most likely to be done to make the diagnosis of chronic RS?
- Plain film is NOT recommended
- CT w/o contrast is the modality of choice to confirm CRS. Mucosa thickening >5mm is consistent with sinus infection
- MRI reserved for DDX.
- US comparable to plain film or less predictive.
- Bacterial culture is NOT required for bac RS dx.
- Blood tests NOT required but may be helpful to DDX difficult cases.
- Nasal secretions could be assessed for cytology. Leukocytes suggest bacterial or viral infection. Eosinophils suggest allergic rhinitis.
- Allergy testing may be helpful.
Are plain films recommended for Dx chronic RS?
No
What is the modality of choice to confirm CRS? And what is the sign?
CT w/o contrast
Mucosa thickening >5 mm is consistent with sinus infection
How does the presence of polyps (multiple or singular) affect your management plan for chronic RS?
With Polyps:
• 2-3 week trial of oral corticosteroids (refer to prescriber)
Note: Long term/frequent use should be avoided because of potential harmful side effects when corticosteroids are given systemically. Risks include: sepsis, thromboembolism, fracture
What are the risk factors for AOM?
- Bottle feeding and pacifier use
- Secondary smoke 4x
- Day care 3-4X
- Low socioeconomic status
- Winter months
- Craniofacial distortions e.g. fetal alcohol syndrome, trisomy 21
- Dairy
- Allergies
- Lack of Vit A, zinc, essential fatty acids
What are the 3 criteria for “certain” AOM?
1 - Rapid onset
2 - Presence of middle ear effusion
3 - Signs and Sx of middle ear inflammation
In what critical ways is AOM different form OME?
Only AOM has acute onset of signs and Sx
What physical exam findings suggest the presence of middle ear effusion?
1 - Limited or absent mobility of tympanic membrane as Dx by pneumatic otoscopy, tympanogram or acoustic reflectometry
2 - Tympanocentesis*
3 - Physical presence of fluid in external ear as a result of perforation
- a minor surgical procedure that refers to puncture of the tympanic membrane with a small gauge needle in order to aspirate fluid from the middle ear cleft or to provide a route for administration of intratympanic medications.
What is the most accurate in-office test for middle ear effusion?
Pneumatic otoscopy should remain the primary method of otitis media Dx because the instrument is readily available in practice settings, is cost-effective, and is accurate in experienced hands.
What physical examination procedures should be done in the case of a patient with ear pain?
Evaluate for pain referral from other sources: TMJ, CN (V, VII, IX, X), lateral and medial pterygoid and masseter and SCM for MFTP and tonsilitis, pharyngitis, carcinoma of hypopharynx, larynx, cleft defects
What would a basic conservative care plan look like for AOM?
Fill it in
What are the 4 most likely causes of referred pain to the ear when the ear itself is not the pain generator?
TMJ syndrome
Dental causes
Tonsilitis or pharyngitis
Cervical spine syndrome
What would a basic conservative care plan look like for AOM?
Watchful waiting 48-72 hours
Mild AOM / OME: Affect the Eustachian tube and identify/eliminate the impact of risk factors for future recurrence
In office: endonasal technique and auto inflation
Optional procedures: Tx spine for joint dysfunction C0-C3 especially. Auricular adjustment. Perform soft tissue massage and instruct the patient on how to massage the soft tissue structures of the neck to promote lymph drainage
What are the indications to refer someone for antibiotics if they have AOM?
When they have bacterial middle ear infection:
• Distinct redness of tympanic membrane should NOT be sole criterion for referring for antibiotics
• Elevated temp in general have limited value in regard to etiology, severity, prognosis, outcome. However they can be used to help decide which patients may be candidates for antibiotic therapy
