Week 3-NURS 6501 exam with verified solutions.

Classification of acute sinusitis Symptoms < 4 week Classification of subacute sinusitis Symptoms 4-12 weeks Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:09 / 0:15 Full screen Classification of chronic sinusitis Symptoms > 12 weeks Classification of recurrent sinusitis 3+ events/year without symptoms in between and last < 2 weeks What percentage of cases of sinusitis receive antibiotics? How many cases recover on their own without antibiotics? 80% 70% What is an uncomplicated sinusitis? No clinical evidence of extension of infection outside of paranasal sinuses and nasal cavity without neurological, ophthalmologic, or soft tissue involvement What is the most common site of sinusitis? maxillary sinuses (largest sinuses) Risk factors of sinusitis -History of allergic rhinitis -History of asthma, CF, chronic respiratory syndrome -First or 2nd hand cigarette smoke -Small nasal passages Common viral causes of sinusitis -Influenza -Rhinovirus -Parainfluenza -RSV -Adenovirus Common bacterial causes of sinusitis -Strep pneumonia -H flu -Moraxella catarrhalis -Staph aureus Fungal sinusitis is ________ and typically seen in _______________ Rare Immunosuppressed patients Symptoms of acute rhinosinusitis -Purulent anterior nasal dx -Purulent or discolored posterior nasal discharge -Nasal congestion or obstruction -Facial congestion, fullness -Hyposmia, anosmia -Fever -HA -Ear pain, pressure, fullness -Halitosis -Dental pain -Fatigue 3 cardinal symptoms of bacterial sinusitis 1) Mucopurulent discharge 2) Nasal obstruction 3) Facial pain, pressure 4 cardinal symptoms of chronic sinusitis 1) Mucopurulent discharge 2) Nasal obstruction 3) Facial pain, pressure 4) Decreased or loss of smell > 12 weeks Infectious Disease Society of American (IDSA) classification of bacterial sinusitis -4 weeks of purulent nasal discharge with nasal obstruction -Facial pain for 3 days Clinical presentation of bacterial sinusitis -Fever > 101.5-102F -Duration > 10 days -Severe HA -Skin infection -Purulent nasal discharge > 4 weeks -Facial pain/pressure/fullness/dental pain (no improvement for 10 days) -Decreased smell -Cough -Fatigue -Ear pain Important PMH to illicit when assessing a patient presenting with sinusitis -History of sinus infection -History of nasal polyps -Recent head injury Sinusitis PE -VS, recent fevers? -Allergic shinier, periorbital edema -Nasal edema, erythema, discharge, septal deviation, polyps -Throat PND, erythema, lymphoid hypertrophy -Dental abscess, gingivitis -Lymph node palpation -Percussion of frontal, maxillary sinuses -Eye exam (ophthalmoscope) -Ear exam (otoscope) When should you consider a facial CT when a patient presents with signs of sinusitis? -Recurrent bacterial sinusitis -Orbital or soft tissue involvement -Comborbidities (immunodeficiency, diabetes, labs) -Facial trauma Presentation of trigeminal neuralgia Unilateral facial pain around the 5th cranial nerve Differential diagnosis for sinusitis presentation -Common cold -Dental abscess -Trigeminal neuralgia -Optic neuritis -Meningitis -Orbital cellulitis -Allergic rhinitis -Migraine or cluster HA -Foreign body -Tumor -Nasal polyps -Head injury -Fungal infection Treatment for sinusitis (symptom relief) -Analgesics (NSAIDs, acetaminophen) -Saline nasal irrigation -Antitussive (weak evidence) -Mucolytics/expectorants (guaifenesin; thins mucus) -Decongestants (3-5 days_ -Oxymetazoline -Nasal steroid -Hydration -Rest -Humidified air When doing the "watchful waiting" approach for treating acute sinusitis, when you should have patient follow to assess if antibiotics need to be started? after 7 days of no improvement with supportive therapy Oxymeetazoline use for sinusitis (Neo-Synnephrine) -Decreases nasal congestion, edema -Promotes drainage Antibiotics for sinusitis should cover what bacteria? -S pneumonia -Morexella -H flu What is the first line antibiotic choice for bacterial sinusitis? -Amoxicillin 500-750mg BID x 5-7 days -Augmentin (for high resistance risk) 875/125mg BID x 5-7 days What should you do if you start a patient on abx for ABS and they do not improve? -Reconfirm ABS diagnosis & assess for complications -Prescribe abx that will cover likely resistant organism -Augmentin 2g/125g PO BID -Levofloxacin 500-750 PO qd -Moxifloxacin 400g PO qd What are common complication of antibiotic treatment? -Nausea/vomiting/diarrhea -Abdominal pain -HA -Rash -Photosensitivity -Vaginal yeast infection What are abx choices for ABS for patients with penicillin allergic patients? -Doxycycline 100-200mg qd -Levofloxacin 500-750mg qd -Moxifloxacin Why are macrolide not recommended for acute bacterial sinusitis? High resistance rates to S. Pneumonia Treatment for chronic or recurrent sinusitis -Look for comorbidities that may contribute (allergies, asthma, CF, ciliary, dysfunction, immune deficiency) -Nasal steroid use (8-12wk) -Saline irrigation (200mL warm water daily) -Longer course of antibiotics -Refer for allergy testing When should you order a CXR if a patient has sinusitis symptoms with cough? > 3 weeks Sinusitis with > 2 weeks of progressive dyspnea plan Refer to otolaryngologist or allergist What are possible complications of acute bacterial sinusitis? -Chronic cough -Pneumonia -Osteomyelitis -Orbital abscess -Meningitis -Brain abscess -Orbital cellulitis -Intracranial abscess What type of sinusitis is associated with increased risk of orbital abscess? Ethmoid sinusitis When should you refer to otolaryngology for patients with acute bacterial sinusitis? ABS symptoms after 2 treatment with antibiotic therapy When should symptoms improve with antibiotic therapy for ABS? within 48-72 hours (cough may linger for 7-10 days) What are the possible adverse effects of topical nasal steroids? -Epistaxis -HA -Nasal itching ABS prevention tips -Treat allergies, asthma symptoms -Avoid cigarette smoke -Humidifier -Avoid getting URI -Consider decongestant when flying if problems -Avoid chlorine in swimming pools -Avoid scuba diving Clinical s/sx of vestibular neuritis -Severe vertigo -Nausea -Vomiting aggravated by head movement -Tinnitus, hearing intact -Spontaneous nystagmus when directing fast phase from affected ear Treatment for vestibular neuritis -Anticholinergics (1st line) -Antihistamines (1st line); meclizine common, safe in pregnancy -Antiemetics (acute episode, only for 3 days) -Steroids (methylprednisolone once daily x 22 days) -Benzos (reserved for severe) Why should antiemetics not be prescribed for more than 3 days in vestibular neuritis? longer can hamper vestibular recovery Clinical presentation for acute otitis externa -Pain of affected ear, auricle -Feeling of fullness, itching -Drainage from affected ear, hearing loss PE findings acute OE -Pain, tenderness on palpation or manipulation of tragus/auricle -Canal erythematous, edematous; may be filled with debris, slough; may be fully blocked -TM may be erythematous -Cellulitis may extend to external ear with enlargement of periauricular nodes; possible hearing deficit What should antibiotic choice cover for treatment of otitis externa? P. aeruginosa S. aureus Topical antibiotic choices for otitis externa -Fluoquinolone (ciprofloxacin, combo with steroid) -Neomycin-polymyxin B What topical antibiotic should not be used for AOE if there is a perforated TM? Aminoglycosides (ototoxic) -> neomycin What topical antibiotic is safe for perforated TM in AOE? fluoroquinolones -> ciprofloxacin What treatment can be used for fungal otitis externa? acetic acid 5% clotrimazole otic oral diflucan What is otitis media? fluid in the middle ear What is acute otitis media? How does it present? What is it associated with? -Bacterial or viral infection of the middle ear fluid -Rapid onset, short duration -Associated with seasonal allergies, URI Is AOM usually unilateral or bilateral in adults? Unilateral AOM is more common in what population for adults? smokers Why are children more prone to AOM? narrow eustachian tubes What viruses can cause AOM? -Influenza A -RSV -Paninfluenza What bacteria can cause AOM? -S pneumonia -Moraxella caterrhalis -H influenza What are the main risk factors for AOM? -Allergies -Smoking -Eustachian tube dysfunction -Chronic sinusitis -URI -Craniofacial abnormalities (Cleft palate, Down's syndrome) -Immunosuppresion What is acute suppurative OM? pus in the middle ear What is chronic suppurative OM? -Long standing middle ear infection -Associated with perforated TM What is cholesteatoma? Squamous epithelium present in middle ear, usually has odorous discharge