Chronic Rhinosinusitis Quiz

ENT 3

• ENT 3 course offered by Professor Boucher at South College
• Course focuses on diseases of the nose, sinuses, nasopharynx, oropharynx, and oral cavity.

Topics

• Nose and sinus disorders: chronic rhinosinusitis, invasive fungal rhinosinusitis, foreign bodies, trauma
• Nasopharyngeal and paranasal sinus neoplasms: polyps, inverted papillomas
• Oropharyngeal disorders
• Oral cancer

Instructional Objectives

• Describe epidemiology, etiology, clinical manifestations, diagnosis, and management of epistaxis, nasal polyps, rhinitis, rhinosinusitis, and nasal trauma. Learning objective numbers 1-5, 7
• Identify and describe etiology, clinical manifestations, diagnosis, and management of foreign bodies in the nose. Learning objective numbers 1-5, 7
• Demonstrate evaluation, diagnosis, and management of benign and malignant neoplasms of the nasopharyngeal and paranasal sinuses. Learning objective numbers 1-5, 7
• Identify and describe clinical manifestations, diagnosis, and treatment of diseases of the teeth and gums, including necrotizing ulcerative gingivitis. Learning objective numbers 1-5, 7
• Identify and describe clinical manifestations, diagnosis, and treatment of infectious/inflammatory oropharyngeal disorders, including aphthous stomatitis/ulcers, candidiasis, deep neck infection, epiglottitis, herpes simplex/labialis, laryngitis, peritonsillar abscess, and pharyngitis. Learning objective numbers 1-5, 7
• Identify and describe clinical manifestations, diagnosis, and treatment of salivary disorders, including sialadenitis and parotitis. Learning objective numbers 1-5, 7
• Identify and describe clinical manifestations, diagnosis, and treatment of oropharyngeal trauma. Learning objective numbers 1-5, 7
• Identify and describe clinical manifestations, diagnosis, and treatment of other oropharyngeal disorders, including leukoplakia. Learning objective numbers 1-5, 7
• Identify and describe clinical manifestations, diagnosis, and treatment of oral squamous cell carcinoma (SCC). Learning objective numbers 1-5, 7
• Identify and describe etiology, clinical manifestations, diagnosis, and management of foreign bodies of the larynx and pharynx. Learning objective numbers 1-5, 7

Chronic Rhinosinusitis (CRS)

• Inflammatory condition of the paranasal sinuses and nasal passages lasting 12 weeks or more
• Affects 5-12% of the general population (children and adults); mean age at diagnosis is 39
• Onset is either abrupt or insidious (months to years)
• Diagnosis requires objective evidence of mucosal inflammation

Chronic Rhinosinusitis (CRS) Risk Factors/Associated Conditions

• Allergic rhinitis
• Asthma
• Aspirin-exacerbated respiratory disease (AERD)
• Depression
• Smoking
• Irritants and pollutants
• Immunodeficiency
• Defects in mucociliary clearance (e.g., cystic fibrosis)
• Viral infections
• Systemic illnesses
• Dental infections
• Anatomical abnormalities
• Indoor dampness and mold exposure

Chronic Rhinosinusitis (CRS) Clinical Features

• (Adults):
  • Anterior and/or posterior nasal mucopurulent drainage (opaque white or light yellow)
  • Nasal obstruction/blockage/congestion (bilateral)
  • Facial pain, pressure, or fullness (headache)
  • Reduction or loss of sense of smell
• (Children):
  • Same as adults except the 4th symptom is cough instead of loss of smell

Chronic Rhinosinusitis (CRS) Danger Signs & Complications

• High fever
• Double (or reduced) vision
• Proptosis
• Dramatic periorbital edema
• Ophthalmoplegia
• Other focal neurologic signs
• Severe headache
• Meningeal signs
• Significant or recurrent epistaxis

Chronic Rhinosinusitis (CRS) Evaluation

• Clinical history (4 cardinal symptoms, duration, risk factors, previous treatments, and imaging)
• Objective documentation of mucosal disease using anterior rhinoscopy, nasal endoscopy, and/or CT scans (showing purulent mucus, edema, polyps, thickening, or opacification of the paranasal sinuses)
• Allergy evaluation (optional testing; mainly perennial allergens)
• Consideration of immunologic defects or infectious complications (patients with recurrent episodes of acute purulent sinusitis, history of pulmonary infections, or recurrent otitis media)

Chronic Rhinosinusitis (CRS) Diagnosis

• Based on presence of suggestive symptoms and objective evidence of mucosal inflammation.
• Must have at least two of the four cardinal signs and symptoms.
• Symptoms must be present for more than 12 weeks.
• Must have one or more findings on nasal endoscopy or CT showing purulent (not clear) mucus or edema in the middle meatus or ethmoid regions; polyps in the nasal cavity or middle meatus.
• Radiographic imaging must demonstrate mucosal thickening or partial or complete opacification of the paranasal sinuses.

Chronic Rhinosinusitis (CRS) Subtypes

• Three distinct clinical syndromes/subtypes: CRS with nasal polyposis (20-33%); allergic fungal rhinosinusitis (AFRS) (<5%); CRS without nasal polyposis (60-65%)
• Subtypes are differentiated by CT findings and/or tissue biopsy

Chronic Rhinosinusitis (CRS) Treatment

• Primary care management, but ENT and allergy specialists often required (especially for refractory CRS and AFRS)
• Intranasal saline (irrigation and/or sprays)
• Intranasal corticosteroids (i.e., fluticasone, budesonide)
• Oral corticosteroids (severe/refractory mucosal edema, to reduce polyp size, minimize inflammation of AFRS; typically 10-15 days)
• Antibiotics (only to manage acute exacerbations, not long-term)
• Antileukotriene agents (adjunct in patients with allergic rhinitis or nasal polyps)
• Endoscopic sinus surgery (for medical polypectomy or insufficient results)
• Biological agents

Invasive Fungal Rhinosinusitis

• Rare, aggressive fungal infection of the sinuses
• Time course: days to weeks
• Most cases occur in immunosuppressed individuals (e.g., diabetes mellitus, HIV, organ transplant recipients)
• Chronic or acute (profound immunosuppression)
• Causes: Aspergillus and Mucor species

Invasive Fungal Rhinosinusitis (Symptoms)

• Symptoms of acute illness (similar to acute bacterial rhinosinusitis [ABRS]): fever, facial pain (facial numbness with cranial nerve involvement), nasal congestion, possible visual or mental status changes (diplopia).

Invasive Fungal Rhinosinusitis (Diagnosis & Treatment)

• Diagnosis: CT and/or MRI, but confirmed with tissue biopsy
• Treatment: medical and surgical emergency
• Hospital admission and ENT referral
• IV antifungal therapy (voriconazole or amphotericin B)
• Prompt/wide surgical debridement

Nasal Foreign Bodies

• Common in children and developmentally disabled
• Inorganic materials (beads, pebbles, etc.)
• Organic materials (beans, peas)
• More difficult to remove as they swell with time
• Button batteries and magnets require immediate attention due to risk of septal perforation
• Symptoms: unilateral foul-smelling discharge, nasal obstruction
• Management: patient can blow nose or trial of insufflation; pretreat with nasal decongestant and topical anesthetic; conscious sedation if needed; use of a Katz extractor, Foley catheter, or forceps

Nasal Foreign Bodies (Referral Criteria)

• Foreign body refractory to removal attempts
• Chronic foreign body with localized reaction
• Young or developmentally delayed patients requiring conscious sedation
• Significant trauma on attempted removal
• Sharp, penetrating, or hooked foreign body

Nasal Foreign Bodies (Instruments)

• Jobson-Horne probe, hook, and alligator forceps

Nasal Trauma

• Nasal fracture: nasal pyramid is the most frequently fractured bone in the body
• Symptoms: epistaxis, pain, soft tissue hematomas (periorbital hematoma/black eye)
• Evaluation: Full HEENT exam (intranasal exam to rule out septal hematoma); crepitus; palpable and mobile bony segments; step-off of the infraorbital rim (zygomatic complex fracture) ; x-rays for facial, spinal, pulmonary, and intracranial injuries (based on mechanism of injury [MOI])

Nasal Trauma (Treatment)

• Goal: maintenance of long-term nasal airway patency and cosmesis
• Septal hematoma: urgent referral to ENT; bilateral internal drainage (I&D) + fluid cultures; nasal packing (3-5 days) to prevent re-formation of hematoma
• Anti-staphylococcal antibiotics (e.g., cephalexin, clindamycin) (3-5 days or the duration of packing) to reduce the risk of toxic shock syndrome
• Closed reduction of fracture (local or general anesthesia)

Malignant Nasopharyngeal & Paranasal Sinus Neoplasms

• Squamous cell carcinoma (SCC): most common neoplasm found in sinuses and nasopharynx
• Adenocarcinoma, mucosal melanomas, sarcomas, and non-Hodgkin lymphomas—less common
• Early symptoms similar to rhinosinusitis
• Common symptoms: unilateral nasal obstruction and discharge, otitis media
• Cancer-related symptoms: pain and recurrent hemorrhage
• Most cases are advanced at presentation and treated with chemoradiation therapy.
• Poor prognosis for advanced tumors

Benign Nasopharyngeal Neoplasms (Nasal Polyps)

• Pale, edematous, mucosal-covered masses
• Common association with allergic rhinitis
• Possible chronic nasal obstruction and dysosmia
• Topical intranasal steroids improve quality of life (for small polyps), (1-3 months)
• Consider short course oral steroids
• Surgery for massive polyps or failed medical therapy

Benign Nasopharyngeal Neoplasms (Inverted Papillomas)

• Usually arise on the lateral nasal wall
• Caused by HPV
• Unilateral nasal obstruction and occasional hemorrhage
• Malignant potential; squamous cell carcinoma (SCC) seen in ~10% of cases.
• Complete excision is strongly recommended.

Oropharyngeal Disorders

• Diseases of the teeth and gums
• Infectious and inflammatory disorders
• Salivary disorders
• Other disorders

Neutrophilic Ulcerative Gingivitis (Vincent's Angina or Trench Mouth)

• Often from infection with spirochetes and fusiform bacilli
• Young adults under stress (e.g., medical/dental students)
• Underlying systemic diseases possible
• Painful, acute gingival inflammation and necrosis.
• Possible bleeding, halitosis, fever, and cervical lymphadenopathy
• Treatment: warm 1/2 strength peroxide rinses, metronidazole 500 mg PO q8h for 7 days (or until lesions have healed), dental gingival curettage

Infectious/Inflammatory Oropharyngeal Disorders

• Aphthous stomatitis (canker sores)
• Recurring, painful, solitary or multiple ulcers typically covered by a white-to-yellow pseudomembrane and surrounded by an erythematous halo (7-14 days)
• Differential diagnosis (DDx): erythema multiforme or drug allergies, herpes simplex, pemphigus, pemphigoid, bullous lichen planus, Behçet disease, inflammatory bowel disease (IBD), and squamous cell carcinoma (SCC).
• Treatment: good oral hygiene, avoidance of exacerbating factors/foods, pain control (viscous lidocaine 2% or benzocaine 10%), 1 week tapering course prednisone (40-60 mg), topical corticosteroids (e.g., fluocinonide gel), medicated mouthwash
• Oral candidiasis (thrush)
• Infection of oral mucosa usually caused by Candida albicans
• Risk factors: immunocompetent patients (dentures, xerostomia, antibiotic/steroid use, diabetes mellitus, anemia), immunocompromised patients (HIV/AIDS, hematologic malignancies, transplant recipients, chemotherapy, steroids, head, and neck radiation therapy [RT])

Deep Neck Infections

• Cellulitis of the submandibular space (often due to infection of mandibular dentition); most commonly encountered neck space infection
• Edema and erythema of the upper neck and floor of the mouth
• Tongue may be displaced upward and backward; may occlude airway
• May have pus in floor of the mouth
• Diagnosis: clinical, augmented by CT with contrast
• Treatment: hospital admission, IV ceftrriaxone + metronidazole, Cx/Sens., dental consult/ENT consult, + drainage
• Deep neck abscess
• Usually caused by odontogenic infections, pharyngeal infection, suppurative lymphadenitis, direct spread, penetrating trauma, pharyngoesophageal FB, cervical osteomyelitis, IV drug injection into internal jugular vein
• Marked neck pain and edema, + fever
• Untreated or inadequately treated may spread to mediastinum or cause sepsis
• Diagnosis: clinical, augmented with CT with contrast
• Treatment: secure airway, IV antibiotics, I&D, may require intubation or tracheotomy

Epiglottitis

• Inflammation of the epiglottis and supraglottic structures
• Usually due to viral or bacterial infection, (also caustic ingestion, thermal injury, or trauma)
• Most common bacterial cause is Haemophilus influenzae type B (Hib)
• Usual presentation: rapidly developing severe sore throat or odynophagia out of proportion to minimum oropharyngeal findings on exam
• More common in diabetics and those who have not received routine vaccinations

Epiglottitis (Examination and Imaging)

• Exam: Indirect laryngoscopy (not in children) revealing edematous and erythematous epiglottis; children may be in tripod position to increase airway patency
• Imaging: X-ray, or CT scan—imaging should not delay airway management X-ray: Enlarged epiglottis (thumbprint sign)

Epiglottitis (Treatment)

• Airway management and evaluation; keep patient calm; avoid agitating patient (especially children); avoid sedation (unless needed for intubation), inhalers, or racemic epinephrine; hospitalization for IV antibiotics (e.g., ceftriaxone or amoxicillin/clavulanate); IV dexamethasone; analgesic/antipyretic; supplemental humidified oxygen

Herpes Labialis

• "Cold sores" or "fever blisters"
• Reactivation of HSV-1 oral vesicles along the vermilion border.
• Common (15-45% of US population)
• Triggers: immunodeficiency, stress, exposure to sunlight, fever, trauma, dental procedures
• Symptoms & signs: prodrome (pain, burning, tingling, pruritus); eruption of clustered vesicles (7-14 days)
• Treatment: local anesthetics (e.g., topical lidocaine); oral antivirals (e.g., acyclovir, famciclovir, valacyclovir); topical antiviral (acyclovir) less effective than oral antivirals.

Herpes Labialis (Treatment Strategy)

• No treatment (mild symptoms, no prodrome)
• Episodic therapy (mild-moderate symptoms with prodrome)
• Chronic suppressive therapy (severe disease, frequent recurrences, especially if no prodrome, recurrences bothersome, recurrences associated with serious systemic complications [e.g., erythema multiforme])

Acute Laryngitis

• Common cause of hoarseness; often follows a URI (viral or bacterial)
• Signs and symptoms: hoarseness; +/- sore throat, congestion
• Treatment: supportive (voice rest, PO hydration, humidified air)
• Antibiotics usually not necessary
• Complications: vocal fold hemorrhage, polyps, cysts

Peritonsillar Abscess

• Most common deep infection (polymicrobial) of the head and neck.
• Usually forms in the soft palate, just above the superior pole of the tonsil, in the location of Weber's glands.
• Occurs mostly in young adults (20-40)
• More commonly in November-December and April-May
• Risk factors include periodontal disease and smoking

Peritonsillar Abscess (Signs & Symptoms)

• Ill-appearing, fever, malaise; severe sore throat, foul breath, dysphagia, or otalgia.
• Trismus, odynophagia, drooling
• Muffled voice (“hot potato voice”)
• Tense swelling and erythema of anterior tonsillar pillar and soft palate
• Tonsil is usually displaced inferiorly and medially with contralateral deviation of the uvula
• Tender cervical lymphadenopathy

Peritonsillar Abscess (Diagnosis & Treatment)

• Diagnosis: needle aspiration; intraoral or submandibular ultrasound; CT/MRI (an adjunct)
• Small abscess (<1 cm): observation and antibiotics
• Drainage of abscess larger than 1 cm: needle aspiration, I&D, and/or tonsillectomy, antibiotics (e.g., piperacillin-tazobactam IV; alternatives include IV metronidazole + ceftriaxone or clindamycin)
• Hydration and analgesia and airway management

Peritonsillar Abscess (Complications)

• Airway obstruction
• Aspiration pneumonia
• Death secondary to hemorrhage
• Extension of infection into the deep neck or mediastinum
• Poststreptococcal sequelae (if caused by Group A beta-hemolytic streptococcus [GABHS])

Pharyngitis

• Very common; peak seasons are late winter and early spring
• Causes: mostly viral and bacterial; others include GERD, postnasal drip (rhinitis), persistent cough, thyroiditis, allergies, foreign body, and smoking
• Symptoms: scratchy feeling, sore throat.
• Consider SARS-CoV-2 testing in patients with acute pharyngitis

Viral Pharyngitis

• Most common cause of pharyngitis
• Signs and symptoms: Coryza, conjunctivitis, malaise, hoarseness, low-grade fever
• Treatment: conservative - Systemic PO analgesics (e.g., acetaminophen, NSAIDs, ASA); topicals (e.g., lozenges, sprays, beverages, foods); breathing humidified air; avoid tobacco smoke

Infectious Mononucleosis

• Pharyngitis with significant fatigue
• Cause: Epstein-Barr virus (EBV)
• Most common in ages 15-30

Infectious Mononucleosis (Examination)

• Pharyngeal injection with exudates (shaggy, white-purple)
• Posterior cervical and auricular lymphadenopathy
• Palatal petechiae
• Hepatosplenomegaly

Infectious Mononucleosis (Diagnosis & Treatment)

• Diagnosis: Heterophile antibody test (e.g., Monospot) or EBV-specific antibody test to confirm; CBC: lymphocytosis (absolute count >4,500/µL); peripheral smear: differential count >50% (or atypical lymphocytosis)
• Treatment: Supportive (fluids, rest, acetaminophen or NSAIDs, no contact sports for min 3-4 weeks); No antibiotics

Group A Beta-Hemolytic Streptococcal Pharyngitis (GABHS)

• Group A beta-hemolytic streptococcus (GABHS)
• Highest incidence in children (ages 5-15)
• Signs & symptoms
• Acute-onset sore throat; fever; pharyngeal edema; patchy tonsillar exudates; prominent, tender anterior cervical lymphadenopathy
• Supportive features: palatal petechiae, scarlatiniform rash, and strawberry tongue

GABHS Pharyngitis (Diagnosis)

• For most patients with suspected GAS pharyngitis: test with a sensitive rapid antigen detection test (RADT); follow-up throat culture not always needed; positive RADT - treat with antibiotics; negative RADT - additional testing not usually needed; reserve throat cultures to confirm negative RADT results in selected patients (children, high-risk infection or complications [e.g., history of ARF or immunocompromised], high-risk people such as caregivers for infants, immunocompromised individuals, living in areas with high GAS prevalence [e.g., college dorms], in areas with ARF outbreaks, and high clinical suspicion of GAS but is negative RADT [e.g., > 3 Centor criteria])

GABHS Pharyngitis (Treatment)

• Analgesic (e.g., NSAIDs, acetaminophen)
• PO antibiotic preferred 1st line (e.g., penicillin VK, cefuroxime, cefpodoxime) x 10 days
• Can also use amoxicillin 500 mg BID x 10 days
• PO antibiotic for PCN allergy (e.g., erythromycin, azithromycin)
• Antibiotic for compliance problems or inability to take PO meds (e.g., benzathine PCN or procaine PCN as a single IM injection)

GABHS Pharyngitis (Complications)

• Acute rheumatic fever (ARF)
• Rare (1 case per 100,000)
• Joint swelling/pain, subcutaneous nodules, erythema marginatum, myocarditis, chorea
• Poststreptococcal glomerulonephritis
• Intrinsic renal failure
• Hematuria, edema
• Peritonsillar abscess
• Rare (<1%)
• Toxic appearance
• Scarlet fever
• Punctate, erythematous, blanchable, and sandpaper-like exanthem, accentuated in body folds and creases (Pastia's lines).
• Strawberry tongue

Other Bacterial Pharyngitis

• Gonococcal pharyngitis - Sexually active patients, Fever, dysuria, greenish exudate, Ceftriaxone 250 mg IM + Azithromycin 1 gm PO x 1 dose
• Diphtheria - Sore throat, low-grade fever, Adherent grayish membrane, Antitoxin + Antibiotic, Tender cervical adenopathy, Erythromycin 500 mg IV QID or PCN G 50,000 units/kg IV q12h

Salivary Disorders

Sialadenitis

• General: acute swelling of the parotid or submandibular gland; can also occur with dehydration and chronic illness (e.g., Sjögren's syndrome; chronic periodontitis); often bacterial (e.g., S. aureus)
• Signs and symptoms: increased pain and swelling with meals

Sialadenitis (Physical Examination & Treatment)

• Physical Examination: Tenderness and erythema of the duct opening, pus often massaged from the duct.
• Treatment: Hydration, warm compresses, sialagogues (e.g., lemon drops), massage the gland; IV antibiotics (PO for less severe cases)

Suppurative Parotitis

• Acute infection of the parotid gland (viruses and bacteria)
• Typically S. aureus and mixed oral aerobes and anaerobes
• Most common in debilitation, dehydration, and poor oral hygiene, particularly among elderly postoperative patients
• Consider mumps in children and young adults; sarcoidosis
• Evaluate testicles (epididymo-orchitis)

Suppurative Parotitis (Signs & Symptoms)

• Firm, erythematous swelling
• Pain and tenderness
• Possible trismus and dysphagia
• Systemic: fever and chills
• Exam: possible purulence from Stenson's duct

Suppurative Parotitis (Diagnosis & Treatment)

• Diagnosis: US (preferred initially), CT, MRI; elevated serum amylase in the absence of pancreatitis; Gram stain & culture discharge
• Treatment: inpatient hydration and IV antibiotics (admission); surgical I&D if no response in 48 hours

Oropharyngeal Disorders (Other)

• Precancer: Leukoplakia
• White adherent patch or plaque
• Premalignant lesion
• Risk factors include tobacco, dentures, lichen planus.
• Dysplasia or early SCC (2-6%)
• Diagnosis: biopsy
• Treatment: watchful waiting + exision
• Oral hairy leukoplakia
• White, corrugated, painless plaques usually on lateral tongue
• Plaques cannot be scraped off
• Prevalent in HIV, organ transplant, malignancy, steroids (systemic or inhaled)
• Associated with EBV
• Not considered premalignant
• Treatment usually not indicated
• Antivirals may provide temporary resolution

Oral Cancer

• Squamous cell carcinoma (SCC)
• Risk Factors: increasing age, tobacco use, alcohol use
• Physical Examination: Raised, firm, white lesions with ulcers at the base, can lead to nodularity or ulceration; usually involves the lateral surface of the tongue; quite painful with gentle palpation.
• Diagnosis: biopsy
• Treatment: surgery/radiation

Upper Airway Foreign Bodies

• More common in young children
• One study of 1068 foreign body aspirations:
• 3% in larynx
• 13% in trachea
• 52% in right main bronchus
• 6% in right lower lobe bronchus
• 18% in left main bronchus
• 5% in left lower lobe bronchus
• Signs & symptoms: sudden episode of choking or coughing; subsequent wheezing, coughing, or stridor; 1/3 of parents were unaware of the aspiration or remembered an event that occurred more than a week prior

Upper Airway Foreign Bodies (Airway Management)

• Airway management: 5 x back blows; 5 x chest thrusts (alternate)

Esophageal Foreign Bodies

• Usually due to food bolus impaction
• Most will pass spontaneously (80%)
• Peak incidence between 6 months and 6 years
• Small batteries (necrosis/perforation)
• Complete obstruction: drooling, inability to handle secretions
• Treatment: flexible endoscope; glucagon 1.0 mg IV (relaxes the esophagus)

Emergent Airway Management

• Cricothyroidotomy: quick, relatively easy stab through cricothyroid membrane; insert any small round airway (e.g., biro casing); anaesthetic not essential; life-saving
• Formal tracheostomy: not usually an emergency; needs full anaesthetic; ideal for temporary or permanent intubation; hole cut in 2nd & 3rd tracheal rings; usually after dividing thyroid isthmus; inferior thyroid veins can be troublesome

References

• Current Medical Diagnosis & Treatment 2025, Papadakis
• Handbook of Otolaryngology: Head and Neck Surgery, 2nd Ed. Goldenberg
• UpToDate online

Test your knowledge on chronic rhinosinusitis with this quiz that covers key facts, risk factors, and diagnostic details. Understand the duration, signs, and prevalence of this common condition. Perfect for healthcare students and professionals looking to refresh their knowledge.