Nose and Sinus Conditions: Rhinitis, Rhinosinusitis PDF

8/25/2023 Nose and Sinus Conditions: Rhinitis, Rhinosinusitis NURS641 FNP1 Prepared and Presented by Lori -Jeanne West ©Lori-Jeanne West, 2023 Reproduction of this material is prohibited without the author’s consent. Posting or sharing of thes...

8/25/2023 Nose and Sinus Conditions: Rhinitis, Rhinosinusitis NURS641 FNP1 Prepared and Presented by Lori -Jeanne West ©Lori-Jeanne West, 2023 Reproduction of this material is prohibited without the author’s consent. Posting or sharing of these materials without the author’s consent is a copyright violation. Rhinitis 1  8/25/2023 Overview and Presentation Inflammation of the nasal mucosa characterized by nasal congestion, rhinorrhea, sneezing, pruritis, and/or postnasal drainage (acute or chronic) Allergic (AR) vs Non Allergic rhinitis (NAR): Dunphy, Box 24.1, page 350 – Most common forms are viral rhinitis and AR (differentiated by pruritis) – Common irritants seasonal AR: pollen and mold, perennial AR: dust mites, insect debris, animal dander Medication/Drug induced – Antihypertensives (ACE inhibitors, beta blockers, clonidine, hydralazine, prazosin), NSAIDs, guanethidine chlordiazepoxide, amitriptyline, aspirin, oral contraceptives, hormone therapy, prolonged use of nasal decongestants, illicit drugs Atrophic: thinning of nasal mucosa caused by decreased mucociliary clearance leading to overgrowth of bacteria, or surgery, radiation, inflammatory condition Hormonal: pregnancy, contraceptives, HRT, puberty induced Overview and Presentation Allergic Rhinitis (AR): nasal congestion, headache, clear rhinorrhea, sneezing, pruritis of nasal passages, conjunctivae, palate, pharynx, postnasal drainage, frequent throat clearing, sore throat, coughing, epiphora. Non Allergic Rhinitis: – Viral Rhinitis: Sneezing, coughing, sore or burning throat, malaise, headache, occasional fever – Occupational/environmental: weather changes, tobacco smoke, diesel or automotive fumes, strong odors, perfumes – Vasomotor: Temperature changes, exercise, strong odors (onset of nasal congestion is rapid) – Gustatory: Eating hot or spicy foods (acute onset of clear rhinorrhea) – NARES: nasal cytology shows increased eosinophils but negative allergy testing – Senile: triggered by foods, odors, environmental irritants Overview and Presentation Medications/Drugs: nasal congestion, rebound nasal congestion, thick post-nasal drip, nasal crusting, frequent throat clearing, anosmia, foul odor of nose, epistaxis, perforation Atrophic: nasal crusting, nasal dryness, congestion, anterior/posterior nasal drainage Hormonal: nasal congestion and rhinorrhea, resolves after initial hormone increase 2  8/25/2023 Physical Exam Mucosa appears pale, boggy, edematous, pale pink or bluish hue – NAR or vasomotor rhinitis: bright red to bluish and hypertrophied turbinates – Rhinitis medicamentosa: injected, edematous, dry/rubbery, pale turbinates – Atrophic rhinitis: crusted, dried mucus or blood Turbinates hypertrophied Clear watery discharge → yellowish color → greenish or thick yellowish-white Conjunctivae inflamed, edematous Allergic shiners (dark circles under eyes), Dennie Lines (wrinkle under lower lids) Allergic salute (horizontal crease across external nose) Enlarged adenoids in children Erythema, cobblestoning posterior pharynx Wheezing (concurrent asthma) Diagnostics Diagnosis is based on history and exclusion Uncomplicated Case- no labs/work up indicated Exudate (colored or translucent nasal discharge) – CBC – Bacterial culture – Giemsa or Wright’s-stained smear Leukocytosis, polymorphonuclear neutrophils - infection other than typical viral URI Eosinophilia- AR Allergy testing (skin and blood tests) Nasal cytology (NARES, CSF leak) Nasal mucosal biopsy (atrophic rhinitis) CT Imaging- concern for chronic sinusitis, neoplasm, polyps Differentials Dunphy, Table 24.1, pages 352- 355 Allergic Non-Allergic Atrophic Rhinosinusitis Medication/drug induced Hormonal Others: – Nasal polyposis – Structural – Systemic and inflammatory causes – Cerebrospinal fluid leak 3  8/25/2023 Treatment Relief of symptoms, self care, avoid triggers – Dunphy, Table 24.1, page 356-362 Fev er and headache: – acetaminophen 325 -650mg PO q4h prn Rhinorrhea: – Pseudoephedrine 30- 60mg PO q4h prn – phenylephrine 0.25% -0.5% nasal spray 1-2 sprays in nostril q4h prn no more than 3 days – Intranasal ipratropium 0.03% 2 sprays in each nostril 2-4x/day prn Treatment Cough: – Dextromethorphan 15 – 30mg PO q4h prn – Codeine 10 -15mg PO q4h prn Nasal saline irrigation Expectorants: – Guafinesin 200- 400mg PO q4h prn or extended release 600 – 1200mg PO q12h prn Intranasal corticosteroids for AR: – Fluticasone, mometasone, triamcinolone 2 sprays each nostril daily x 2-3 weeks Treatment (intermittent AR) 4  8/25/2023 Treatment (persistent AR) Treatment Vasomotor: – treat symptomatically, humidifier, avoid environmental triggers, saline irrigation, phenylephrine 10mg q4h prn, intranasal ipratropium bromide 0.03% 2 sprays 2- 4x/day prn Rhinitis Medicamentosa: – Stop the medications, intranasal cortiicosteroids in the interim (resolves 2-3 wks) – Systemic steroids prednisone 30mg PO daily x5 days Atrophic: – Mupirocin antibiotic ointment intranasally 2-3x daily Desensitizing immunotherapy Surgery – Anatomical condition like nasal polyps, septal deviation Patient Education/Follow Up Limit exposure to irritants and others with acute URI Follow up in 2-3 months Complications may include OM, repeat respiratory infections, restless sleep, chronic fatigue, asthma may worsen allergic episodes Referral to allergist as needed Referral to otolaryngology Be aware of risk of bacterial superinfection 5  8/25/2023 Rhinosinusitis Overview and Presentation Inf lammation of the nasal mucosa and mucous membranes or one or more of the f ollowing paranasal sinuses: f rontal, sphenoid, posterior ethmoid, anterior ethmoid, maxillary Ty pically dev elops after viral URI Classif ied as acute, recurrent (RARS), or chronic >95% of acute rhinosinusitis cases are caused by self limiting v iruses, only 0.5% - 2% progress to acute bacterial sinusitis Overview and Presentation Acute v iral (AVRS) v s acute bacterial (ABRS): – AVRS: Purulent nasal drainage presenting with focal facial pain/pressure and nasal congestion/obstruction ranging 10 days – 12 weeks – ABRS: If symptoms worsening after 10 days, fever > 101, focal f acial pain, headache, malaise, sore throat, cough, elevated WBC Chronic: persistent cough with postnasal drip or cold like sy mptoms lasting > 12 weeks, thick mucus, popping ears, anosmia, halitosis, f oul nasal odor 6  8/25/2023 Physical Exam Nasal exam- – Purulent nasal secretions, erythema of mucosa and turbinates – Red swollen nasal mucosa (infection) -vs- pale swollen watery secretions (allergic) Sinus exam- – Palpation- tenderness of affected sinuses – Ethmoid sinus involvement- chemosis, proptosis, conjunctival injection, extraocular muscle palsy, orbital fixation Inspect oral cavity - – Rule out dental abscess - Maxillary cavity involvement Otoscopic exam- – ear popping, otalgia, hearing loss, aural fullness - Rule out OM or OM effusion Diagnostics History, Signs/Symptoms, Duration No labs or imaging recommend for uncomplicated cases Stains or cultures of nasal/throat secretions not recommended Culture of sinus aspirates may assist with abx selection- done by otolary ngologist Sinus mucosal biopsy, sinus culture, and fiber optic rhinoscopy by otorhinolaryngologist if suspecting invasive fungal infection CT scan w contrast- chronic conditions with complications MRI- suspecting neoplasm or extension to intracranial tissues Differentials Dunphy table 24.2, page 369-370 – AVRS v ABRS – Recurrent acute RS – Acute fungal RS – Invasive fungal RS – Chronic RS – Mucormycosis – Allergic vs Non allergic rhinitis – Nasal polyps – Structural abnormalities – Migraines – Dental problems 7  8/25/2023 Treatment Nasal saline spray, irrigation, cool mist humidifier, increase fluid intake, heated mist to face Oral analgesics for pain: – Ibuprofen 400-600g every 6-8 hrs prn, acetaminophen 650mg every 4-6 hours prn Nasal decongestants: – Phenylephrine 1-2 sprays each nostril 3-4x day prn (limit 3 days) – Afrin 1-2 sprays each nostril 2-3x day prn (limit 3 days) Oral decongestants: – Pseudoephedrine 30- 60mg PO q4h prn Treatment Expectorants: – Guaf inesin 200- 400mg PO q4h prn or extended release 600 – 1200mg PO q12h prn Intranasal corticosteroids: – Fluticasone, mometasone, triamcinolone 2 sprays each nostril daily x 2-3 weeks Antibiotic therapy: – Empiric abx therapy for 5-10 days to cover most common organisms (S. pneumoniae, H. influenza, M. catarrhalis) Treatment Antibiotic therapy: – Empiric abx therapy for 5-10 days to cover most common organisms (S. pneumoniae, H. influenza, M. catarrhalis) while awaiting lab confirmation Uncomplicated ABRS: – Amoxicillin 500mg PO 3x/day or Amoxicillin 1G PO 2x/day – Augmentin 500mg PO 3x/day or Augmentin 875mg PO 2x/day – Penicillin Allergy: Doxycycline 100mg PO 2x/day Macrolides no longer recommended due to resistance to S. pneumoniae Reserve fluoroquinolones as last resort (high risk complications) 8  8/25/2023 Treatment Acute infections that fail one course of therapy- treat with second course from different drug class x14 days Chronic rhinosinusitis- treat for 3-6 weeks: – Augmentin XR 875 – 1000mg /125mg PO q12h – Cef uroxime 250 – 500mg PO 2x/daily – Penicillin Allergy: Doxycycline 100mg PO 2x/day AND clindamycin 300mg PO q6h Patient Education/Follow Up Check for improvement 48-72 hours Return visit 10-14 days Be aware of serious complications Avoid cigarette smoke, allergens Antihistamines dry nasal secretions Decongestants may exacerbate HTN and tachycardia Drink fluids, irrigate with saline Complete full course of antibiotics References Buttaro, T.M., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). Elsevier. Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2022). Primary care: The art and science of advanced practice nursing and interprofessional approach (6th ed.). F. A. Davis Company. 9