Evaluation and Management of Nose Disorders PDF

Part 8 Evaluation and Management of Nose Disorders  Epistaxis (Chapter 73, Slide 1 of 3) Epistaxis—Nosebleed Most nosebleeds are idiopathic; incidence is highest in individuals younger than 10 years of age and over the age of 40. Local triggers Nasal trauma, rhinitis, drying of...

Part 8 Evaluation and Management of Nose Disorders  Epistaxis (Chapter 73, Slide 1 of 3) Epistaxis—Nosebleed Most nosebleeds are idiopathic; incidence is highest in individuals younger than 10 years of age and over the age of 40. Local triggers Nasal trauma, rhinitis, drying of the nasal mucosa from low humidity, nasal septum deviation, alcohol use, and chemical irritants (e.g., cocaine) Systemic conditions Genetic or acquired coagulation disorders, hematologic cancers, and anticoagulation medication  Epistaxis (Chapter 73, Slide 2 of 3) Examine for blood emerging from the nares. Ask about history of clotting disorders or blood thinner/antiplatelet use. Anterior nosebleeds Usually unilateral with continuous moderate bleeding Depending on the amount of bleeding, small clots may also emerge. Bleeding may be spontaneous or following nasal trauma. Posterior nosebleeds Can occur bilaterally, are associated with severe bleeding, and are difficult to treat Bleeding into the pharynx is indicative of a posterior epistaxis.  Epistaxis (Chapter 73, Slide 3 of 3) Assess ABC and CBC. Management Anterior epistaxis Application of direct pressure to the anterior portion of the nose for 15 minutes Have patient sit upright (to reduce venous pressure). Have patient lean forward to decrease the swallowing of blood. May use short-acting topical nasal decongestants (e.g., phenylephrine 0.125% to 1% solution (to stop blood flow). Nasal packing Posterior epistaxis Requires specialist consultation  Rhinitis (Chapter 75, Slide 1 of 2) Rhinitis, an inflammation of the nasal sinus cavity, can be caused by various exposures that trigger the body's response to remove the foreign material from the nasal cavity. Allergic rhinitis, also known as allergic rhinosinusitis (AR), is a heterogeneous, inflammatory response affecting the paranasal and sinus mucosa. Characterized by sneezing, rhinorrhea, mucosal swelling, obstruction, conjunctivitis, and nasal- ocular and pharyngeal itching in response to an allergen exposure. The membranes typically have a pale, violaceous color and are edematous (boggy). Other causes Infectious, anatomic, pharmacological, food/drink related Rhinitis medicamentosa Other medical-related causes Pregnancy, hypothyroidism, cocaine use, and atrophic change  Rhinitis (Chapter 75, Slide 2 of 2) Diagnostics are based on clinical findings Cytologic studies (Wright stain) Allergy referral, RAST testing Management Antihistamines Oral decongestants Intranasal steroids Environmental avoidance Thorough medication review is also necessary because medications are often associated with rhinitis. Common culprits include reserpine, methyldopa, nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, β blockers, and snorting or sniffing street drugs (e.g., cocaine, heroin).  Sinusitis (Chapter 76, Slide 1 of 3) An inflammation of the mucosal surface of the paranasal sinuses Acute sinusitis Resolves with treatment within 2 to 3 weeks Bacterial, viral, fungal, allergic Presentation Abrupt onset Nasal congestion, purulent nasal discharge, headache more intense when the patient bends forward, fever, fatigue, and other constitutional symptoms are common. Physical exam and diagnostics Full HEENT and dermatologic exam Nasal congestion, facial or dental pain, postnasal drip, headache, fever, and yellow or green nasal discharge Sensations of pain in the teeth and forehead are worse in the morning and when the patient bends forward from the waist. Frontal and maxillary sinus pain on palpation Prodromal common cold and allergic and idiopathic rhinitis A sore throat is common; may develop from the postnasal drip.  Sinusitis (Chapter 76, Slide 2 of 3) Subacute sinusitis Resolves within 4 to 12 weeks Chronic sinusitis Continues 12 weeks or longer Clinical presentation Prolonged sinus infection greater than 12 weeks that resists treatment or with recurrent acute infections that are inadequately treated and never resolve Frequent exacerbations of sinus infections that are caused by gram-negative or anaerobic microorganisms Symptoms as with acute Full HEENT and dermatologic exam. Nasal congestion, discharge, and a cough that lasts for more than 30 days are common, dull headache. Diagnostics CT scan for recalcitrant cases MRI with/without contrast if a mass is suspected  Sinusitis (Chapter 76, Slide 3 of 3) Management Symptomatic treatment of rhinorrhea, sneezing, and coughing (viral rhinosinusitis) Pharmacotherapy First-generation antihistamine NSAID Decongestant or cough suppressant Antibiotics for symptoms greater than 10 days and/or purulent discharge Antibiotic choice should be individualized based on community resistance. Referral for evidence of visual changes, periorbital cellulitis, mental status changes, high fever, or acute focal pain  Smell and Taste Disturbances (Chapter 77, Slide 1 of 3) Anosmia: Loss of the sense of smell Parosmia: Smell distortion Hyposmia: Diminished sense of smell Can result from aging, tobacco, toxins, medications, malignant neoplasms, nasal inflammation, infection, malnutrition, head or facial trauma, Parkinson disease, Alzheimer disease, multiple sclerosis, diabetes, or inflammatory autoimmune disease.  Smell and Taste Disturbances (Chapter 77, Slide 2 of 3) Hypogeusia: Diminished taste Aliageusia: Unpleasant taste Dysgeusia: Persistent taste Ageusia: Absent taste Can result from the same causes as olfactory changes in addition to endocrinologic dysfunction, anesthesia, malignant neoplasms, head and neck irradiation, surgical procedures, iatrogenic causes, kidney or gastric dysfunction, metabolic or hepatic disorders, environmental exposure, substance abuse, or psychiatric disorders.  Smell and Taste Disturbances (Chapter 77, Slide 3 of 3) Exam and diagnostics Perform an HEENT exam. Cranial nerve exam University of Pennsylvania Smell Identification Test and the Sniffin’ Sticks CBC, electrolytes, BUN, creatinine, LFTs, TSH, ANA, ESR, SSA, LA/SSB, vitamin level, metal concentrations MRI CT Management Treatment of underlying conditions may resolve the problem. Rhinitis, sinusitis, infection, gastroesophageal reflux disease, or anemia Discontinue use of trigger medications. Intranasal glucocorticoid steroid treatment is effective in most cases. Adjunctive treatment includes antihistamines and leukotriene inhibitors. PPIs (for GERD—Throat pain) TCA antidepressants (for burning mouth symptoms) Referral to a specialist may be indicated if interventions are ineffective.  Tumors and Polyps of the Nose (Chapter 78, Slide 1 of 2) Malignant tumors can occur in the nose, nasopharynx, and paranasal sinuses. Malignant lesions include Carcinomas, lymphomas, sarcomas, and melanomas, squamous cell cancer (is the most common) The most common is squamous cell carcinoma Presentation Remain late in asymptomatic until their course Early symptoms are nonspecific (similar to rhinitis). Unilateral nasal obstruction and discharge with pain, recurrent hemorrhage, headache, or visual or olfactory changes suggest the presence of cancer. Benign tumors Juvenile angiofibroma, nasal polyps Most common type of benign tumor is an inverted papilloma. Presentation Symptoms include nasal obstruction, discharge, or facial swelling. These tumors can bleed easily and cause recurrent epistaxis.  Tumors and Polyps of the Nose (Chapter 78, Slide 2 of 2) Complete HEENT and nasopharynx exam Diagnostics Sinus X-ray studies CT scan MRI Endoscopic evaluation and biopsy are the “gold standard.” Lab studies as indicated Management Nasal topical steroids Topical intranasal capsaicin may be effective in treating nasal polyps. Surgical excision Otorhinolaryngology referral If tumor is malignant, chemotherapy or radiotherapy may be indicated.