GNMD II -Howell Quiz 3 (1) PDF

Anterior segment tissue connective fibrous...

Anterior segment tissue connective fibrous sclera amberaEnsaimber cyyga.tn byiys aautitenhmo infeiinf.fiiris The Eye A&P Review Corneal Portions of the edl Finedw segment posterior Fx’s of Iris & humor vitreous Angle ftp.ifeng Effect of Refractive Conjunctiva Ciliary Body Structure’s cutting optic Power Drainagesystem chiasm on visual field Cornea = Continuous Iris: regulates Contents: iris, Cutting optic anterior 1/6th of w/cornea amount of light front of ciliary chiasm = eye surface, (mucous entering the eye body, trabecular bitemporal stratified membrane, (smooth meshwork & hemianopsia, squamous bulbar portion muscle), Cilary canal of loose R & L epithelium, covers the body: focuses schlemm temporal field 2/3rd of eye’s sclera (whites of lens, prod. -Aqueous humor peripheral refractive power eye), palpebral aqueous humor, from ciliary body vision, this is (bending of light portion lines contraction flows through what causes power), no BV’s inner eyelids) relaxes fibers pupil -> ant. tunnel vision in cornea just suspending Chamber -> nerve endings lens, lens trabecular thickens - focus meshwork -> is up close canal of schlemm -Balance bw prod. & drainage of aqueous humor determines IOP, normal IOP = 8-21 mmHg Common Signs & Sx’s: mostconcerning leastconcerning ➔ pain, erythema/edema, discharge, blurred vision/visual changes, eye strain, photophobia Hyphema Scotomas Floaters Hemorrhage in ant. chamber Negative: blind/dark spot in Proteins in vitreous humor; -> usually caused by trauma field of vision, sign of retinal usually benign detachment - leads to vision loss more c oncerning *could be a sign of retinal Positive: a luminous patch, detachment multicolored & vibrating in field of vision, caused by abnormal visual stimulation, could mean nothing or disturbed retina (usually in one eye only)  Astigmatism warpedeyeball Visual Acuity Abnormalities Hyperopia Myopia Presbyopia Most common refractive error Nearsightedness (can see Loss of elasticity w/age - AKA farsightedness (can’t up close but not far) Lens can’t accommodate see up close*) Eyeball is too long - focus is (thicken) to near vision Eyeball is too short in front of the retina Common after 40 y/o When you bend the light the Need a concave lens to focal point is behind the correct retina (need a convex lens to correct it) Minor Superficial Disorders External “External stye”, inflammation involving hair follicles, zeiss or moll hordeolum sebaceous gland blockage, sebum released can cause a foreign body rxn Sx: pain, redness & tenderness at lid margin, *no severe pain try to get pt to not mess w/eye Comp: lacrimation, photophobia & foreign body sensation (doesn’t lead to anything worse) Internal “Internal stye”, inflammation of meibomian gland on eyelid, suppuration hordeolum on conjunctival side of eyelid, abscess may form & recurrence common - Refer to ophthalmologist if there is no improvement in 2-3 days or if it is not completely resolved in 1-2 wks Chalazion Chronic meibomian gland enlargement Sx: usually painless, swelling under eyelid, takes a couple of months to resolve Entropion & Entropion = lid inversion, atrophy or scarring Ectropion - Can get ulcerations on cornea, eyelashes can grow into eye & scratch it - *can turn green from fluorescence Ectropion = lid eversion due to tissue relaxation - Sx: redness of conjunctiva, excessive tearing - *common in aging  F Pinguecula & *usually on nasal side of conjunctiva 1 pterygium Pinguecula = conjunctival thickening leading to mild scar tissue Pterygium = conjunctival thickening expanding into cornea & affecting vision (worst one!) *both caused by wind & sun exposure Blepharitis Causes: - Bacterial: usually staph, red scales & crusts - Allergic: no inflammation & greasy scales Sx: itch, burning, foreign body sensation, loss of lashes, inflammation of eyelids The Acutely Red Eye ➔ Danger signs: pain & vision loss ➔ Use a fluorescein straining to R/O corneal abrasion & ulceration ◆ Use a slit lamp to see Conjunctivitis *most common cause of red-eye Inflamed, red conjunctiva, common in kids Causes: infectious (mostly viral but can be bacterial), allergic, welding arc (bright light) Sx: itching, discharge (yellow/green that clears throughout day w/slight purulence) & conjunctival injectionpink PE: shows normal visual acuity (EMOI/PERRLA) & pupillary responses w/a negative fluorescein stain *usually self-limiting *copious discharge = ER immediately Subconjunctival Bleeding into space behind conjunctiva, many causes: hemorrhage - Can be idiopathic, caused by straining (after childbirth), can occur from severe febrile illness/bleeding disorders No associated sx: no pain, discharge, change in vision R/O trauma & foreign body (seen in conjunctivitis) 4-5 days/wks to go away selflimiting Keratitis Corneal inflammation Causes: infectious = bacterial, fungal, or viral (herpes simplex/zoster), non-infectious = trauma, UV light Sx: pain (persistent & severe), photophobia, blurred vision, little or no D/C Dx: fluorescein stain positive for damaged epithelium, hypopyon (pus in ant. chamber) may be seen **Refer to ophthalmologist immediately! HSV-1: begins on cornea w/keratitis - Sx: redness, photophobia, tearing, dec. visual acuity, no D/C, can have pain or no pain - Slit lamp reveals dendritic ulcers w/terminal bulbs - 25% chance of recurrence Herpes Zoster (Hutchinson’s sign): starts w/keratitis - may progress to retinitis w/necrosis of retina & vision loss - 10% of cases will be in eye - Reactivation of varicella in ophthalmic division of CNV - Dermatomal rashes often present in regional pattern of CNV - Loss of extraocular movements (EOM) possible - Dendrites have tapered ends Anterior uveitis Inflammation of iris vs iridocyclitis - inflammation of ciliary body & iris Causes: non-granulomatous = usually idiopathic & associated w/HLA-B27 arthropathies (ankylosis spondylitis), granulomatous = infectious like TB, syphilis & sarcoidosis P: breakdown of blood/ocular barrier leads to extravasation of WBCs & proteins into aqueous humor Sx: dull, aching pain (abrupt in onset) that can be referred to temple/periorbitally, worse w/a accommodation (cause pupil constriction), photophobia, blurred vision, red w/incrasing tear but no D/C *Most cases are unilateral PE: ciliary flush (circumcorneal redness) - dilated BV most intensely around cornea, small pupil initially - then irregular leading to scarring that causes adhesions bw iris & lens *fluorescein positive: flares, cells & hypopyon, dec. IOP from dec. aqueous humor Complications: cataract & glaucoma Acute glaucoma *Emergency! Refer to ophthalmologist! (closed-angle) Most common cause: pupillary block - If the ant. Iris becomes stuck to the trabecular meshwork, the angle closes & drainage is interrupted - Can be idiopathic (spontaneous) or after cataract surgery  Other causes: plateau iris (genetically narrow-angle that becomes occluded w/pupil dilation), medications: sulfa derivatives (can cause effusion which leads to swelling & closure of angle) & bronchodilators, space-occupying lesions of the brain Sx: severe eye pain w/NV, unilateral vision loss or halo vision, diffuse redness w/a hazy cornea, large & fixed pupil, eye feels hard, IOP = 40-80 mmHg - Common to come on at night - Middle age & older pts get this due to shallow ant. Chamber & narrow angles - Impaired drainage or aqueous humor inc. IOP - Dilation of pupil exacerbates this b/c your eyelids are closer to the lid Optic nerve atrophy & cupping: open-angle glaucoma = leading cause *inc. IOP can cause optic N. damage - leading to cupping of optic disc - often leads to gradual, painless vision loss Sudden Vision Loss #1 main cause = diabetes Arterial Occlusion Venous Occlusion Vitreous Retinal detachment *ACUTE hemorrhage Causes: *More common than *More common in Associated w: DM, atherosclerosis, arterial diabetics ROP, trauma emboli, inflammation Incidence: 2nd most Hx of floaters - Sx: floaters (inc, in # Sx: amaurosis fugax common cause of usually benign, & frequency), flashing (lasts sec-min, temp. vision loss due to floaters (seen inc. lights, descending Etenment Vision loss usually in retinal vascular w/retinal detachment curtain in field of one eye, “a curtain in disease which follows vision my field of vision that (#1 is diabetic hemorrhage) inc. in # Appearance: retinal closes”), dec. visual retinopathy) & frequency folds & retina acuity, retinal pale & Causes: HTN, inc. Sx: unable to see becomes pearly grey edematous, cherry blood viscosity (will retina due to blood in - what TM looks like red spot on macula, if dec. vitreous humor NOT retina occlusion is >1 hr = circulation/diabetes & - Absent red reflex *emergency referral optic N. atrophy (no COPD pts who can (cause = tumor or blood flow) become retinal blastoma) *auscultate head & polycythemic), flame *vitrectomy if blood carotid to r/o hemorrhages, does not reabsorb temporal arteritis swollen optic disc, w/in a few months engorged retinal veins *BRVO > CRVO BASKE Blood thunder CRVO Gradual Vision Loss *more common than acute vision loss Cataracts Chronic Glaucoma Diabetic Retinopathy Hypertensive (open-angle) Retinopathy Cataracts = cloudy - Can occur w/out *macular edema leads Copper-silver (opacity) of the lens sudden inc. in IOP to dec. visual acuity at wiring of arterial in eye, leads to - atrophic changes to either stage wall on retina - due blurred vision optic N. occur due to *#1 cause of to engorged BV inc. - Seen mostly inc. in aqueous humor preventable blindness in light reflex w/aging but in ant. chamber diabetes Noneovascularization *normal should be children can have Risk factors: age, fam Nonproliferative: (stage transparent this hx, diabetes, 1 of diabetic - A/V nicking due - Children present hypothyroidism, retinopathy) to thickened arterial w/squinting myopia - dec. circulation walls &amblyopia - Pt complains of blind w/endothelial damage - flame (crossing of the spots in vision - - retinal ischemia occurs hemorrhages & eyes) negative scotomas - microaneurysms soft exudates - dec. red reflex can appear develop & rupture - - optic disc edema - Pale optic disc leads to superficial flame (indistinct disc w/cupping occurs hemorrhages & deeper margins) - optic due to thinning of blot hemorrhages disc may be neuroretinal rim - soft exudates = caused several times large, - Pt usually has by leakage of also happens normal visual acuity proteinaceous material w/brain tumor until later in course of - hard exudates = fatty (papilledema) due disease deposits on retina to inc. IOP - cotton wool spots - *if not controlled - due to nerve fiber should see an ischemia ophthalmologist Proliferative (of blood vessels): (Stage 2 of D.R) - same findings as stage 1 - more severe - stage 1 = inc. chance of getting stage 2 - neovascularization near optic disc - new vessels bleed easily (leads to possible retinal detachment Tx: photocoagulation —-------------------------- *Type I DM: diagnosed days w/in starting; start ophthalmology exam w/in first 5 yrs of dx *Type II: commonly left  undiagnosed so need ophthalmology exam at time of dxIMMEDIATELY Macular Degeneration (senile) ➔ Affects central field of vision ➔ Usually bilateral ◆ Pigmented macula, exudates ➔ Drusen appearance = fatty deposits around macula ➔ Pts have a hard time w/their central focus (focus on the menu) Types of Hearing Loss Conductive Sensorineural - Lesion in external canal or middle ear - Lesion in the inner ear or 8th CN - Air conduction of sound isn't getting into cochlea *Differentiated by comparing air conduction w/bone conduction (Rinne pattern) & lateralization w/Weber test (normal =same sound in both ears) Weber & Rinne tests Weber Test Rinne Test Look at bone conduction Put handle of tuning fork on mastoid process Tuning fork placed on top of head then to ear when sound from bone goes away ➔ Conductive loss = sound will ➔ Normal pattern = AC > BC lateralize/be louder in bad ear bc of no ➔ Conductive loss = BC > AC AC, only bone ➔ Sensorineural loss = AC > BC ➔ Sensorineural loss = sound will *hearing may be less in affected ear lateralize to unaffected/good ear where the good nerve is intact Etiologies of Hearing Loss Presbycusia Most common cause of sensorineural hearing loss (nerve deafness) is age-related - more common in men, starts in 40’s, high-frequency sound loss first! Infection Otitis media is most common cause of temporary conductive hearing loss (pus & fluid can also cause this) Ex: bacterial cause of meningitis, cytomegalovirus becoming intrauterine causing baby to be deaf Otosclerosis Most common inherited cause of conductive hearing loss (ossicle change) Meniere’s Disease Trifecta: hearing loss, tinnitus & vertigo Noise Destroys cochlea hair cells (sensorineural loss) Medications Aspirin toxicity, chemotherapy, IV antibiotics Other Severe cerebral palsy, tumors, trauma to head  Tinnitus Vertigo Perception of sound in absence of stimulus - Sensation of moving around in space can be a ringing, tingling & intermittent, or (subjective) or having objects move around pt continuous Both ear = peripheral cause vs CNS disease Etiology: ASA (aspirin) toxicity, noise, trauma, = central infection Etiology: viral URI, otitis media, drugs, - Other conditions = otosclerosis, Meniere’s disease, otosclerosis, tumors hypothyroidism, Meniere's disease, cholesteatoma, acoustic neuroma Inner Ear Disorders (sensorineural) Meniere’s Disease vs. Syndrome Understanding Ménière’s Disease ➔ Disease = idiopathic endolymphic HTN (sensorineural) ➔ Syndrome = caused by conditions interfering w/endolymph prod. or resorption ➔ Condition Ex’s: thyroid disease, autoimmune conditions (RA, SLE), syphilis, medications, trauma, electrolyte imbalance Onset of Disease 20-40 y/o - there is familial predisposition Sx’s Vertigo: sudden onset, severe, pts have N/V for several hrs, attacks are isolated (reoccur) Progressive hearing loss: usually unilateral - 10-15% is bilateral hearing loss Tinnitus: constant or intermittent Endolymphic HTN: underlying mechanism - Bony labyrinths filled w/perilymph = scala vestibuli & scala tympani - Scala media is the membranous labyrinth filled w/endolympth Pathophysiology Perilymph = Na+ rich Endolymph = K+ rich - Membrane can break here separating the fluids & causing them to mix = causing hearing loss & sx Blockage of depolarization in vestibular n. receptors - leads to sensation of vertigo Mechanical distortion or organ of Corti - Caused by HTN/inc. pressure - Get hearing loss & tinnitus Hearing loss Progressive & usually unilateral 10-15% are bilateral Low freq. Sounds are lost first bc apex of cochlea is more sensitive to inc. pressure Weber & Rinne tests Weber test = sound will lateralize to good ear (unaffected) Rinne test = AC > BC Neuro exam - Romberg test check for balance (truncal  stability), proprioception & vision (will they sway or stand straight?) Diagnostic criteria 1. ≥ 2 episodes of vertigo each 20 min to 12 hrs 2. Documented low to mid freq. sensorineural hearing loss in affected ear 3. Fluctuating sx’s 4. Sx not better explained by another vestibular illness Labs: thyroid studies, electrolytes & glucose - CBC, ESR, ANA, fluorescent treponemal antibodies Imaging: MRI of brain - r/o brain tumor or acoustic neuroma if suspect central vertigo Vestibular Neuronitis *peripheral problem Understanding Vestibular Neuronitis Incidence & definition Sx’s Type of nystagmus & characteristics of the nystagmus Inflammation of vestibular Unidirectional horizontal Nystagmus = involuntary eye division of CNVIII - usually nystagmus - cause of movements, named by viral peripheral vertigo direction eyes move in fast 30 - 40 y/o phase (fast phase goes Abrupt onset of debilitating Romberg test: pts fall on towards the good ear) vertigo affected side 2 types: peripheral & central - First attack is usually Peripheral Nystagmus: most severe, typically Labs: CBC & glucose - Latency & fatiguing recurrent & can go for (most common 7-10 days *MRI is suspected CNS characteristic) accompanied w/bad cause of vertigo - Unidirectional peripheral - Goes away in 1 min nystagmus - Ameliorated by gaze - Several more attacks fixation (look towards over 12-18 months affected ear & it will (mild & short in go away) duration) Central Nystagmus: - NO hearing loss or (Ex: acoustic neuroma) tinnitus - No latency or fatigue - Multidirectional - Exacerbated by gaze fixation Vestibular Migraine’s What is Vestibular Migraine? - Chapter 1: Migraine Types - Explain… Clinical ft. Diagnostic Criteria Episodic vertigo: lasts min to hrs, can be - At least 5 ep. of vestibular sx of moderate or spontaneous or triggered by things like severe intensity, lasting bw 5 min & 72 hrs flashing - One or more migrainous ft. w/at least 50% HA: most commonly associated sx, but pt of vestibular ep. doesn’t always have a HA when they have - associations w/HA: photophobia, ep. of vertigo migraine HA, visual auras & throbbing pain Interictal sx: (mild vertigo in bw attacks) - Current or past hx of migraine HA susceptible to motion sickness - Sx not better accounted by another dx Benign Positional Vertigo ➔ NO hearing loss or tinnitus ➔ Most common cause of vertigo sensation: sudden & intermittent (lasts < 30 sec) ➔ Elicited by certain head positions ➔ Occasional ep. for days to weeks, pt usually well bw attacks ➔ Rinne test: AC > BC ➔ Pathology: The inner ear has 3 semicircular canals (SCC) ◆ Crista ampularis in SCC detects flow of fluid to determine head rotation ◆ Particles (otoliths) interfere w/sensory input & cause vertigo Acoustic Neuroma Understanding Acoustic Neuromas Definition Sx & Nystagmus Dx Benign tumor of CN VIII - - Unilateral tinnitus usually MRI & audiogram to dx derived from Schwann cells first sx in vestibular division - Hearing loss occurs yrs later - Central vertigo (vertical nystagmus worsened by gaze fixation, non-fatiguing) Middle Ear Disorders (conductive) Acute Otitis Media (AOM) Acute Otitis Media (Causes, Pathophysiology, signs and symptoms, treatment and compli… Incidence 70% peak age 6-24 months will have at least 1 ep. (infants & children) Pathogenesis ET dysfunction usually follows a URI - Difficulty draining causes bacteria to build & cilia can lose motility w/infection ET in infants is shorter, narrower, & more compliant (collapses easily) & is more horizontally situated  Sx Otalgia, irritability, fever, V/D, dec. oral p.o intake (leads to dehydration, hypoglycemia, respiratory distress in infants, infants rub face or head *8 wks or under = a fever of 100.5 or more must r/o sepsis & meningitis Risk factors: daycare, being around smoke, having fx members who have hx of recurrent OM Prevention: breastfeeding, keeping upright when they eat, no secondhand smoke, slow down w/dairy products it thickens mucus & inc. water Ear findings TM w/erythema (usually unilateral), dec. light reflex & thickened - may not be able to see malleus - Causes dec. mobility Bulging out of TM w/effusion (fluid behind it) Drainage w/TM rupture (if ear is draining do NOT put anything in ear except for antibiotic drops! Bacterial causes Strep pneumoniae, H. influenza, MCAT (moraxella catarrhalis) Tx Amoxicillin: antibiotic of choice for initial & uncomplicated OM Topical benzocaine: ear drops for pain unless TM is ruptured Immediate abx tx if: - Infants < 6 mo, toxic appearing (severe pain, fever, dec. oral intake), immunocompromised, craniofacial abnormalities (cleft palate)) - w/o risk some choose observation for 48-72 hrs before abx - especially in children 2 or older *start abx if no improvement after 48 hrs Chronic Otis Media *conductive hearing loss ➔ Definition: recurrent or persistent infections ➔ Sx & hearing loss: ◆ Usually associated w/loss of hearing - TM becomes scarred or gets serous fluid ◆ May or may not be painful ➔ Ear findings: ◆ Perforation of TM is common May not have pain if fluid drains from the ear ◆ May need tympanoplasty or tubes Otits Media w/Effusion ➔ Definition & causes: ◆ Serous effusion of middle ear (not pus) ◆ Causes: allergies, enlarged adenoids, ET obstructions ◆ This leads to hearing loss ◆ No abx (treat disease) or abx prophylaxis (prevent disease)  ➔ Sx & Ear findings: ◆ TM retractable & immobile, bubbles, air/fluid levels seen Bullous Myringitis - Bullous Myringitis Video ➔ Sx & Ear findings: ◆ Sudden onset of severe pain - will drain clear fluid from vesicles & pain will go away ◆ Vesicles seen of TM *still intact! Clear, watery type of drainage w/vesicle ruptures ➔ Etiology: ◆ Viral usually *don't use abx or eardrops Cholesteatoma Understanding Cholesteatomas ➔ “Glue ear” - persistent/recurrent watery discharge ➔ Pathophysiology: ◆ Associated w/chronic OM ◆ Chronic negative pressure in middle ear ◆ Pars flaccida pulled in forming sac ◆ Sac fills w/debris Granulation tissue that develops & grows into ear ossicles - erodes bone & leads to hearing loss ➔ Ear findings: ◆ Conductive hearing loss due to bone erosion ◆ Have persistent or recurrent watery/stinky drainage from ear ➔ Complications: ◆ Bone erosion, hearing loss, facial muscle paralysis, meningitis Acute Mastoiditis Mastoiditis - Causes, Signs, Symptoms, Diagnosis, Treatment & Comp… ➔ Cause: sequelae of AOM ➔ Definition: subperiosteal abscess in mastoid ➔ Sx/labs/exam: ◆ Erythema, edema, & tenderness - ear can be bulging & sticking off side of head High fever & D/C common ◆ Labs: leukocytosis, inc. ESR, blood c/s ◆ MRI to plan surgical tx plan ◆ Abx given & myringotomy to drain fluid Otosclerosis Understanding Otosclerosis ➔ Progressive hearing loss w/a normal TM considered a metabolic bone disease ➔ Pathology: ◆ Periosteal bone replaces endochondral bone - bone growth can extend into the inner ear in late stages & cause vertigo ➔ Onset: 15-35 y/o, familial ➔ Sx: tinnitus in 75% of pts External Ear Disorders (conductive) Acute Otitis Eterna “swimmer ear” Otitis Externa (Swimmer's ear) - Causes, Symptoms, Diagnosis, Treatment ➔ Etiology: ◆ Cause: bacterial (staph, strep, pseudomonas) ◆ Sx: pain can be severe Touchin pinna will hurt or lying down on the affected ear Ear canal becomes boggy & macerated ➔ Complication: cellulitis (causes high fever & LAO) ➔ Tx: ◆ Keep ear canal dry - no shower or drops except for abx (reduce pain) ◆ Meds can be tylenol w/codeine Chronic Otis Externa Video ➔ Associated w/skin disorders - psoriasis, atopic dermatitis, seborrheic dermatitis ➔ Sx: intense pruritis ➔ *secondary bacterial infection possible Perichondritis Video ➔ Can cause avascular necrosis ➔ Pathology: bacterial infections from piercings (example) ➔ Pinna may become deformed Relapsing polychondritis Relapsing Polychondritis Demystified: From Symptoms to Solutions ➔ Involves nasal septum ➔ Seen in middle-aged adults - pinna is affected but not ear lobe ➔ Multisystem, episodic inflammation of cartilage ➔ Initial sx: ear pain & erythema - later sx: joint pain & weight loss ➔ Death as a result of airway cartilage destruction ➔ Audio & vesicular damage can occur ➔ Violaceous color ➔ Zero negative factor (nothing supports dx lab-wise) Herpes Zoster oticus Herpes Zoster Oticus or Ramsay Hunt Syndrome: A Short Overview ➔ Cause: sequelae of shingles ➔ Sx: severe pain before rash, loss of taste, dry eyes & mouth can occur ➔ Ramsey-Hunt syndrome: facial paralysis, paroxysmal deep ear pain, vertigo, tinnitus, ipsilateral hearing loss (on affected side) Nasal disorders Epistaxis Understanding Nosebleeds (Epistaxis) ➔ (nose bleeds) ”friable” can be a sign of something else going on especially if recurring ➔ Anterior: 90% anterior nasal septum or inferior turbinate ➔ Posterior: involves posterior nasal cavity or nasopharynx ➔ Kiesselback plexus is what usually bleeds Incidence 2-10 y/o - due to nose picking or URI 50-80 y/o - seen in individuals w/dementia Important questions in hx Control the bleeding first before hx taking Ask: - Duration & site of original bleeding - Previous episodes or medications (blood thinners) - HTN or liver disease - Any other easy bleeding areas (gums,wms periods, easy bruising) Etiology - Foreign bodies - Dry mucous membranes - from dry & cold weather - Acute rhinitis or chronic sinusitis - Nose picking - Trauma - Allergies - HTN - Bleeding disorders (hemophilia, leukemia) Labs - CBC - INR/PT - CT scan if tumor suspected - Bleeding time to screen for disorders - leukemia can lead this is to repeated episodes Rhinitis Allergic Rhinitis - causes, symptoms, diagnosis, treatment, pathology Two main categories Allergic (IgE mediated) Non-allergic - same sx w/less nasal itching & conjunctival irritation - 43% of rhinitis is allergic - 23% is nonallergic rhinitis - 34% is combination Acute (non-allergic) Cause: common cold (URI) - viral Sx: watery, profuse discharge, sneezing, malaise, swelling of nasal mucosa *anosmia may occur Atrophic (non-allergic) Causes: idiopathic or secondary to rhinoplasty Sx: thinning of nasal mucosa, nasal crust formation, stuffiness  (congested), painful nasal passage, dry/shiny membranes, fetid odor Vasomotor Cause: intermittent engorgement of middle meatus not related (non-allergic) to allergies Sx: sneezing, temp changes, watery d/c Cocaine (non-allergic) Constant runny nose, watery while high & congested while sober, may be chronic decongestant users, may see chemical burns, septal perforation - leads to chronic sore throat & hoarseness Rhititis Medicamentosa Runny nose caused by different medications Ex: ACE inhibitors (for HTN), beta-blockers, NSAIDs Allergic “Hay Fever” Pathology: recognition of allergen by IgE (type 1 HSR) - Ag/Ab complex binds to mast cells in nasal mucosa or circulating basophils - Histamine & leukotrienes are released - Inflammatory cells then attracted Sx: sneezing, rhinorrhea, post-nasal drip, *No fever unless hay fever & severe Risk factors: genetic predisposition/family hx of atopy, exposure to tobacco or indoor allergens such as animals or dust mites, high pollution areas - Less common in those exposed to common childhood illnesses - Onset can be anytime & sx often wane in older adults *Can contribute or be misdiagnosed as other conditions (sleep disorders & learning disabilities) Atopy: type 1 HSR, allergic rhinitis, atopic dermatitis, asthma associations Rhinorrhea ➔ Definition: nasal discharge ➔ Causes: ◆ Trauma: ominous sign for possible skull fx, might be cerebrospinal fluid so check w/Benedict’s solution for sugar ◆ Foreign body: d/c, odor (unilateral) - drainage from on side of the nose ◆ Neoplasm: bloody d/c ➔ Choanal atresia: ◆ Congenital defect in septal development w/obstruction of nasopharynx on one or both sides If bilateral you can notice right after birth & EENT will break membrane If unilateral can lead to foul d/c later in life & recurrent Nasal Polyps Nasal Polyps - causes, symptoms, diagnosis, treatment, pathology ➔ More associated w/non-allergic rhinitis Definition & causes - Peduncular tumor on stalk - Manifestation of chronic inflammation - due to inc. Na+ reabsorption by mucosal cells which inc. H2O retention *inc. vascular permeability = edema & polyp formation Association bw mult. Polyps Mult. polyps are associated w/other conditions: & other cond. - 85% of pts w/fungal sinusitis have mult. nasal polyps - 50% of polyps have ETOH (alcohol) intolerance *all children w/mult. polyps should be evaluated for cystic fibrosis & asthma - Polyps can turn malignant but rare! Sx if large vs. small - Small can have no sx - If large: - Nasal obstruction - Congestion or rhinorrhea - Dec. sense of smell - Dull HA - Snoring - If polyp causes blockage, can lead to acute sinusitis or chronic sinusitis * epistaxis may be a sign of malignancy Where they usually arise Middle meatus Sinusitis Understanding Sinusitis Development of - Ethmoid & maxillary sinuses are very tiny at birth sinuses - Sphenoid sinus pneumatized by 5 yrs - Frontals appear at 7-8 yrs of age, but sinuses are not completely developed until late adolescence (18 y/o) *babies cannot get sinus infections bc they have only bone so abx do not work at this age! Incidence - 80% of acute bacterial sinusitis follows a viral URI - Bacterial cases are ½-2%, rest are viral - 20% are associated w/allergic rhinitis - Children have 5-10 viral URIs/yr - smaller nasal passages - Acute bacterial OM & acute bacterial sinusitis are the most common sequelae of viral URI - H.influenzae, strep pneumoniae, MCAT Definition of Acute bacterial sinusitis: infection lasting