Disorder Cause Symptoms Diagnosis Treatment Notes
Acute Viral
Rhinitis
Contaminated objects•
Airborne droplets•
Rhinorrhea •
Nasal congestion •
Sneezing •
Sore throat •
Cough •
Malaise HA •
Fever possible (not common)•
Exam: Nasal d/c,
edema/erythema of nasal
mucosa, pharyngitis possible
Symptomatic treatment
Fluids- hydration, warm fluids (soup, tea) •
Nasal saline- flushes nasal cavity•
Antipyretics/analgesics •
Decongestants •
Rhinovirus and
Coronavirus most
common
Acute Viral
Rhinosinusitis
Most common
Rhinovirus, , influenza virus,
parainfluenza virus
•
Numerous serologic types which is
why we stay susceptible
•
Patho: Viral inoculation via direct
contact to conjunctiva or nasal
mucosa > viral replication >
symptoms
•
Inflammation > hypersecretion
and increased vascular
permeability > transudation of
fluid
-
Impaired mucociliary clearance -
Risk factors: older age, smoking,
changes in atmospheric pressure,
swimming, asthma/allergies,
dental disease, immunodeficiency
•
Nasal congestion •
Sinus pressure/pain (worse
with bending forward)
•
Watery to purulent
rhinorrhea
•
Erythema/edema of nasal
mucosa with discharge
•
Tenderness over sinuses
possible
•
Sneezing •
Decreased sense of smell •
Malaise •
Sore throat (worse at night)•
Headache •
Cough (d/t post nasal drip) •
Fever (maybe low grade)•
Ear pressure (ET dysfxn)•
Clinical•Self limited •
Symptomatic (nasal saline, NSAIDs,
decongest ants, nasal stero ids)
•
Rest & fluids•
Last 10-14 days, first week worse•
Acute: symptoms <4
weeks
•
Subacute: symptoms
4-12 weeks
•
Chronic: symptoms
persist >12 weeks
•
Recurrent acute:less
than 4 episodes/yr w
interim symptoms
resolution
•
Acute Bacterial
Rhinosinusitis
Uncommon
(0.5-2%)
Complication of viral infection •
Maxillary is most common form•
Streptoccoccus pneumonia (most
common), H. influenza, Moraxella
catarrhalis & group A strep
•
Patho: Mucosal inflammation >
ostial obstruction > negative
pressure > retained secretions >
secondary infections
•
Purulent nasal discharge •
Nasal congestion •
Facial/sinus pain/pressure
(edema)
•
Dental pain (can have with
viral too)
•
Erythema/edema of nasal
mucosa
•
Tenderness over sinuses
possible
•
Altered smell •
Cough •
Fever •
Headache •
Fatigue•
Usually clinical •
CT (contrast)- fluid in sinuses,
air bubbles
•
Culture (refractory or
complicated cases)
•
**typically distinguished from
viral by persistence of
symptoms for more then 10
days after onset or worsening
of symptoms within 1 0 days
after initial improvement
40-69% will improve within 2 wks without
abx
•
Symptomatic: NSAIDs, decongestants,
nasal ster oids
•
Consider abx when symptoms lasts longer
than 10-14 days or when symptoms are
severe or complicated by
immunodeficiency.
Adults 65 y/o 1st line:Am oxicillin
(500mg Q8H or 875mg Q12H) or
*Augmentin (875 mg Q12H)
•
Adults >65 y/o, hospitalization in
prior 5 days, abx use in the prior
month, immunocompromised,
multiple comorbidities or severe
infection 1st line:High dose
Augmentin (2000mg/125mg Q12H)
•
PCN allergy 1st line: Doxycycline or
(Clindamycin plus a cephalosporin)
•
•
Refer: failure to resolve after adequate
abx send to otolaryngologist for eval
•
Complications:
Preseptal/Orbital
Cellulitis
•
Subperiosteal
abscess
•
Osteomyelitis •
Meningitis •
Intracranial
abscess
•
Septic cavernous
sinus thrombosis
•
Allergic Rhinitis Seasonal-pollens and spores •
Spring: Flowering shrub and tree
pollens
-
Summer: Flowering plants and
grasses
-
Fall: Ragweed and molds
-
Perennial-year round symptoms •
Dust, house mites, air pollution
and pet dander
-
Patho: Allergens enter nose >
trigger IgE > IgE activates mast
cells > release of mediators
(histamine, prostaglandins) >
mediators stimulate blood vessels,
nerves, and glands > symptoms
-
Nasal
Itching •
Watery rhinorrhea •
Nasal Congestion •
Sneezing•
Ocular
Irritation •
Pruritus •
Conjunctival erythema •
Excessive Tearing•
Other
Fatigue•
Poor sleep•
*Similar to viral rhinitis but
usually persistent and may
show seasonal variation
External Exam
Allergic shiners (dark circles),
Dennie Morgan lines, Allergic
salute(transverse nasal crease)
•
Internal Exam
Pale bluish, edematous nasal
mucosa/turbinates due to
venous engorgement
•
Nasal polyps are associated
with long standing allergic
rhinitis.
•
Other Findings
Cobblestoning in the posterior
pharynx
•
Retracted TMs with or w/o
serous fluid behind them
•
Allergic conjunctivitis •
Intranasal corticosteroids are 1st line
(fluticasone, triamcinolone)
•
Intranasal antihistamines (azelastine,
olopatadine)
•
Oral antihistamines (cetirizine, loratadine,
fexofenadine)
•
Cromolyn nasal spray •
Montelukast (Singulair)-useful if
concomitant asthma or nasal polyposis
•
Avoid or reduce exposure to allergens•
Refer: severe uncontrollable allergies can
be referred to allergist f or possible tes ting
and immunotherapy
Serum: RASTs, IgE immunoassays •
Hypersensitivity skin testing •
•
Additional Forms of
Rhinitis:
Vasomotor Rhinitis-
elderly, chronic
drip/runny nose due to
nerve
Rhinitismeticomentosa
-rebound congestion
(Afrin)
Nasal Polyps Can be seen in chronic sinusitis,
cystic fibrosis, allergies, and
asthma
•
Patho: Thought to be caused
mostly by chronic inflammation
•
Pale, edematous, mucosally
covered masses
•
Looks like water balloon •
Nasal obstruction and
diminished smell
•
Intranasal corticosteroids 1st line •
Short course of oral steroids •
If large or meds unsuccessful they can be
removed surgically
•
*Avoid aspirin in patients with nasal
polyps and history of ast hma as it can
cause severe bronchospasm (ASA or
Samter’s tri ad)
Nasal Trauma Trauma Crepitance or palpably
mobile bony segments
•
Epistaxis, pain, black eyes
•
*r/o septal hematoma:
Septal cartilage re ceives its only
nutrition f rom its closely
Aimed at maintaining nasal airway
patency an d cosmetic appear ance
•
Closed reduction can be done under local
•
Nose & Sinus Disorders
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Nose Disorders Page 1
