PANCE Blueprint EENT (7%)

Nose and Sinus Disorders (PEARLS)

NCCPA™ PANCE EENT Content Blueprint  nose and sinus disorders

osmosis Osmosis (High Yield Nasopharyngeal Diseases)
Epistaxis (ReelDx)
ReelDx Virtual Rounds (Epistaxis)
Patient will present as → a 14-year-old who is brought to your Emergency Department (ED) with an intractable nosebleed. Pinching of the nose has failed to stop the bleeding. In the ED, a topical vasoconstrictor is tried but also fails to stop the bleeding.

Kiesselbach's Plexus or Little's Area is the most common site for anterior bleeds

The sphenopalatine artery (Woodruff’s plexus) is generally the source of severe posterior nosebleeds. Direct pressure for 15 minutes, posterior balloon packing is used to treat posterior epistaxis

DX: The majority do not require testing other than direct visualization

  • Patients with symptoms or signs of a bleeding disorder and those with severe or recurrent epistaxis should have CBC, PT, and PTT.
  • CT may be done if a foreign body, a tumor, or sinusitis is suspected.

TX: Most nosebleeds are anterior and stop with direct pressure

  • Apply direct pressure for at least 10-15 minutes, seated and leaning forward
  • Short-acting topical decongestants (Afrin, phenylephrine, cocaine)
  • Anterior nasal packing 
    • Patients with nasal packing must be treated with antibiotics (cephalosporin) to prevent toxic shock syndrome, and the patient has to return to take the packing out.
  • If there is no packing in the nose, place a small amount of petroleum jelly or antibiotic ointment inside the nostril 2 times a day for 4–5 days
  • Posterior balloon packing is used to treat posterior epistaxis. These patients must be admitted to the hospital, and prompt consultation with an otolaryngologist is indicated
  • Recurrent epistaxis: Must rule out hypertension or coagulation disorder (like vWD)

Image by Lecturio

Nasal polyps
Patient will present as → a 6-year-old female who is being seen for a routine well-child exam is noted to have multiple teardrop-shaped growths partially obstructing the nasal passages. The child has a history of chronic sinusitis and recurring ear infections. As an astute PA, you order a sweat chloride test.

Teardrop-shaped growths that form in the nose or sinuses

  • Samter's triad:
    1. asthma 
    2. aspirin sensitivity
    3. nasal polyps
  • Usually benign, often with allergic rhinitis. Consider Cystic Fibrosis when multiple polyps are seen
  • Chronic congestion and decreased sense of smell

DX: Diagnosis is clinical

  • Patients may complain of chronic congestion and a decreased sense of smell

TX: Topical nasal corticosteroid (3-month course) is the initial treatment choice. This is effective for small polyps and can reduce the need for surgical intervention.

  • Oral steroids (6-day taper) can also help reduce the size
  • Surgical removal may be necessary if therapy is unsuccessful or if polyps are large

Rhinitis (ReelDx)
ReelDx Virtual Rounds (Rhinitis)
Patient will present as → a 13-year-old boy with clear fluid discharge from his nose for 2 days duration. This has also been associated with sneezing. On nasal exam, the mucosa and turbinates appear edematous and slightly bluish. He has swollen dark circles under his eyes and a transverse nasal crease.

Clear nasal drainage, pruritis, pale, bluish, boggy mucosa, allergic shiners, IgE-mediated mast cell histamine release

DX: Diagnosis is by history and occasionally skin testing

TX: Avoid any known allergens and use antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes, and immunotherapy

  • Intranasal decongestants not to be used more than 3-5 days may cause rhinitis medicamentosa

Allergic shiner in pediatric patient

Allergic shiners

Allergic salute

Allergic salute with transverse nasal crease

Sinusitis (ReelDx)
Patient will present as → a 34-year-old previously healthy male with complaints of facial pressure and rhinorrhea for the past 3 weeks. The patient reports that several weeks prior, he had a “common cold,” which resolved. However, he has since developed worsening facial pressure, especially over his cheeks and forehead. He reports over 1 week of green-tinged rhinorrhea. His temperature is 100.1 F (37.8 C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min. The nasal exam reveals edematous turbinates and purulent discharge. The patient has facial tenderness with palpation over the involved sinus.

After URI. Sinus pain/pressure (worse with bending down and leaning forward). Facial tap elicits pain.

  • Viral: Most common, symptoms < 7 days. Bacterial: Symptoms 7+ days and associated with bilateral purulent nasal discharge
  • Organisms: S. pneumoniae, H. influenzae, M.catarhalis
  • Chronic = lasts 12 weeks or longer

DX: Plainview X-ray (waters view) is a good initial screening, CT is the Gold Standard

TX: Indications for antibiotics in rhinosinusitis include the duration of symptoms >10 days without improvement, onset of fever > 102.2 and purulent nasal discharge or facial pain > 3-4 days, and worsening of symptoms after viral URI > 5-6 days that was initially improving

  • Amoxicillin-clavulanate 875 mg/125 mg orally twice daily (x 7 days adults and 14 days pediatrics)
  • Penicillin-allergic: Doxycycline 100 mg orally twice daily (x 7 days adults and 14 days pediatrics)

**Macrolides (clarithromycin or azithromycin) and trimethoprim-sulfamethoxazole are not recommended for empiric therapy because of high rates of resistance to S. pneumoniae

Risk for resistance or antibiotic failure

  • Augmentin 2 g PO BID (x 7 days adults and 14 days pediatrics)
  • Levofloxacin 750 mg PO daily once daily x 7 days

Chronic rhinosinusitis (CRS) lasts 12 weeks or longer despite attempts at medical management. Therapy is typically given for at least three weeks and may be extended for up to ten weeks in refractory cases

  • Amoxicillin-clavulanate: 875 mg twice daily or two 1000 mg extended-release tablets twice daily
  • Pen allergic: Clindamycin 300 mg four times daily or 450 mg three times daily

Sinuses and Sinusitis (5937085231)

Front view illustration and side-by-side CT scans of normal and chronic sinusitis

Trauma and Nasal foreign body (ReelDx)
Patient will present as → a 4-year-old boy with unilateral purulent, foul-smelling nasal discharge for three days. The child has no other respiratory symptoms.

  • Persistent foul-smelling purulent unilateral nasal discharge in a young child without other respiratory symptoms should raise suspicion for a retained nasal foreign body, even without a history of witnessed foreign body insertion.

DX: Diagnosis is clinical

TX: Prior to removal, consider using oxymetazoline drops to shrink the mucous membrane

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