PANCE Blueprint EENT (7%)

Nose and Sinus Disorders (PEARLS)

osmosis Osmosis (High Yield Nasopharyngeal Diseases)
Epistaxis (ReelDx) Kiesselbach's Plexus or Little's Area is the most common site for anterior bleeds

Sphenopalatine artery (Woodruff’s plexus) is generally the source of severe posterior nosebleed, direct pressure for 15 minutes, posterior balloon packing is used to treat posterior epistaxis

TX: Most nosebleeds are anterior and stop with direct pressure

  • Apply direct pressure at least 10-15 minutes, seated leaning forward
  • Short-acting topical decongestants (Afrin, phenylephrine, cocaine)
  • Anterior nasal packing 
    • Patients with nasal packing must be treated with antibiotics (cephalosporin) prevent toxic shock syndrome and 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 of hypercoagulable disorder
Nasal polyps 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

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

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
Sinusitis (ReelDx) 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: Plainview X-ray (waters view) is a good initial screening, CT is the Gold Standard
  • Chronic = lasts 12 weeks or longer

TX: Indications for antibiotics in rhinosinusitis include the duration of symptoms >10 days without improvement. Treatment five to seven days

  • Amoxicillin (500 mg orally three times daily or 875 mg orally twice daily) or amoxicillin-clavulanate (500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily)
  • Penicillin-allergic: Doxycycline 100 mg orally twice daily or 200 mg orally daily
  • Macrolides (clarithromycin or azithromycin) and trimethoprim-sulfamethoxazole are not recommended for empiric therapy because of high rates of resistance of S. pneumoniae
  • kids Amoxicillin x 10-14 days

Chronic sinusitis: 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
Trauma and Nasal foreign body (ReelDx) Purulent, foul-smelling nasal discharge

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

EENT Benign and Malignant Neoplasms (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: Nose, Sinus, Mouth and Throat Disorders
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