Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2590_Библиотеки_им_академика_М_И_Перельмана
.pdf
178
ID:c0006-ti0465
ID:c0006-ti0470AID:c0006-p2375
ID:c0006-ti0475
ID:c0006-p2380
ID:c0006-ti0480DoID:c0006-p2385
ID:c0006-ti0485
ID:c0006-p2390
ID:c0006-p2395
ID:c0006-p2400
ID:c0006-p2405
ID:c0006-p2410
ID:c0006-p2415
ID:c0006-p2420
ID:c0006-p2425
ID:c0006-p2430
ID:c0006-p2435
ID:c0006-p2440
ID:c0006-p2445
ID:c0006-p2450
ID:c0006-p2455
https://t.me/med1917
CLIENT
TEACHING GUIDE
CERUMEN IMPACTION (EARWAX)
PROBLEM
temporary hearing loss.
CAUSE
tion and trauma. The wax is continuously being produced and removed from the ear via its own mechanism. Ears are self-cleaning
organs. However, at times, an overproduction of wax may build up and remain in the external ear canal. With age, the normal
mechanisms of the ear for removing earwax are decreased. This is called cerumen impaction. Use of cotton swabs to remove earwax can push the wax further into the ear and cause problems deeper into the ear canal.
PREVENTION/CARE
the ear canal and lead to an external ear infection and/or cause further impaction.
TREATMENT
A.
It is generally safe to clean the external ears with a wet washcloth. The external ear that is visible is the only part of the ear that
should be cleaned.
B.
In general, it is preferable to allow your healthcare provider or your otolaryngologist to clean your ears.
Activity:
Diet:
buildup of earwax in the external ear canal that may cause itching, pain, dizziness, ear ringing, aural fullness, and/or
Earwax
production is a normal, healthy process of the gland of the ear. Earwax is produced to protect the ear from infec-
not use cotton swabs, paper clips, bobby pins, or other objects to clean your ears. These can damage
PLAN
As tolerated.
As tolerated.
Medications:
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If:
A.
You are unable to hear.
B.
You have colored drainage or uid draining from your ears.
C.
You run a fever.
D.
You have dizziness.
E.
Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
ID:c0006-ti0490
ID:c0006-ti0495
ID:c0006-p2460
ID:c0006-ti0500
ID:c0006-p2465
ID:c0006-ti0505
ID:c0006-p2470
ID:c0006-p2475
ID:c0006-p2480
ID:c0006-p2485
ID:c0006-p2490
ID:c0006-p2495
ID:c0006-p2500
ID:c0006-p2505
ID:c0006-p2510
ID:c0006-p2515
ID:c0006-p2520
ID:c0006-p2525
ID:c0006-p2530
ID:c0006-p2535
ID:c0006-p2540
ID:c0006-p2545
ID:c0006-p2445ID:c0006-p2450ID:c0006-p2455ID:c0006-ti0490ID:c0006-ti0495ID:c0006-p2460ID:c0006-ti0500ID:c0006-p2465ID:c0006-ti0505ID:c0006-p2470ID:c0006-p2475ID:c0006-p2480ID:c0006-p2485ID:c0006-p2490ID:c0006-p2495ID:c0006-p2500ID:c0006-p2505ID:c0006-p2510ID:c0006-p2515ID:c0006-p2520ID:c0006-p2525ID:c0006-p2530ID:c0006-p2535ID:c0006-p2540ID:c0006-p2545
https://t.me/med1917
179
CLIENT
TEACHING GUIDE
TINNITUS
PROBLEM
CAUSE
strong association between tinnitus, stress, anxiety, and depression. Stressors include emotional, physical (comorbidities), environmental, and so forth. You do not have to have hearing loss to have tinnitus.
TREATMENT
A.
A hearing evaluation will be performed to determine if there is hearing loss.
B.
A CT or MRI may be performed to rule out rare worrisome causes of the tinnitus.
C.
Rest, exercise, and mindfulness meditation are encouraged to reduce stress, depression, and anxiety.
Activity:
Diet:
coffee, soft drinks) is encouraged.
Medications:
You
You
Tinnitus
Tinnitus
is the perception of sound heard in the ear and/or head with no external source. It may be in one or both ears.
is poorly understood and the cause is not known. It probably originates in the brain and not in the ear. There is a
PLAN
There is no activity restriction.
Some foods may make the tinnitus worse. Therefore, reducing the amount of sodium, nicotine, alcohol, and caffeine (tea,
Consider avoidance of aspirin. Aspirin may aggravate the severity of tinnitus.
Have Been Prescribed:
Need to Take:
You
Need to Notify the Office if You Have:
A.
Fever.
B.
Ear pain.
C.
Noticed a change in hearing loss or speech development.
D.
Dizziness.
E.
Any other new symptoms that occur.
F.
Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
https://t.me/med1917
C H A P T E R
ID:c0007-ti0005
ID:c0007-p0005
ID:c0007-ti0010
ID:c0007-ti0015
ID:c0007-p0015
ID:c0007-ti0020
ID:c0007-p0020
ID:c0007-ti0025
ID:c0007-p0025
ID:c0007-ti0030
ID:c0007-p0030
ID:c0007-p0035
ID:c0007-p0040
ID:c0007-p0045
ID:c0007-ti0035
ID:c0007-p0050
ID:c0007-p0055
ID:c0007-p0060
ID:c0007-p0065
ID:c0007-p0070
ID:c0007-p0075
ID:c0007-ti0040
ID:c0007-p0080
ID:c0007-p0085
ID:c0007-p0090
ID:c0007-p0095
ID:c0007-p0100
ID:c0007-p0105
ID:c0007-p0110
ID:c0007-p0115
ID:c0007-ti0045
ID:c0007-p0120
ID:c0007-p0125
ID:c0007-p0130
ID:c0007-p0135
ID:c0007-p0140
ID:c0007-p0145
ID:c0007-p0150
ID:c0007-p0155
ID:c0007-p0160
ID:c0007-ti0050
ID:c0007-p0165
ID:c0007-p0170
ID:c0007-p0175
ID:c0007-p0180
ID:c0007-p0185
ID:c0007-p0190
ID:c0007-p0195
ID:c0007-p0200
ID:c0007-p0205
ID:c0007-p0210
ID:c0007-p0010
https://t.me/med1917
NASAL
Jill
C. Cash and Sarah Hendershott Taylor
ALLERGIC
RHINITIS
GUIDELINES
DEFINITION
A.
Allergic rhinitis is a chronic or recurring condition charac-
terized by nasal congestion, rhinorrhea, sneezing, pruritus of
the nose, palate, and eyes, and watering and redness of the
eyes. It can occur seasonally after exposure to allergens, such
as tree pollen, grass pollen, and weed pollen. It can also occur
perennially related to inhalants such as dust mites, molds, and
pet dander. These classications can occur distinctly, or clients
can have combined seasonal and perennial allergic rhinitis.
INCIDENCE
A.
Prevalence varies according to geographic region, affect-
ing 10% to 30% of children and adults in the United States and
developed countries. This prevalence is increasing, mostly in
urban areas. Allergic rhinitis accounts for six million missed
workdays and two million missed school days per year.
PATHOGENESIS
A.
Allergic rhinitis is an immunoglobulin E (IgE)-mediated
inammation of the naso-ocular mucosa. Repeated exposure
to aeroallergens leads to allergic sensitization. In subsequent
exposure to the aeroallergen, IgE antibodies bind to mast cells
in the respiratory epithelium and histamine is released. This
results in naso-ocular inammation, leading to congestion,
rhinorrhea, sneezing, and pruritus. The nasal allergic response
has an immediate and late phase. The immediate phase peaks
15 to 30 minutes after allergen exposure, while the late phase
peaks 6 to 12 hours after exposure.
PREDISPOSING
A.
Genetic predisposition to allergy (especially for individu-
FACTORS
als with eczema or asthma).
B.
Exposure to indoor allergens.
C.
Birth during pollen season.
D.
Maternal smoking exposure (during rst year of life).
COMMON
A.
B.
C.
D.
E.
F.
OTHER
A.
B.
COMPLAINTS
Nasal congestion/obstruction.
Sneezing.
Clear rhinorrhea.
Cough from postnasal drip.
Pruritus of the nose, eyes, oral mucosa, or face.
Watering and redness of eyes.
SIGNS AND SYMPTOMS
Dry mouth from mouth-breathing.
Snoring.
C.
Eczema.
D.
Hyposmia.
E.
Shortness of breath, difculty breathing, and wheezing.
F.
Headache.
G.
Halitosis.
H.
Fatigue.
SUBJECTIVE
A.
Onset, pattern, and duration of symptoms.
B.
Characteristics of nasal discharge.
C.
Exposure to people with similar symptoms or family his-
DATA
tory of similar symptoms.
D.
Seasonal impact on symptoms.
E.
Inquire about other diseases caused by allergens, such as
asthma, eczema, and urticaria.
F.
Rule out pregnancy.
G.
Ask about systemic medications that can induce nasal
symptoms (e.g., contraceptives, antihypertensives, erectile
dysfunction drugs, and psychiatric drugs).
H.
Exposure to irritants.
I.
Prior nasal trauma.
PHYSICAL
A.
Check vitals: Make sure to include temperature as fever
EXAMINATION
would indicate an alternate etiology for the client’s symptoms.
B.
Inspect:
1.
Examine face:
a.
Note Dennie–Morgan lines (skin folds below lower
eyelids), allergic crease (“allergic salute,” transverse
crease on nose from chronic rubbing), and allergic
shiners (infraorbital edema and darkening from subcutaneous vasodilation).
2.
Examine eyes:
a.
Note conjunctival injection, excess lacrimation, and
discharge.
3.
Examine ears, nose, and throat.
a.
Ears: Red, dull, bulging, perforated tympanic mem-
brane is seen with otitis media.
b.
Nose: Look for enlarged and pale (boggy) inferior
turbinates, rhinorrhea, septal deviation, septal perforation, and polyps. Mucosa will appear pale (blue) and
boggy with clear discharge in chronic allergy. Findings
such as nasal redness, inammation, enlarged turbinates, and thick/discolored drainage are seen with
upper respiratory infection (URI).
c.
Throat: Cobblestone appearance (“cobblestoning”)
in posterior pharynx is seen in chronic allergies. Look
for tonsillar hypertrophy and postnasal drip.
The
contributions of Moya Cook to this chapter in prior editions are acknowledged here.
182
ID:c0007-p0215
ID:c0007-p0220
ID:c0007-p0225
ID:c0007-p0230
ID:c0007-p0235
ID:c0007-p0240
ID:c0007-p0245
ID:c0007-p0250
ID:c0007-ti0055
ID:c0007-p0255
ID:c0007-p0260
ID:c0007-p0265
ID:c0007-ti0060
ID:c0007-p0270
ID:c0007-p0275
ID:c0007-p0280
ID:c0007-p0285
ID:c0007-p0290
ID:c0007-p0295
ID:c0007-ti0065
ID:c0007-p0300
ID:c0007-p0305
ID:c0007-p0310
ID:c0007-p0315
ID:c0007-p0320
ID:c0007-p0330
ID:c0007-p0335
ID:c0007-p0340
ID:c0007-p0345
ID:c0007-p0350
ID:c0007-p0355
ID:c0007-p0360
ID:c0007-p0365
ID:c0007-p0370
ID:c0007-p0375
ID:c0007-p0380
ID:c0007-p0385
ID:c0007-p0390
ID:c0007-p0395
ID:c0007-p0400
ID:c0007-p0405
ID:c0007-p0410
ID:c0007-p0415
ID:c0007-p0420
ID:c0007-p0425
ID:c0007-p0430
ID:c0007-p0435
ID:c0007-p0440
ID:c0007-p0445
ID:c0007-p0450
ID:c0007-p0455
ID:c0007-p0460
ID:c0007-p0465
ID:c0007-p0470
ID:c0007-p0475
ID:c0007-p0480
ID:c0007-p0485
ID:c0007-p0490
ID:c0007-p0495
ID:c0007-p0500
ID:c0007-p0505
ID:c0007-p0510
ID:c0007-p0515
ID:c0007-p0520
ID:c0007-p0525
ID:c0007-p0530
ID:c0007-p0535
ID:c0007-p0540
ID:c0007-p0545
ID:c0007-p0550
ID:c0007-p0555
ID:c0007-p0560
ID:c0007-p0565
ID:c0007-p0570
ID:c0007-p0575
https://t.me/med1917
C.
Palpate:
1.
2.
D.
Percuss:
1.
2.
E.
Auscultate:
1.
DIAGNOSTIC
A.
Diagnosis may be made from history and physical.
B.
Best test: skin prick-puncture method to detect allergen
7: NASAL GUIDELINES
Frontal and maxillary sinuses for tenderness.
Head and neck for enlarged lymph nodes.
Frontal and maxillary sinuses for tenderness.
Chest for consolidation.
Heart and lungs.
TESTS
sensitization.
C.
Serum tests for allergen-specic IgE antibodies (e.g., IgE
immunoassay).
DIFFERENTIAL
A.
Rhinitis caused by systemic medications.
B.
Rhinitis caused by nasal decongestant or cocaine abuse
DIAGNOSES
(“rhinitis medicamentosa”).
C.
Rhinitis of pregnancy.
D.
Rhinosinusitis.
E.
Work-related (irritant, corrosive).
F.
URI.
TREATMENT
A.
General interventions:
1.
The most effective is allergy avoidance.
2.
Implement changes in work and home environment
to reduce contact with allergens, such as removing upholstery and carpets to reduce reservoirs for dust mites.
3.
Nasal saline sprays and irrigation can be used to wash
allergens from nasal passages. These should be used prior
to application of topical medications.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Allergic Rhinitis.”
C.
Pharmaceutical therapy:
1.
Topical therapy:
a.
Topical corticosteroids are the single most effec-
tive maintenance therapy for allergic rhinitis. They
have been proven more effective than oral or topical
antihistamines.
i.
Fluticasone propionate (Flonase), 50 mcg/spray:
1)
Not recommended for children under
4 years.
2)
Children 4 to 11 years, one spray each nare
daily.
3)
12 years to adult, two sprays each nare daily.
ii.
Mometasone (Nasonex), 50 mcg/spray:
1)
Not recommended for children under
2 years.
2)
Children 2 to 11 years, one spray each nare
daily.
3)
12 years to adult, two sprays each nare
daily.
iii.
Beclomethasone (Beconase) 42 mcg/spray or
Qnasl 80 mcg/spray:
1)
Not recommended for children under
6 years.
Children 6 to 11 years, start with one spray
2)
BID with 42-mcg product.
3)
12 years to adult, two sprays each nare daily
with 80-mcg product.
iv.
Budesonide (Rhinocort), 32 mcg/spray:
1)
Not recommended for children under
6 years.
2)
Children 6 to 11 years, one spray each nare
BID.
3)
12 years to adult, two sprays each nare
daily.
v.
Triamcinolone (Nasacort), 55 mcg/spray:
1)
Not recommended for children under
2 years.
2)
Children 2 to 5 years, one spray each nare
daily.
3)
6 years to adult, two sprays each nare daily.
vi.
Flonase furoate (Flonase Sensimist), 27.5 mcg/
spray:
1)
Not recommended for children under
2 years.
2)
Children 2 to 11 years, one spray each nare
daily.
3)
12 years to adult, two sprays each nare
daily.
b.
Topical antihistamine:
i.
Azelastine hydrochloride (Astelin) 0.1% or
0.15% spray:
1)
Only lower strength can be used in children
6 months to 6 years, one spray per nare BID.
2)
6 to 12 years can use either strength, one
spray per nare BID.
3)
12 years to adult can be administered one to
two sprays each nare, one or two times daily.
ii.
Olopatadine (Patanase), 665 mcg/spray:
1)
Dose for children 6 to 11 years is one spray
each nare BID.
2)
Dose for 12 years to adult is two sprays each
nare BID.
c.
Other agents:
i.
Nasal saline:
1)
Nasal spray or irrigations help lavage irri-
tants from the mucosa.
2)
Saline gel can help lubricate nasal mucosa
to help prevent dryness.
ii.
Ipratropium bromide (Atrovent Nasal) 0.03%
spray:
1)
Useful in reducing rhinorrhea.
2)
6 years to adult, two sprays each nare, two
to three times daily.
iii.
Oxymetazoline (Afrin) 0.05% spray:
1)
6 years to adult, one to two sprays each
nare, one to two times daily.
2)
Must not use longer than 3 days due to
rebound congestion.
3)
Decongestants are NOT recommended as
monotherapy in chronic treatment, but can
help with severe nasal congestion.
iv.
Phenylephrine (Neo-Synephrine) 1% spray or
drops:
1)
12 years to adult, two sprays/drops in each
nare Q4H.
2)
Therapy should not last longer than 3
days.
3)
Decongestant NOT recommended as
monotherapy in chronic treatment, but can
help with severe nasal congestion.
2.
ID:c0007-p0580
ID:c0007-p0585
ID:c0007-p0590
ID:c0007-p0595
ID:c0007-p0600
ID:c0007-p0605
ID:c0007-p0610
ID:c0007-p0615
ID:c0007-p0620
ID:c0007-p0625
ID:c0007-p0630
ID:c0007-p0635
ID:c0007-p0640
ID:c0007-p0645
ID:c0007-p0650
ID:c0007-p0655
ID:c0007-ti0070
ID:c0007-p0660
ID:c0007-ti0075
ID:c0007-p0665
ID:c0007-p0670
ID:c0007-ti0080
ID:c0007-p0675
ID:c0007-p0680
ID:c0007-p0685
ID:c0007-p0690
ID:c0007-p0695
ID:c0007-p0700
ID:c0007-ti0085
ID:c0007-ti0090
ID:c0007-ti0095
ID:c0007-p0705
ID:c0007-ti0100
ID:c0007-p0710
ID:c0007-ti0105
ID:c0007-p0715
ID:c0007-ti0110
ID:c0007-p0720
ID:c0007-p0725
ID:c0007-p0730
ID:c0007-p0735
ID:c0007-p0740
ID:c0007-p0745
ID:c0007-p0750
ID:c0007-p0755
ID:c0007-p0760
ID:c0007-p0765
ID:c0007-p0770
ID:c0007-p0775
ID:c0007-p0780
ID:c0007-p0785
ID:c0007-p0790
ID:c0007-ti0115
ID:c0007-p0795
ID:c0007-ti0120
ID:c0007-p0800
ID:c0007-p0805
ID:c0007-p0810
ID:c0007-p0815
ID:c0007-p0820
ID:c0007-p0825
ID:c0007-ti0125
ID:c0007-p0830
ID:c0007-p0835
ID:c0007-p0840
ID:c0007-p0845
ID:c0007-p0850
ID:c0007-p0855
ID:c0007-p0860
ID:c0007-p0865
https://t.me/med1917
Oral therapy:
a.
Antihistamines (H1 receptor antagonists) are the
preferred agent. Several may need to be tried before
an effective one is found. Drugs may also need to be
switched occasionally to prevent tolerance.
i.
Cetirizine (Zyrtec):
1)
6 months to 2 years, 2.5 mg daily.
2)
Children 2 to 5 years, 5 mg daily.
3)
6 years to adult, 10mg daily.
ii.
Levocetirizine (Xyzal):
1)
Children 6 to 11 years, 2.5 mg daily.
2)
12 years to adult, 5 mg daily.
iii.
Loratadine (Claritin):
1)
Children 2 to 5 years, 5 mg daily.
2)
6 years to adult, 10mg daily.
iv.
Fexofenadine (Allegra):
1)
6 months to 2 years, 15mg BID.
2)
Children 2 to 11 years, 30mg BID.
3)
12 years to adult, 180mg daily.
FOLLOW-UP
A.
Client should return for follow-up visit in 4 to 6 weeks,
earlier if symptoms worsen after 3 days of treatment.
CONSULTATION/REFERRAL
A.
Refer the client to an allergist if symptoms continue and
interfere with daily activities.
B.
The allergist may prescribe immunotherapy following
identication of offending allergens.
INDIVIDUAL
A.
Pregnancy:
1.
2.
3.
CONSIDERATIONS
Skin testing should be deferred until after delivery.
Implement nonpharmacologic therapy rst.
Cromolyn sodium nasal spray is rst line for mild
allergic rhinitis during pregnancy/breastfeeding.
4.
Budesonide (Rhinocort) is the only pregnancy category
B nasal corticosteroid.
5.
Immunotherapy should not be initiated during preg-
nancy but can be continued at regular dose during
pregnancy.
BIBLIOGRAPHY
deShazo, R., & Kemp, S. (2021). Pharmacotherapy of allergic rhinitis. In J.
Corren (Ed.), UpToDate. Wolters Kluwer. https://www.uptodate.com
/contents/pharmacotherapy-of-allergic-rhinitis?search=allergic%20r
hinitis%20treatment&source=search_result&selectedTitle=1~150&us
age_type=default&display_rank=1#H104439168
deShazo, R. D., & Kemp, S. F. (2020). Allergic rhinitis: Clinical
manifes-tations, epidemiology, and diagnosis. In J. Corren (Ed.),
UpToDate. Wolters Kluwer. https://www.uptodate.com/contents/
allergic-rhinitis-clinical-manifestations-epidemiology-and-diagnosis#
H3018812
Peden, D. (2020). An overview of rhinitis. In J. Corren (Ed.), UpToDate.
Wolters Kluwer. https://www.uptodate.com/contents/an-overview
-of-rhinitis#H2176292974
EPISTAXIS
DEFINITION
A.
Epistaxis is a nosebleed or hemorrhage from the nose. It
may be classied as anterior or posterior, depending on the
source of bleeding. Up to 90% of nosebleeds are anterior and
can often be managed denitely in the primary care setting.
EPISTAXIS
183
INCIDENCE
A.
Epistaxis occurs in up to 60% of the general population;
only 10% seek medical attention. Most cases occur before the
age of 10 or between the age of 45 and 65.
PATHOGENESIS
A.
Epistaxis is caused by disruption of the nasal mucosa.
Up to 90% of nosebleeds occur within the vascular area of
the anterior nasal septum at the site of anastomosis of three
primary vessels (known as the Kiesselbach plexus). Anterior
epistaxis is mostly self-limited or managed in the primary
care setting. Posterior bleeds arise most commonly from the
sphenopalatine artery and result in signicant hemorrhage.
Posterior nosebleeds require prompt referral to ED for care by
an otolaryngologist and possible nasal packing, cautery, and/
or hospital admission.
PREDISPOSING
A.
Local trauma, usually from nose-picking (digital trauma)
FACTORS
or vigorous nose-blowing.
B.
Acute inammation, often from URI, acute sinusitis, aller-
gic rhinitis, or common cold.
C.
Low moisture, causing nasal dryness and irritation.
D.
Chronic use of nasal corticosteroid spray.
E.
Inhalation of chemical irritants.
F.
Presence of foreign body.
G.
Trauma.
H.
Cocaine use.
I.
Pregnancy.
J.
Neoplasm.
K.
Systemic causes:
1.
Bleeding disorders (most common).
2.
Hypertension.
3.
Heart failure.
4.
Anticoagulation.
COMMON
A.
COMPLAINT
Common complaint is unusually severe or recurrent
nosebleeds.
OTHER
SIGNS AND SYMPTOMS
A.
Anterior epistaxis:
1.
Unilateral.
2.
Continuous, mild/moderate bleeding from nasal
septum.
B.
Posterior epistaxis:
1.
Brisk (arterial) hemorrhage.
2.
Blood owing into pharynx (indicates a more serious
problem).
SUBJECTIVE
A.
Onset (with trigger or spontaneous), frequency, and dura-
DATA
tion of bleeding.
B.
Use of oral anticoagulants, aspirin, or aspirin-containing
products (e.g., Pepto-Bismol and Excedrin).
C.
Recent or current URI, acute sinusitis, and so forth.
D.
Family history of abnormal bleeding, bleeding disorders
(e.g., hemophilia or von Willebrand disease).
E.
Recent surgery or trauma.
F.
Rule out pregnancy.
G.
Ask about possible foreign body in the nose.
H.
Ask about cocaine use or occupational exposure to irri-
tants or chemicals.
184
ID:c0007-p0870
ID:c0007-p0875
ID:c0007-p0880
ID:c0007-ti0130
ID:c0007-p0885
ID:c0007-p0890
ID:c0007-p0895
ID:c0007-p0900
ID:c0007-p0905
ID:c0007-p0910
ID:c0007-p0915
ID:c0007-p0920
ID:c0007-p0925
ID:c0007-p0930
ID:c0007-p0935
ID:c0007-p0940
ID:c0007-p0945
ID:c0007-p0950
ID:c0007-p0955
ID:c0007-p0960
ID:c0007-ti0135
ID:c0007-p0965
ID:c0007-p0970
ID:c0007-p0975
ID:c0007-p0980
ID:c0007-p0985
ID:c0007-p0990
ID:c0007-ti0140
ID:c0007-p0995
ID:c0007-p1000
ID:c0007-p1005
ID:c0007-p1010
ID:c0007-p1015
ID:c0007-p1020
ID:c0007-p1025
ID:c0007-ti0145
ID:c0007-p1030
ID:c0007-p1035
ID:c0007-p1040
ID:c0007-p1045
ID:c0007-p1050
ID:c0007-p1055
ID:c0007-p1060
ID:c0007-p1065
ID:c0007-p1070
ID:c0007-p1075
ID:c0007-p1080
ID:c0007-p1085
ID:c0007-p1090
ID:c0007-p1095
ID:c0007-p1100
ID:c0007-p1105
ID:c0007-p1110
ID:c0007-p1115
ID:c0007-p1120
ID:c0007-p1125
ID:c0007-p1130
ID:c0007-p1135
ID:c0007-p1140
ID:c0007-ti0150
ID:c0007-p1145
ID:c0007-p1150
https://t.me/med1917
I.
If the client has a history of nosebleeds, how did the client
7: NASAL GUIDELINES
treat previous nosebleeds? Has prior cautery or nasal packing
been performed?
J.
Has the client ever been evaluated for a blood clot-
ting abnormality, such as thrombocytopenia or platelet
dysfunction?
K.
Does the client complain of bruising easily, melena, or
heavy menstrual periods?
PHYSICAL
A.
Check vitals: temperature, blood pressure (check for ortho-
EXAMINATION
static hypertension), pulse, and respirations. Look for signs of
airway compromise or hypovolemic shock. If nasal packing
is required, take precaution and monitor the client closely for
vasovagal episode during insertion of nasal packing.
B.
Inspect:
1.
Check airway patency with the client sitting and lean-
ing forward.
2.
Encourage client to expectorate clots and posterior pha-
ryngeal blood into an emesis basin; this will help reduce
risk of emesis and aspiration.
3.
Observe skin, mucous membranes, and conjunctiva
for rash, pallor, purpura, petechiae, telangiectasias, or
ecchymosis.
4.
The nasal cavity should be anesthetized prior to nasal
exam with topical lidocaine.
5.
Using nasal speculum, examine nose closely for sep-
tal perforation, ulcerations, or erosion. This may indicate
cocaine use or can occasionally be associated with certain
autoimmune diseases (such as lupus).
6.
Examine nasal discharge. Unilateral bleeding accom-
panied by purulent discharge indicates a foreign body in
the nose. If the discharge is bilateral, sinusitis is also in the
differential diagnosis.
7.
After bleeding has stopped:
a.
Inspect nasal mucosa; look closely at the nasal vesti-
bule, septum, and turbinates for bleeding source.
b.
Inspect nasal septum for deviation, perforation,
and/or crusting.
C.
Palpate:
1.
Check for enlarged lymph nodes or masses in the neck
to rule out sarcoidosis, tuberculosis, or malignancy.
D.
Auscultate:
1.
Heart.
2.
Lungs.
DIAGNOSTIC
A.
None required unless the client has recurrent epistaxis
TESTS
or severe blood loss.
B.
Drug screen or pregnancy test if indicated.
C.
Hematocrit and hemoglobin if bleeding is severe.
D.
Complete blood count with differential.
E.
Platelets, prothrombin time, and partial thromboplas-
tin time if bleeding disorder is suspected or if the client is
anticoagulated.
F.
Sinus lms if recurrent sinus pain, tenderness, bleeding, or
if nasal mass is suspected.
DIFFERENTIAL
A.
Foreign body.
B.
Septal deviation or perforation.
C.
Nasal tumors or mass.
D.
Coagulation disorder (von Willebrand disease).
DIAGNOSES
E.
Drug-induced coagulopathy.
F.
Hypertension.
G.
Pregnancy.
PLAN
A.
General interventions:
1.
Main goal is control of bleeding or reduction of
recurrence.
B.
Client teaching: See Client Teaching Guide for this chapter,
“Nosebleeds.”
C.
Treatment:
1.
Anterior epistaxis:
a.
Have client sit and lean forward to prevent swal-
lowing of blood.
b.
Initial tamponade:
i.
Soak a cotton pledget in phenylephrine
(Neo-Synephrine) or oxymetazoline (Afrin); place
this plug into bleeding nostril and hold pressure
over nasal alae for 10 to 15 minutes without releasing pressure.
ii.
Remove and check for bleeding.
iii.
If this fails, chemical cautery may be needed.
c.
Cautery:
i.
Only do cautery if site of bleeding is visualized.
ii.
Warn client that this may be a little painful.
Anesthetize mucous membrane by applying cotton
soaked with 2% lidocaine, lidocaine with epinephrine, or 4% cocaine.
iii.
Apply silver nitrate by applying applicator tip
to the site of bleeding for no longer than 10 seconds
until a white precipitate forms. While silver nitrate
needs moisture to work, it will only work on a relatively bloodless surface.
iv.
Avoid overzealous cautery, which can lead to
ulceration and perforation.
v.
Avoid cautery of both sides of the septum,
which can lead to tissue necrosis.
vi.
If bleeding continues, repeat initial tamponade
and cautery, then place a small amount of oxidized
regenerated cellulose (Surgicel) against the bleeding
artery. If client continues to have high-ow epi-
staxis, nasal packing may need to be performed in
emergency setting.
vii.
If bleeding stops, give client antibiotic ointment
to apply gently with ngertip or cotton swab TID
for 3 days. Saline gel or Vaseline can also be used.
2.
Posterior epistaxis:
a.
Have client sit and lean forward to prevent swal-
lowing of blood.
b.
As it can be difcult to determine the source of epi-
staxis, try to control bleeding rst with the previous
steps of topical vasoconstrictor and anesthetic and then
apply pressure.
c.
Consult a physician. The client needs ED care
immediately due to rapid blood loss.
d.
Monitor vital signs (blood pressure and pulse);
order hematocrit; blood type and crossmatch may be
needed.
FOLLOW-UP
A.
Anterior epistaxis: as needed.
B.
Posterior epistaxis: need admission to hospital and referral
to an otolaryngologist.
NONALLERGIC RHINITIS
ID:c0007-ti0155
ID:c0007-p1155
ID:c0007-p1160
ID:c0007-ti0160
ID:c0007-p1165
ID:c0007-p1170
ID:c0007-p1175
ID:c0007-p1180
ID:c0007-p1185
ID:c0007-p1190
ID:c0007-p1195
ID:c0007-p1200
ID:c0007-p1205
ID:c0007-p1210
ID:c0007-p1215
ID:c0007-p1220
ID:c0007-p1225
ID:c0007-p1230
ID:c0007-ti0165
ID:c0007-ti0170
ID:c0007-ti0175
ID:c0007-p1235
ID:c0007-ti0180
ID:c0007-p1240
ID:c0007-ti0185
ID:c0007-p1245
ID:c0007-p1250
ID:c0007-p1255
ID:c0007-p1260
ID:c0007-p1265
ID:c0007-ti0190
ID:c0007-p1270
ID:c0007-p1275
ID:c0007-p1280
ID:c0007-ti0195
ID:c0007-p1285
ID:c0007-p1290
ID:c0007-p1295
ID:c0007-p1300
ID:c0007-p1305
ID:c0007-ti0200
ID:c0007-p1310
ID:c0007-p1315
ID:c0007-p1320
ID:c0007-p1325
ID:c0007-p1330
ID:c0007-p1335
ID:c0007-p1340
ID:c0007-p1345
ID:c0007-p1350
ID:c0007-p1355
ID:c0007-ti0205
ID:c0007-p1360
ID:c0007-p1365
ID:c0007-p1370
ID:c0007-p1375
ID:c0007-p1380
ID:c0007-p1385
ID:c0007-p1390
ID:c0007-p1395
https://t.me/med1917
185
CONSULTATION/REFERRAL
A.
Anterior epistaxis: Referral to an otolaryngologist is rec-
ommended for unsuccessful cessation of hemorrhage or persistent, recurrent epistaxis despite interventions.
B.
Posterior epistaxis: Refer to a physician and/or otolaryn-
gologist immediately.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Nosebleeds are common, possibly due to hyperemia of
the nasal tissue.
2.
Suggest use of saline spray to keep the mucous mem-
branes moist throughout the day.
3.
Use Vaseline or saline gel applied gently with ngertip
or cotton-tipped applicator before bed; use humidier in
the bedroom.
B.
Pediatrics:
1.
Nosebleeds commonly occur due to trauma from
nose-picking or rubbing. Nosebleeds in children are rarely
severe.
2.
Advise parents to keep children’s ngernails short.
3.
Apply saline gel or spray (avoid Vaseline in children)
to rims of nostrils to maintain mucosal moisture.
4.
If child is using topical corticosteroid, it should be
discontinued.
C.
Geriatrics:
1.
Monitor older adults clients very closely for airway
compromise or hypovolemic shock.
2.
Anticoagulated clients are at high risk of nosebleeds.
3.
Suggest use of saline spray to keep the mucous mem-
branes moist throughout the day.
4.
Use Vaseline or saline gel applied gently with ngertip
or cotton-tipped applicator before bed; use humidier in
bedroom.
BIBLIOGRAPHY
Alter, H. (2021). Approach to the adult with epistaxis. In A. B. Wolfson&
D. G. Deschler (Eds.), UpToDate. Wolters Kluwer. https://www.uptod
ate.com/contents/approach-to-the-adult-with-epistaxis?search=epist
axis&source=search_result&selectedTitle=1~150&usage_type=default
&display_rank=1#H18
Lockwood, C. J., & Magriples, U. (2021). Prenatal care: Patient education,
health promotion, and safety of commonly used drugs. In V. Berghella
(Ed.), UpToDate. Wolters Kluwer. https://www.uptodate.com/cont
ents/prenatal-care-patient-education-health-promotion-and-safetyof-commonly-used-drugs?search=epistaxis%20in%20pregnancy&sou
rce=search_result&selectedTitle=1~150&usage_type=default&display
_rank=1
Messner, A. H. (2020). Management of epistaxis in children. In A. M.
Stack& G. C. Isaacson (Eds.), UpToDate. Wolters Kluwer. https://
www.uptodate.com/contents/management-of-epistaxis-inchildren?search=epistaxis%20in%20pediatrics&source=search_result
&selectedTitle=1~150&usage_type=default&display_rank=1
NONALLERGIC
RHINITIS
DEFINITION
A.
Nonallergic rhinitis is rhinitis without an identiable eti-
ology and without an immunoglobulin E-dependent component. It is characterized by nasal congestion, postnasal
drainage, rhinorrhea, and sneezing. It is associated with some
degree of autonomic dysregulation. It is classied in various
ways: idiopathic, vasomotor, atrophic, geriatric, drug-induced,
gustatory, occupational, or rhinitis of pregnancy.
INCIDENCE
A.
Nonallergic rhinitis may be responsible for 17% to 52% of
all rhinitis cases in adults.
PATHOGENESIS
A.
No single theory of pathogenesis for chronic nonallergic
rhinitis has been determined, but it can be divided into nonin-
ammatory and inammatory. It is a diagnosis of exclusion.
B.
Clients exhibit clinical hypersensitivity of nasal mucosa to
certain odors and irritants.
C.
Atrophic and geriatric rhinitis results from progressive
atrophy of nasal mucosa.
D.
Overuse of topical nasal decongestants or cocaine and
some systemic medications can result in nasal dysfunction.
E.
Rhinitis of pregnancy results from hormonal changes;
symptoms abate with delivery.
PREDISPOSING
A.
Age: onset of nonallergic rhinitis usually after the age
FACTORS
of 20 (whereas allergic rhinitis usually presents before 20
years).
B.
Abrupt changes in temperature, odors, and emotional stress.
C.
Other predisposing factors depending on type (e.g., over-
use of medications, side effects of systemic medications, and
occupational environment).
COMMON
A.
B.
C.
D.
E.
COMPLAINTS
Nasal congestion.
Postnasal drainage.
Rhinorrhea.
Sneezing.
Perennial symptoms, often exacerbated by weather
conditions.
SUBJECTIVE
A.
Clinical history is the most important tool used to make
DATA
distinction between allergic and nonallergic rhinitis.
B.
Ask about the onset, duration, and pattern of symptoms.
C.
Inquire about the characteristics of nasal discharge and if it
is bilateral or unilateral.
D.
Ask about potential triggers, including cigarette smoke,
strong scents, or fragrances.
E.
Ask about exposure to other people with similar symptoms.
F.
Inquire about seasonal or weather impact on symptoms,
previous treatments, and results.
G.
Rule out pregnancy.
H.
Ask about use of prescription drugs, over-the-counter
(OTC) drugs (Afrin), and illicit drugs (cocaine).
I.
Review medical history for other respiratory problems,
most importantly asthma.
J.
Pediatric consideration: Determine possibility of a foreign
object in the nostrils.
PHYSICAL
A.
Check vitals: temperature and blood pressure.
B.
Inspect:
EXAMINATION
1.
Examine general appearance.
2.
Examine eyes.
a.
Inspect conjunctivae for “allergic shiners” (dark
circles under eyes), tearing, and eyelid swelling. This
would indicate possible allergic rhinitis; nonallergic
rhinitis is NOT associated with ocular symptoms.
3.
Examine the ears, nose, and throat.
a.
Inspect ears for signs of otitis media (red, bulging, per-
forated tympanic membrane, and purulent drainage).
b.
Inspect nose for redness, swelling, polyps (soft,
pedunculated, nontender, pale, smooth structures),
enlarged turbinates, foreign objects, septal deviation,
septal perforation, ischemia, mucosal injury, atrophy,
186
ID:c0007-p1400
ID:c0007-p1405
ID:c0007-p1410
ID:c0007-p1415
ID:c0007-p1420
ID:c0007-p1425
ID:c0007-p1430
ID:c0007-ti0210
ID:c0007-p1435
ID:c0007-p1440
ID:c0007-ti0215
ID:c0007-p1445
ID:c0007-p1450
ID:c0007-p1455
ID:c0007-p1460
ID:c0007-p1465
ID:c0007-p1470
ID:c0007-p1475
ID:c0007-p1480
ID:c0007-p1485
ID:c0007-p1490
ID:c0007-p1495
ID:c0007-p1500
ID:c0007-ti0220
ID:c0007-p1505
ID:c0007-p1510
ID:c0007-p1515
ID:c0007-p1520
ID:c0007-p1525
ID:c0007-p1530
ID:c0007-p1535
ID:c0007-p1540
ID:c0007-p1545
ID:c0007-p1550
ID:c0007-p1555
ID:c0007-p1560
ID:c0007-p1565
ID:c0007-p1570
ID:c0007-p1575
ID:c0007-p1580
ID:c0007-p1585
ID:c0007-p1590
ID:c0007-p1595
ID:c0007-p1600
ID:c0007-p1605
ID:c0007-p1610
ID:c0007-p1615
ID:c0007-p1620
ID:c0007-p1625
ID:c0007-p1630
ID:c0007-p1635
ID:c0007-p1640
ID:c0007-p1645
ID:c0007-p1650
ID:c0007-p1655
ID:c0007-p1660
ID:c0007-p1665
ID:c0007-p1670
ID:c0007-p1675
ID:c0007-p1680
ID:c0007-p1685
ID:c0007-p1690
ID:c0007-p1695
ID:c0007-p1700
ID:c0007-p1705
ID:c0007-p1710
ID:c0007-p1715
ID:c0007-p1720
ID:c0007-p1725
ID:c0007-p1730
ID:c0007-p1735
ID:c0007-p1740
https://t.me/med1917
7: NASAL GUIDELINES
and “cobblestoned” pharyngeal mucosa. Nasal turbinates can appear boggy and edematous in both allergic and nonallergic rhinitis. In nonallergic rhinitis, the
mucosa is often more erythematous compared with
pale blue in allergic rhinitis. However, none of these
ndings are diagnostic and the mucosa may appear
relatively normal in nonallergic rhinitis.
C.
Palpate:
1.
Head and neck.
D.
Percuss:
1.
Sinuses.
E.
Auscultate:
1.
Heart.
2.
Lungs.
DIAGNOSTIC
A.
Nonallergic rhinitis is a diagnosis of exclusion. Diagnosis
TESTS
is based on characteristic history and physical exam, as well as
absence of clinical allergy to aeroallergens.
B.
Skin testing for allergies may be done to exclude allergic
rhinitis.
DIFFERENTIAL
A.
Allergic rhinitis.
B.
Upper respiratory infection.
C.
Foreign body.
D.
E.
Tumor.
F.
Deviated septum.
G.
Nasal polyps.
H.
Endocrine conditions, such as hypothyroidism and
DIAGNOSES
pregnancy.
I.
Drug use: oral contraceptives, aspirin, alpha-adrenergic
blockers, cocaine, and nasal decongestant overuse (rhinitis
medicamentosa).
J.
Ciliary dysfunction syndrome.
K.
Cerebral spinal uid leak.
L.
Laryngopharyngeal reux.
PLAN
A.
General interventions:
1.
Identify triggers and address alleviating triggers with
avoidance/minimization.
B.
Client teaching:
1.
Teach the client the signicance of individual triggers
for nonallergic rhinitis. Encourage use of a journal to learn
personal triggers.
2.
Avoid triggers such as smoking, smoke-lled rooms,
wood-burning stoves/replaces, sprays, and perfumes.
3.
Other triggers may include weather changes, hor-
monal changes, and medications.
4.
Teach methods of treatment and identify treatments
that work best for the client.
5.
Encourage use of saline irrigation daily to cleanse nasal
and sinus mucosa. Cleansing the mucosa daily will help
remove foreign materials inhaled and will also help with tissue edema. Clean device after each use and allow to air-dry.
C.
Pharmaceutical therapy:
1.
Monotherapy versus combination therapy:
Clients with mild disease may be adequately treated
a.
with intranasal corticosteroid or intranasal antihistamine spray. For clients who are more symptomatic,
clinical evidence has shown combination therapy to
be more effective, with both daily intranasal corticosteroid and antihistamine spray.
b.
Topical corticosteroids:
i.
Fluticasone propionate (Flonase), 50 mcg/spray:
1)
Not recommended for children under 4 years.
2)
Children 4 to 11 years, one spray each nare
daily.
3)
12 years to adult, two sprays each nare
daily.
ii.
Mometasone (Nasonex), 50 mcg/spray:
1)
Not recommended for children under
2 years.
2)
Children 2 to 11 years, one spray each nare
daily.
3)
12 years to adult, two sprays each nare
daily.
iii.
Beclomethasone (Beconase) 42 mcg/spray or
Qnasl 80 mcg/spray:
1)
Not recommended for children under
6 years.
2)
Children 6 to 11 years, start with one spray
BID with 42-mcg product.
3)
12 years to adult, two sprays each nare daily
with 80-mcg product.
iv.
Budesonide (Rhinocort), 32 mcg/spray:
1)
Not recommended for children under
6 years.
2)
Children 6 to 11 years, one spray each nare
BID.
3)
12 years to adult, two sprays each nare
daily.
v.
Triamcinolone (Nasacort), 55 mcg/spray:
1)
Not recommended for children under
2 years.
2)
Children 2 to 5 years, one spray each nare
daily.
3)
6 years to adult, two sprays each nare daily.
vi.
Flonase furoate (Flonase Sensimist), 27.5 mcg/
spray:
1)
Not recommended for children under
2 years.
2)
Children 2 to 11 years, one spray each nare
daily.
3)
12 years to adult, two sprays each nare daily.
c.
Topical antihistamine:
i.
Azelastine hydrochloride (Astelin) 0.1% or
0.15% spray:
1)
Only lower strength can be used
in children 6 months to 6 years,
one spray per nare BID.
2)
Children 6 to 12 years can use either strength,
one spray per nare BID.
3)
12 years to adult, one to two sprays each
nare, one to two times daily.
ii.
Olopatadine (Patanase), 665 mcg/spray:
1)
Dose for children 6 to 11 years is one spray
each nare BID.
2)
Dose for 12 years to adult is two sprays each
nare BID.
2.
If rhinorrhea is the dominant or only symptom (such
as in gustatory rhinitis or rhinitis of older adults), recommend anticholinergic nasal spray.
a.
Ipratropium (Atrovent) 0.03% or 0.06%:
i.
Not recommended for children under 6 years.
ii.
6 years to adult, two sprays each nare, two to
three times daily.
3.
ID:c0007-p1745
ID:c0007-p1750
ID:c0007-ti0225
ID:c0007-p1755
ID:c0007-ti0230
ID:c0007-p1760
ID:c0007-p1765
ID:c0007-ti0235
ID:c0007-p3181
ID:c0007-p1770
ID:c0007-ti0240
ID:c0007-ti0245
ID:c0007-ti0250
ID:c0007-p1775
ID:c0007-p1780
ID:c0007-p1785
ID:c0007-p1790
ID:c0007-ti0255
ID:c0007-p1795
ID:c0007-ti0260
ID:c0007-p1800
ID:c0007-p1805
ID:c0007-p1810
ID:c0007-p1815
ID:c0007-ti0265
ID:c0007-p1820
ID:c0007-p1825
ID:c0007-p1830
ID:c0007-p1835
ID:c0007-p1840
ID:c0007-p1845
ID:c0007-p1850
ID:c0007-p1855
ID:c0007-p1860
ID:c0007-p1865
ID:c0007-p1870
ID:c0007-p1875
ID:c0007-p1880
ID:c0007-ti0270
ID:c0007-p1885
ID:c0007-p1890
ID:c0007-p1895
ID:c0007-p1900
ID:c0007-p1905
ID:c0007-ti0275
ID:c0007-p1910
ID:c0007-p1915
ID:c0007-p1920
ID:c0007-p1925
ID:c0007-p1930
ID:c0007-p1935
ID:c0007-p1940
ID:c0007-ti0280
ID:c0007-p1775
ID:c0007-p1945
ID:c0007-p1950
ID:c0007-p1955
ID:c0007-p1960
ID:c0007-p1965
ID:c0007-p1970
ID:c0007-ti0285
ID:c0007-p1975
ID:c0007-p1980
ID:c0007-p1985
https://t.me/med1917
Oral decongestants:
a.
Oral decongestants can be added to the treatment
regimen, with dosing of pseudoephedrine 30 or 60mg
PO up to TID on symptomatic days. Do not use in clients with prostatic hyperplasia or hypertension.
FOLLOW-UP
A.
Clients receiving chronic therapy for rhinitis should be seen
every 3 to 12 months, depending on severity of symptoms.
CONSULTATION/REFERRAL
A.
Consult with a physician if symptoms continue despite
treatment.
B.
If treatment fails, refer the client to an allergist for testing,
and/or an ear, nose, and throat specialist to consider surgical
approaches for clients with severe, chronic nonallergic rhinitis.
INDIVIDUAL
A.
Pregnancy:
1.
CONSIDERATIONS
Reassure pregnant clients that rhinitis is a common
hormonal response. Nonallergic rhinitis is not contagious
and cannot cross the placenta.
BIBLIOGRAPHY
Lieberman, P. L. (2020). Chronic nonallergic rhinitis. In J. Corren (Ed.),
UpToDate. Wolters Kluwer. https://www.uptodate.com/contents/
chronic-nonallergic-rhinitis?search=nonallergic%20rhinitis&source=se
arch_result&selectedTitle=1~63&usage_type=default&display_rank=
1#H19
Peden, D. (2020). An overview of rhinitis. In J. Corren (Ed.), UpToDate.
Wolters Kluwer. https://www.uptodate.com/contents/an-overview
-of-rhinitis?search=nonallergic%20rhinitis&source=search_result&sel
ectedTitle=2~63&usage_type=default&display_rank=2
SINUSITIS
DEFINITION
A.
Sinusitis (often referred to as rhinosinusitis) is the symp-
tomatic inammation of the mucous membrane lining of
one or more paranasal sinuses. It may be acute, subacute, or
chronic. Diagnosis is based on subjective and objective ndings and depends on duration of symptoms.
1.
Acute sinusitis: symptoms lasting up to 4 weeks.
2.
Subacute sinusitis: symptoms lasting 4 to 12 weeks.
3.
Chronic sinusitis: symptoms lasting longer than 12 weeks.
INCIDENCE
A.
Sinusitis is very prevalent, affecting millions of people in the
United States each year. It is estimated that one in seven individuals in the United States will experience an episode of acute
sinusitis each year. Incidence is higher in females, and among
all adults it is highest in those aged 45 to 64 years. Chronic
sinusitis affects between 5% and 12% of the general population.
PATHOGENESIS
A.
The etiology of acute rhinosinusitis involves factors such
as environmental, anatomic, and systemic. These factors can
occur at the same time and predispose clients not only to acute
sinusitis but also to the development of chronic sinusitis.
B.
The most common cause of acute sinusitis is viral infection,
with the most common causes being rhinovirus, inuenza
virus, and parainuenza virus. Acute bacterial rhinosinusitis
occurs in 0.5% to 2% of all sinusitis episodes. The most common
bacterial organisms are Streptococcus pneumoniae, Haemophilus
inuenzae, and Moraxella catarrhalis. If acute sinusitis infections
are not resolved or become recurrent, Staphylococcus aureus or
Pseudomonas aeruginosa can become dominant.
SINUSITIS
C.
The transition from viral to bacterial has been studied exten-
187
sively and it is thought to be secondary to decreased mucociliary clearance and consequent colonization of bacteria on
retained mucus secretion from the obstruction of outow. The
sinonasal mucosa inammation from the triggering agent stuns
the cilia and mucus remains trapped in the sinuses, and bacteria proliferate. Anatomic abnormalities can also interfere with
normal mucociliary clearance and can prolong illness.
D.
Other causes of acute sinusitis are fungi, dental abscess,
and autoimmune reactions. Fungal sinusitis tends to occur in
immunosuppressed clients.
PREDISPOSING
A.
Recent upper respiratory infection (URI).
B.
Allergic rhinitis.
C.
Cigarette smoke (rsthand or secondhand).
D.
Air pollutant exposure.
E.
Sinonasal anatomy (septal deviation, septal spurs, tur-
FACTORS
binate hypertrophy, Haller cells, adenoidal hypertrophy, or
obstructive mass).
F.
Ciliary dysfunction (as in Kartagener syndrome and cystic
brosis).
G.
Dental anatomy/abscess.
H.
Asthma.
I.
Neoplasms.
J.
Immunodeciency (often associated with recurrent acute
or chronic sinusitis).
K.
Trauma.
L.
Diving and swimming.
M.
Flying or rapid changes in altitude.
COMMON
A.
B.
C.
D.
E.
OTHER
A.
B.
C.
D.
E.
F.
G.
POTENTIAL
A.
COMPLAINTS
Mucopurulent rhinorrhea.
Headache and/or facial pain.
Dental or ear pain.
Loss of smell (anosmia).
Nasal congestion.
SIGNS AND SYMPTOMS
Fever (mostly associated with acute sinusitis).
Malaise or fatigue.
Cough.
Periorbital edema.
Halitosis.
Snoring and mouth-breathing.
Hyponasal speech.
COMPLICATIONS
The following requires immediate ear, nose, and throat
referral.
1.
Meningitis (symptoms are increased fever and stiff
neck).
2.
Preseptal or orbital cellulitis.
3.
Subperiosteal or intracranial abscess.
4.
Epidural abscess.
5.
Cavernous sinus thrombosis (acute thrombophlebitis
due to infection in the area where veins drain into the cavernous sinus).
6.
Osteomyelitis of the sinus bones.
SUBJECTIVE
A.
Ask about onset, duration, and course of symptoms. Have
DATA
symptoms lasted longer than 10 days or longer than 12 weeks?
B.
Inquire whether seasons affect symptoms.
C.
Ask the client about recent URI and how it was treated.
Did the client receive antibiotics or steroids? Did the client nish the full course? Any relief from symptoms?
Соседние файлы в папке Библиотека им академика М.И. Перельмана