Nursing CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT

C H A P T E R 2 5

Nasal symptoms and sinus congestion Concern about symptoms of the “common cold” accounts for a significant proportion of primary care visits by both children and adults, especially in the winter months. Viral infections and self­limiting causes of symptoms require the clinician to provide primarily symptom relief and to avoid overuse of antibiotic treatment. Symptoms include nasal congestion, rhinorrhea, postnasal drip, sneezing, itchy nose, watery and itchy eyes, and frontal headache. Severe symptoms are associated with ageusia (loss of taste) and anosmia (loss of smell).

The nose humidifies, warms, and filters inspired air. The nasal turbinates located in the nasal cavity promote turbulent airflow that causes particulate matter to fall on the mucosa, where it is swept away by ciliated pseudostratified columnar cells to the nasopharynx (Fig. 25.1). Rhinitis, or inflammation of the mucous membranes, is a frequent nasal symptom that is caused by bacterial or viral infection, a response to allergens, a response to medication, or a reaction to extremes in environmental temperature.

FIGURE 25.1 Lateral view of the left nasal cavity. Source: (From Ball JW, Dains JE, Flynn J, et al: Seidel’s guide to physical examination, ed. 8, St. Louis, 2015, Elsevier.)

Nasal polyps, septal deviation, or congenital anomaly can cause nasal obstruction. In children, nasal obstruction is frequently unilateral and may be secondary to a foreign body inserted into the nose.

Epistaxis is a common symptom in both adults and children, with most cases occurring before the age of 10 or between 45 and 65 years of age. Causes are trauma to the nose, mucosal changes related to fluctuations in

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198386.xhtml 6/10/2019

temperature and humidity, and anticoagulation therapy. Blood or structural alterations can lead to nasal obstruction.

Respiratory epithelium lines the paranasal sinuses and creates drainage into the nasal cavity via the superior meatus and middle meatus. The maxillary sinus is the most frequently involved paranasal sinus because its ciliated cells carry maxillary sinus drainage against gravity. When drainage systems become impaired as a result of mucosal edema, mechanical obstruction, or impaired ciliary activity, viruses and bacteria proliferate.

The paranasal sinuses include the frontal, ethmoid, maxillary, and sphenoid (Fig. 25.2). Most sinus infections are caused by bacteria common to the nasopharynx that proliferate when local or systemic defenses are impaired. The most common causative organisms producing bacterial sinusitis in both adults and children are Streptococcus pneumoniae and Haemophilus influenzae. Sinusitis may also be associated with allergies and asthmatic exacerbations or with contiguous infection of the mouth or face.

FIGURE 25.2 Anterior and lateral views of the paranasal sinuses. Source: (From Ball JW, Dains JE, Flynn J, et al: Seidel’s guide to physical examination, ed. 8, St. Louis, 2015, Elsevier.)

Diagnostic reasoning: Focused history What symptoms will help me narrow the possibilities? Key Questions

• Can you describe your symptoms? • Do you have pain? If so, where is the pain located? • How long have symptoms been present? • Do the symptoms occur at any particular time of the year? Do you have a history of nasal problems? • Is there a family history of allergies or asthma?

Acute symptoms

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198386.xhtml 6/10/2019

Acute sinusitis is an abrupt onset of infection of one or more of the paranasal sinuses, and it occurs when the sinus ostia become obstructed, usually after an upper respiratory tract infection. Sinusitis is frequently associated with a sore throat, often irritated by postnasal discharge, facial or tooth pain, or headache over the affected sinus, as well as morning periorbital swelling, fever, and malaise. Other less common causes include anatomical abnormality, adenoid hypertrophy, and contiguous infection, such as a dental abscess or periorbital cellulitis.

Acute symptoms of rhinitis or sinus congestion, usually lasting 48 to 72 hours, are caused by edematous mucosa obstructing the sinus ostia. Systemic symptoms such as fever, myalgias, chills, and acute infectious rhinitis are often caused by rhinoviruses or parainfluenza virus.

Acute symptoms of epistaxis may be related to trauma to the nose, exposure to changes in air temperature or humidity level, or symptoms associated with a rhinosinusitis infection.

Chronic symptoms Chronic symptoms can be caused by prolonged obstruction of the osteomeatal complex, which leads to dysfunction of ciliary motility and movement of mucus within the sinuses. Local factors that cause mechanical obstruction include adenoid hypertrophy, conchae bullosa, nasal polyps, foreign bodies, and nasal deviations. Adults with symptoms that last more than 3 weeks experience upper molar pain or headache, postnasal drip, and nausea. Chronic rhinitis lasting weeks to years is rarely infectious; rather, it is often associated with anatomical abnormalities that impair the sinus drainage system, although the mucociliary clearance mechanisms are normal.

In children, chronic sinusitis is defined as the presence of symptoms for longer than 30 days.

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198386.xhtml 6/10/2019

Chronic epistaxis can be related to nose picking, foreign body (especially in children), platelet disorders, and anticoagulation therapy

Location of pain An adult with sinusitis most often reports prolonged symptoms of nasal congestion and facial pain. Children rarely complain of headache or facial pain. The location of pain may indicate which sinus is involved. Pain of maxillary sinusitis occurs over the sinuses and is sometimes perceived as a maxillary toothache. Frontal sinusitis produces a frontal headache that is worse on morning wakening. Whereas ethmoid sinusitis causes pain that refers to the vertex, forehead, or occipital or temporal region, the pain of sphenoid sinusitis is perceived on the top of the head.

Seasonal occurrence of symptoms Suspect allergic rhinitis if a person describes seasonal occurrence of nasal symptoms associated with sneezing and itchy or burning eyes. A distinguishing feature of the allergic individual is the propensity to develop sustained immunoglobulin E (IgE) response after antigenic stimulation. IgE is an antibody capable of interacting with target cells that release mediators on contact with specific antigens. This reaction is the manifestation of an allergy.

People with perennial allergies have an allergen present in the environment on a year­round basis from such sources as animal dander, house dust, mold, feathers, and cockroaches. Seasonal allergies usually occur in early spring (tree pollens), early summer (grass pollens), and early fall (weed pollens).

Family history Family history of asthma or allergies is frequently associated with allergic rhinitis. Other symptoms may include a sensation of head stuffiness, ear discomfort, fatigue, and a scratchy or mild sore throat.

If I suspect sinus problems, what do I need to know? Key Questions

• Do your symptoms change with position changes? • Do you have a history of sinus problems?

Position change Maxillary sinusitis produces pain that worsens with bending or leaning forward. The postnasal discharge associated with sinusitis produces a cough that worsens while lying down.

History of sinus problems Chronic sinusitis can be attributed to infection, growths in the sinuses (nasal polyps) or a deviated nasal septum. The condition most commonly affects young and middle­aged adults, but it also can affect children.

Does the presence of other symptoms provide any clues? Key Questions

• Do you have other acute symptoms, such as cough, fever, or muscle aches? • Do you have other chronic symptoms, such as eye pain, bad breath, or fatigue?

Other acute symptoms Seropurulent nasal discharge is often present with acute bacterial infection of the nasal and sinus mucosa. Acute rhinitis caused by a bacterial or viral infection produces systemic symptoms such as fever, myalgia, and chills. Allergic rhinitis is associated with sneezing, nasal congestion, clear and profuse rhinorrhea, as well as pruritus of the nose, palate, pharynx, and middle ear. Eye symptoms include conjunctival irritation, itching, erythema, and tearing. Ear symptoms involve a feeling of fullness in the ears with popping. Sinus symptoms are pressure or pain of the cheeks, forehead, or behind the eyes.

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198436.xhtml 6/10/2019

Acute sinusitis in children involves the presence of symptoms for less than 30 days, a persistent cough, fever with a temperature greater than 39°C (102.2°F) for more than 3 days, and malodorous breath. The maxillary and ethmoid sinuses are most commonly affected, the frontal sinus is occasionally affected, and the sphenoid sinus is rarely affected.

Other chronic symptoms Chronic sinusitis involves long episodes of inflammation or repeated infections that lead to anatomical destruction. The recurrent symptoms interfere with daily activities and are not relieved with nonpharmacological measures or over­the­counter medications. Patients often report a cold that does not go away, eye pain, halitosis, chronic cough, fatigue, anorexia, and malaise.

Is the cause viral, bacterial, or allergic? Key Question

• What color is your nasal drainage?

Acute rhinitis is caused by a bacterial or viral infection that produces a watery, profuse nasal discharge early in the onset, and later becomes more mucoid and purulent. Purulent discharge may be the result of a primary viral infection or a secondary bacterial infection. The color of the nasal discharge is not diagnostic. Watery or clear discharge occurs with allergic reactions and is usually persistent or seasonal.

Are there factors that will narrow the diagnosis? Key Questions

• Are symptoms on one side or both sides? • Do you smoke? • Are you exposed to others who smoke? • Have you had a recent history of head or facial trauma? • Have you been diving or swimming? • Have you been exposed to infections in day care, school, or work settings? • Are you pregnant?

E VI DEN C E- B ASE D P R A CT I CE

Do Symptoms Distinguish Between Viral and Bacterial Acute Sinusitis? This systematic literature search was done to assess the diagnostic value of fever and facial and dental pain in adults suspected of acute bacterial rhinosinusitis (ABRS). The prevalence of positive predictive values and negative predictive values were extracted from 3171 records where the diagnosis was confirmed by culture from either sinus puncture or endoscopically obtained antral aspirate. Only one study was deemed to be of good quality. The study reported an odds ratio for fever of 1.02 (0.52–2.00) and 1.65 (0.83–3.28) for facial and dental pain. The authors concluded that evidence is inadequate to support the value of fever and facial and dental pain to differentiate viral or bacterial causes of ABRS in adults. These symptoms should not be used in clinical practice for decision making about prescribing antibiotic treatment.

Reference: Hauer et al, 2014.

Unilateral or bilateral symptoms Infectious rhinitis and allergic rhinitis are usually bilateral. Unilateral symptoms are more indicative of an anatomical cause such as nasal polyps, septal deviation, unilateral choanal atresia, or a foreign body (typically occurs in children).

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198436.xhtml 6/10/2019

Smoking history Smokers have an increased risk of sinusitis. Smoking can lead to the production of more tenacious mucus and to temporary paralysis of the nasal cilia. Exposure to passive smoke causes an increased risk of upper and lower respiratory tract infections.

Trauma history Nasal trauma or fracture may lead to nasal congestion. A rare but serious posttrauma cerebrospinal fluid rhinorrhea can be present. Up to 80% of head injuries involve the paranasal sinuses.

Diving and swimming Sinusitis from diving or swimming is secondary to barotrauma, infection from contaminated water, or an allergic response to chlorine. Chlorine exposure can cause inflammation of the sinus mucosa, restricting nasal discharge.

Exposure Exposure to viral infections increases when children are exposed to other children. The spread of a virus occurs by direct secretion of droplets or contact with contaminated objects.

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198436.xhtml 6/10/2019

Pregnancy The hormonal changes of pregnancy can cause nasal congestion.

Is the patient using any drugs that would cause nasal congestion? Key Questions

• Are you using nasal sprays or drops? • Do you use cocaine or other recreational drugs? • What other medications are you taking?

Nasal spray The use of topical sympathomimetic sprays or drops for more than 1 week can lead to rebound nasal congestion or vasodilation after short periods of vasoconstriction. The use of decongestants and antihistamines with low ambient humidity leads to excessive dryness and impaired ciliary function.

Recreational drug use Chronic or acute cocaine use can cause rebound nasal congestion. Nasal congestion associated with conjunctivitis and irritation of the eyes may be seen in people who abuse drugs by inhalation.

Medications Oral contraceptives, phenothiazines, angiotensin­converting enzyme inhibitors, and β­blockers may cause nasal congestion.

Is there systemic disease present? Key Questions

• Have you noticed any other body symptoms? • Do you have any chronic health problems?

Systemic disorders and chronic health problems Systemic causes of decreased mucociliary clearance include cystic fibrosis, ciliary dyskinesia syndrome, and immunoglobulin deficiency. Individuals with congenital or acquired immune deficiencies, such as diabetes mellitus, leukemia, acquired immunodeficiency syndrome, and cystic fibrosis, have an increased risk of developing acute and chronic sinusitis. Hypothyroidism, acromegaly, Horner syndrome, neoplasm, and granulomatosis disorder can cause nasal symptoms.

Diagnostic reasoning: Focused physical examination

Perform a general inspection Note the patient’s general appearance. Observe for signs of impaired mental status. A severe, unremitting, or new­onset headache, vomiting, or alteration in consciousness requires consideration for immediate referral.

Take vital signs Patients with acute viral rhinitis or acute sinusitis may be afebrile or have a low­grade fever. Patients with allergic rhinitis are afebrile. The presence of mouth breathing suggests chronic nasal obstruction caused by hypertrophied pharyngeal lymphoid tissues.

Inspect the face Children with chronic allergic conditions have an allergic “salute”; this is a crease on the nose from continued wiping up of nasal drainage. Allergic “shiners” are dark circles under the eyes suggestive of venous congestion

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198525.xhtml 6/10/2019

and stasis. Observe for allergic facies from chronic mouth breathing: open mouth, receding chin, overbite, elongated face, and arched hard palate. Observe for facial symmetry and signs of periorbital edema. Periorbital cellulitis is the most common serious complication of severe bacterial sinusitis.

Perform a regional examination of the head and neck Examine the eyes (including visual acuity), ears, and cervicofacial lymph nodes. Complications of severe fulminant sinusitis are rare and are caused by the direct spread of infection, secondary to destruction of the wall between the sinuses and the orbit. Symptoms can include a sudden increase in pain, acute edema of the eyelids, periorbital edema and erythema, decreased visual acuity, diplopia, and displacement of the eye laterally. The patient may experience pain on testing of extraocular muscles. These symptoms mandate immediate referral.

Observe for symptoms of coryza (acute rhinitis) as well as ear and eye drainage. Erythematous tympanic membranes are seen in acute viral rhinitis.

Examine the mouth and teeth Examine the teeth for the presence of abscesses, especially the first and secondary maxillary molars and the alveolar margin of the teeth. Tenderness elicited by tapping on the maxillary teeth with a tongue blade may indicate dental root infection or maxillary sinusitis. Lymphoid hyperplasia, “cobblestoning,” may be seen on the posterior pharynx with chronic allergies. Mouth breathing is associated with hypertrophied gingival mucosa and halitosis. Halitosis can also be a sign of dental abscess or sinusitis.

Children with acute viral rhinitis have mild erythema of the tonsils and posterior pharynx. If there is vasomotor rhinitis, mucus is present in the posterior pharynx.

Test for smell Test for smell by asking the patient to close their eyes and identify simple odors (e.g., coffee, vinegar, chocolate) presented to each naris separately. Severe nasal congestion or ethmoid sinusitis causes anosmia, as do neurodegenerative diseases such as Alzheimer and Parkinson diseases.

Inspect condition of nasal mucosa and turbinates Use a nasal speculum and pen light or head mirror to optimally visualize the condition of the nasal mucosa and turbinates. A topical vasoconstrictive agent may be needed to shrink the swollen mucosa to visualize the middle meatus.

In infants and young children, the nares tend to open forward, and tilting the tip of the nose up with the thumb and directing the light into the nares will allow inspection of the nasal cavities.

Pale, swollen, and wet turbinates are seen with allergic rhinitis. Inflamed mucous membranes are seen with acute coryza or hay fever. Allergic rhinitis may also produce a violet­colored mucous membrane. Ulceration of the nasal mucosa may be found in individuals who abuse drugs by inhalation.

Inspect for masses Observe for the presence of nasal polyps, which look like skinned grapes and are usually bilateral and hang from the middle turbinate into the lumen of the nose. Septal deviation or anatomical anomalies may predispose to infection. Nasal septum deviation can also lead to nasal obstruction. Squamous cell carcinoma usually occurs unilaterally. Masses that increase in size and pulsate on Valsalva maneuver may indicate a meningocele.

Note the presence and color of any discharge Pus in the ostium of the middle turbinate suggests a bacterial sinusitis. Cerebrospinal fluid (CSF) drainage will increase in a forward position. Identify CSF by testing nasal drainage for glucose and protein levels comparable to those of CSF. Foul­smelling nasal discharge is a characteristic feature of sinusitis of dental origin. Foul­ smelling unilateral purulent discharge may indicate a foreign body in the nasal cavity.

Transilluminate the sinuses

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198525.xhtml 6/10/2019

Frontal sinuses can be transilluminated by placing a light source below the supraorbital rim. Transillumination of maxillary sinuses can be done in two ways. Place a transilluminator over the infraorbital rim, blocking light from the examiner’s vision with the free hand, and judge the amount of light transmission (opaque, dull, normal) through the hard palate. This should be performed in a completely darkened room. Dentures must be removed. A second method is to place the transilluminator in the patient’s mouth, sealing the lips, and observe the amount of light transmitted through the maxillary sinuses.

Light will pass through air­filled sinuses. Transillumination is used to assess the presence of fluid in the frontal and maxillary sinuses and cannot be used to examine the ethmoid or sphenoid sinuses. Normal transillumination of the frontal sinus rules out frontal sinusitis in 90%

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198525.xhtml 6/10/2019

of cases. Complete opacity of sinuses suggests infection. However, the results of transillumination are often nonspecific, and reduced illumination does not lead to a diagnosis.

Palpate and percuss frontal and maxillary sinuses for tenderness Percuss and palpate the cheeks for tenderness and swelling, indicating maxillary sinusitis of dental origin. To assess for tenderness in the frontal sinuses, exert pressure over the eyebrow or slightly upward pressure under the brow. Direct percussion may elicit tenderness over the affected sinus.

Test for facial fullness and pressure Bending forward from the waist (with head dropping downward) or performing a Valsalva maneuver will worsen the symptoms if a partial or complete sinus obstruction is present.

Examine the lungs Auscultate the lungs for signs of wheezing, rales, and loudness of breath sounds. Peak flow volume or PO2

saturation as measured using a pulse oximeter will detect the presence of reactive upper airway disease that may be associated with nasal symptoms.

Perform neurologic testing if indicated To detect any complications from sinusitis, assess neurologic and cranial nerve function if the patient appears severely ill. A rare but severe complication of sinusitis is cavernous sinus thrombosis. Cavernous sinuses are trabeculated sinuses located at the base of the skull that drain venous blood from facial veins. Cranial nerves III, IV, V, and VI are commonly affected because they are adjacent to the cavernous sinuses.

Laboratory and diagnostic studies

C-reactive protein C­reactive protein is a glucoprotein produced by the liver in response to inflammation caused by infectious or noninfectious processes.

Nasal smear A nasal smear performed to look for eosinophils confirms the diagnosis of allergic rhinitis. Nasal scraping of the surface epithelium and a sample of secretions are more reliable in detecting the presence of eosinophils than is the sampling of secretions alone. Either method can be used to detect the presence of neutrophils. Specimens are graded using a scale of 0 to 4+, based on the concentration of cells.

Sinus radiographs Radiographs are not routinely indicated but may be obtained in patients who have severe symptoms and fail to respond to treatment. Severe symptoms may indicate complications of sinusitis such as orbital cellulitis, brain abscess, osteomyelitis, or cavernous sinus thrombosis. A sinus radiographic series consists of four views: an anteroposterior (Caldwell) view of the ethmoid sinus, a view (Chamberlain) of the frontal sinus, a lateral view of the sphenoid and frontal sinuses, and an occipitomental (Waters) view of the maxillary sinuses.

Computed tomography scan A computed tomography (CT) scan shows air, bone, and soft tissue and optimally facilitates definition of regional anatomy and the extent of disease. A CT scan is done when sinusitis becomes chronic and does not respond to symptomatic or antibiotic treatment. A CT scan may also show causes for chronic sinusitis by visualizing disorders not detected by plain films such as facial fractures, nasal polyps, cysts, chronic mucosal thickening, temporomandibular joint disorders, foreign bodies, and tumors.

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198585.xhtml 6/10/2019

Magnetic resonance imaging Magnetic resonance imaging (MRI) is used to image soft tissue pathology of the face and neck, especially neoplastic conditions. CT does not delineate soft tissue pathology as well as MRI.

Sinus aspiration Sinus aspiration is the only way to confirm the diagnosis of bacterial sinusitis and is performed by an otolaryngologist. A trocar is introduced into the maxillary sinus through the upper gingival recess.

Nasal endoscopy Nasal endoscopy allows direct observation of the nasal passages, larynx, pharynx, and surrounding tissue and aids in the diagnosis of nasal polyps, chronic sinusitis, or laryngeal trauma. Before a flexible fiberoptic scope is threaded through the nasal passages, an anesthetic spray is applied to the nasal tissue while the patient is in a sitting position. This procedure is generally performed by an otolaryngologist.

Allergy skin testing Results of skin testing can confirm immunological disease and identify specific antigens responsible for allergic rhinitis, which may come from exposure to irritants in the patient’s environment. The presence of serum IgE antibody suggests an allergic response.

Differential diagnosis

Infectious rhinitis Infectious rhinitis is an acute condition frequently associated with a history of recent upper respiratory tract infection. A definitive sign of this condition is the presence of yellow or green purulent discharge and red nasal mucosa.

Allergic rhinitis Allergic rhinitis is distinguished by a recurrent rhinorrhea with clear watery mucus, sneezing, and pruritus. Nasal turbinates are pale and swollen. There is often a family history of allergies. About 25% of the population has some type of allergy. Diagnosis of IgE­mediated reactions to aeroallergens is based on a combination of history, physical examination, and skin tests. Nasal smears can be tested for the presence of eosinophils to confirm an allergenic response.

Seasonal allergies are associated with short bursts of intense exposure to an allergen that creates symptoms consistent with a histamine­mediated response such as pruritus, swelling, sneezing, and rhinorrhea. Perennial allergies are caused by continuous exposure to allergens associated with chronic congestion. Common indoor allergens are animal dander, dust mites, and cockroaches. Outdoor allergens include grasses, trees, pollens, and weeds. A history or pattern of symptoms and exposure is critical in diagnosis.

Nonallergic rhinitis Nonallergic rhinitis may be associated with eosinophilia on a nasal smear. Nonallergic rhinitis with eosinophilia syndrome (NARES) is a diagnosis based on nasal cytology and involves symptoms similar to allergic rhinitis without an identifiable allergen cause. A history will reveal aspirin or nonsteroidal antiinflammatory drug intolerance and rhinorrhea. Noneosinophilia is associated with any other nonallergic cause of rhinitis.

Rhinitis medicamentosa Drug­induced rebound congestion can follow the long­term use of topical nasal decongestants. Rhinitis medicamentosa is also used to describe nasal symptoms secondary to other medications, such as nasal congestion associated with hormone changes of pregnancy. Other drugs that have vasodilative effects include antihypertensives that interfere with adrenergic neuronal function and hormones in oral contraceptives. Nasal vasoconstriction response is completely abolished after the administration of reserpine.

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198585.xhtml 6/10/2019

Acute sinusitis Acute sinusitis is characterized by purulent nasal discharge, postnasal drip, and localized facial pain over the sinus involved. It often follows a viral upper respiratory tract infection. However, symptoms such as halitosis, reduced sense of smell, and morning cough have been reported in children in the absence of facial pain. Physical examination will elicit localized tenderness to palpation or percussion over the affected sinus. Pressure and pain will increase in a forward­bending position. Purulent discharge may be visible in the posterior pharynx or may be seen emerging from the ostia of the middle turbinate. Transillumination will indicate unilateral or bilateral obstruction. Ciliary function is impaired with

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560198585.xhtml 6/10/2019

infection and may not be completely restored for 2 to 6 weeks. The diagnosis of sinusitis in children requires two of three major criteria (cough, purulent nasal discharge, purulent pharyngeal drainage), or one major and two minor criteria (sore throat, wheezing, foul breath, facial pain, periorbital edema, headache, earache, fever, toothache).

Chronic sinusitis An incompletely treated acute sinusitis can lead to a chronic condition. The patient has persistent symptoms of low­grade infection and intermittent acute exacerbations typical of acute sinusitis. Symptoms are recurrent and not controlled with over­the­counter or nonpharmacologic remedies. Multiple pathogens may be causative organisms, with the most common being Moraxella catarrhalis, H. influenzae, and S. pneumoniae. A diagnosis of chronic sinusitis requires sinus radiographs or a CT scan that reveals mucosal thickening of 5 mm or greater. Allergy testing may reveal a perennial allergy that creates chronic inflammation.

Nasal or sinus obstruction A history of aspirin intolerance or asthma with polyps is associated with obstruction. Acute obstruction suggests edema secondary to infection, allergic response, exposure to irritants, or foreign body (in children). Chronic obstruction may be secondary to congenital deformity, nasal polyps, or septal deviation. In infants, congenital choanal atresia can cause obstruction.

Nasal polyposis This syndrome has multiple causative factors, including a history of asthma and aspirin intolerance. The polyps are translucent, grapelike growths that are mobile, rarely bleed, and prolapse into the nasal cavity. The resulting obstruction can be associated with chronic sinusitis. Any suspicious polyps should be biopsied.

Osteomyelitis of the frontal bone Osteomyelitis can occur as a complication of sinusitis. Osteomyelitis occurs in children and young adults and may follow head trauma or scuba diving. Staphylococcus pyogenes or anaerobic streptococci are the causative organisms. Patients appear severely ill and may have edema of the upper eyelid and puffy swelling over the frontal bone. Diagnosis is by radiography and blood culture.

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560199054.xhtml 6/10/2019

DIFFERENTIAL DIAGNOSIS OF Common Causes of Nasal Symptoms and Sinus Congestion

CONDITION HISTORY

Infectious rhinitis Perennial, but more common in winter months; recent URI

Allergic rhinitis Family history of allergies; sneezing; recurrent pattern; more common in children and young adults

Nonallergic rhinitis No allergenic cause identified

Rhinitis medicamentosa

History of medication use: oral contraceptives, nasal sprays, antihypertensives; nasal congestion

Acute sinusitis Smoker; recent URI; winter months; frontal headaches made worse with forward bending; sensation of fullness or pressure

In children nasal discharge, cough, for >10 days, fever >38°C with purulent rhinorrhea for 3 days

Chronic sinusitis History of previous sinus infections; dull ache or no pain; persistent symptoms

Obstruction History of asthma, aspirin intolerance; foreign body in children; tumor in adults; infants with choanal atresia: difficulty feeding; cyanosis if bilateral

Nasal polyposis History of asthma, aspirin intolerance

Osteomyelitis of frontal bone

History of head trauma, diving

http://e.pub/isc9kypqjl4sstrvk47e.vbk/OEBPS/xhtml/CHP0025-print-1560199054.xhtml

PHYSICAL FINDINGS

Red, swollen mucosa; purulent discharge

Pale, boggy mucosa; rhinorrhea with clear, watery mucus

Similar to allergic rhinitis

Swollen mucosa; clear mucus or dry mucosa

Purulent discharge; maxillary toothache on percussion; postnasal drainage; decreased transillumination; fever

Same as in acute sinusitis; decreased or no transillumination; obstruction such as deviated septum, polyps

Increased pain with forward motion or Valsalva; pain with percussion and palpation of sinuses; no transillumination; septal deviation

Presence of polyps

Appears severely ill; periorbital and frontal edema

6/10/2019

DIAGNOSTIC STUDIES

Nasal smear for neutrophils, intracellular bacteria, CRP

Nasal smear for eosinophils; allergy testing

Absence of eosinophilia on nasal cytology

None

None

CT scan; nasal endoscopy; allergy testing

Sinus radiographs; CT scan

Nasal endoscopy; may require biopsy

Sinus and skull radiographs; blood culture

CRP, C-reactive protein; CT, computed tomography; URI, upper respiratory infection.