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Nasal Topics for the Physician Assistant Exam

As the Physician Assistant Exam will emphasize, your nose isn’t on your face just to hold piercings and keep your eyes apart. This protuberance is a vital component of the respiratory mechanism, and it houses cells that are part of the olfactory system. A variety of conditions can affect the nose.

Sinus problems

The sinuses are spaces in the head, and they’re filled with air. Sinusitis is an inflammation of the sinuses. It’s a common reason people go to see the primary care provider. The pain of a sinus headache can be debilitating.

Just like bronchitis, sinusitis comes in acute and chronic forms:

  • Acute sinusitis: Although acute sinusitis can be either bacterial or viral, many cases are viral in nature. If the PANCE asks about common bacterial causes of acute sinusitis, think of the big three, which are also causes of otitis media. Those bacterial creatures are Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae.

    Some of the most common presentations of acute sinusitis involve the maxillary sinus. This condition can present with acute tooth pain. Common clinical presentations of acute sinusitis can also include facial pain, fever, sinus congestion, Eustachian tube dysfunction, and/or a leaky nose.

  • Chronic sinusitis: Sinusitis is chronic if the symptoms have persisted for more than 12 weeks. In the common clinical scenario, the person still has sinus congestion, facial pain, and rhinorrhea despite rounds of antibiotics. He or she isn’t getting better. This is where you start looking for anatomic problems.

    Obtaining a CT scan isn’t unreasonable, because you want to look at the osteomeatal complex. The use of multiple antibiotics may change the flora in the sinuses and increase the risk of fungal overgrowth, although this idea is somewhat debatable.

    If symptoms persist, you may need to consult an ear, nose, and throat specialist for further investigation. Causes of chronic sinusitis can include nasal polyps, anatomic issues, a blocked osteomeatal complex, allergy, and trauma to the nasal area. Sinus surgery may be recommended.

One consequence of recurrent sinus infections or chronic sinusitis is dysfunction of the Eustachian tube. When this happens, a patient may have decreased hearing as well as pressure in the ears.

Acute and chronic sinusitis may be accompanied by a thick nasal discharge, which is usually green in color and may contain pus or blood.

Nasal polyps

In someone who has recurrent sinusitis or chronic sinusitis, you need to make sure that the person doesn’t have nasal polyps. Nasal polyps are actually just the nasal mucosa gone wild, forming polyps. In addition to sinus symptoms and recurrent sinus infections, other symptoms can include headaches and a loss of smell.

Be aware of other conditions that can increase the risk of nasal polyp formation. One big example is cystic fibrosis.

Although the treatment of nasal polyps can include steroids, it usually involves consulting an ENT about surgical removal.

Allergic rhinitis

Allergies can be a real pain. Sneezing, watering eyes, and rhinorrhea, especially during certain seasons of the year, affect some people big time. An allergen such as ragweed, pollen, mold, or dust may bring on these symptoms. Sometimes people complain of anosmia.

In addition to trying to identify the potential allergen based on history, you can order allergy tests. Testing can include allergy skin testing or blood tests called RAST testing. You may order an immunoglobulin E level to assess the “allergy level” of the body.

The first-line treatment for allergic rhinitis is an intranasal steroid to relieve inflammation and swelling. An example of this is fluticasone propionate. Antihistamines, such as loratadine and cetirizine, can also be used.

You’re evaluating a 45-year-old man who presents with recurrent sneezing, watery eyes, and nasal congestion. He says he has these symptoms every spring. You initially put him on a nasal steroid, which has helped his symptoms somewhat, but they persist. Which one of the following would you add next to help alleviate his symptoms?

(A) Oseltamivir (Tamiflu)
(B) Loratadine (Claritin)
(C) Amoxicillin/clavulanic acid (Augmentin)
(D) Famciclovir (Famvir)
(E) Prednisone (Sterapred)

The correct answer is Choice (B), loratadine. The second-line treatment for allergic rhinitis after the use of an inhaled steroid is an antihistamine.

Nosebleeds: Epistaxis

During your clinical rotations, you’ve likely come across someone with epistaxis — the person’s nose won’t stop bleeding. Here are several points about epistaxis you should be aware of:

  • Know your anatomy. People can have anterior nosebleeds or posterior nosebleeds. About 90 percent of nosebleeds happen at Kiesselbach’s plexus, a venous plexus that’s affected during an anterior nosebleed. For a posterior nosebleed, the acute symptoms can involve swallowing and spitting up blood.

  • Epistaxis has multiple causes. A major cause is uncontrolled high blood pressure. Other causes include nose picking, intranasal steroids, and/or chronic oxygen use. The latter two can dry out the nasal mucosa big time. Other causes include getting hit in the beak or inhaling a nasal irritant.

  • For an anterior nosebleed, the initial treatment is to gently squeeze the anterior aspect of the nose to see whether the blood will clot. Make sure you instruct the affected person to lean his or her head forward.

How to remove stuff stuck up the nose

Little kids like to shove things like toys up their noses. Boys tend to put things up their noses more commonly than girls, and the right nostril is often the nasal orifice of choice. The foreign object usually settles out into one of the nasal turbinates, usually the middle one.

The issue with a foreign body in the nose comes from possible complications, including infection or perforation. The sinuses, ears, and/or ophthalmic areas can become infected. Physical damage can occur, depending on the nature of the foreign body.

Symptoms can include pain, unilateral drainage, headache, loss of smell, and/or fevers. A radiograph or CT scan can sometimes help in localizing and identifying the foreign body. However, nothing beats direct visualization. Removing a foreign body should be done by an experienced professional, usually an ENT.

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