PANCE Blueprint EENT (7%)

Acute and chronic sinusitis (ReelDx + Lecture)

VIDEO-CASE-PRESENTATION-REEL-DX

Sinusitus

24 y/o with fever and and right sided "sinus pain"

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.

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Looking for symptoms that worsen over 5-7 days or do not improve in > 10 days

  • Symptoms: fever, facial pain, a headache that can radiate to the upper teeth, purulent rhinorrhea, congestion, and loss of smell
  • Physical exam: Classically, facial tenderness with palpation over the involved sinus

Acute sinusitis

  • < 4 weeks duration
  • Sudden onset
  • Most commonly caused by S. pneumoniae, H. influenzae, Moraxella catarrhalis
  • Usually precipitated by an acute viral respiratory tract infection which is thought to lead to reduced clearance of mucus

Chronic sinusitis

  • > 12 consecutive weeks
  • Associated bacteria include S. aureus, anaerobes, and gram-negative organisms
  • Other risks include systemic disease, anatomic anomalies, trauma, noxious chemicals such as pollutants or smoke, and medications

The disease is subacute when symptomatic for 4–12 weeks and chronic when symptomatic for >12 weeks.

Plainview X-ray (waters view) has fallen out of favor due to poor sensitivity

  • Sinus CT is the GOLD STANDARD

Indications for antibiotics in rhinosinusitis include

  1. Duration of symptoms >10 days without improvement
  2. Fever greater than 102 F and/or purulent nasal discharge
  3. Rapid worsening of symptoms after initial improvement

First-line therapies for bacterial sinusitis in adults include (treat for 5–7 days in adults)

  • Amoxicillin 500 mg orally three times daily or 875 mg orally twice daily (for patients without risk factors for pneumococcal resistance )
  • Amoxicillin-clavulanate (Augmentin) 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
  • Cephalosporin (cefixime 400 mg daily or cefpodoxime 200 mg twice daily) prescribed with or without clindamycin (300 mg every six hours)

Second-line therapy (for those who fail to improve within 7 days) includes high dose Augmentin (2 g BID x 7 days), Moxifloxacin, Levofloxacin, or a third-generation cephalosporin plus clindamycin. If improvement is seen within 7 days of initiation of therapy, antibiotic treatment should be continued for a total course of 7 to 10 days.

  • Amoxicillin-clavulanate 2 g/125 mg extended-release tablets orally twice daily
  • Levofloxacin 500 or 750 mg orally once daily
  • Moxifloxacin 400 mg orally once daily

For penicillin-allergic patients, options include:

  • Doxycycline 100 mg orally twice daily or 200 mg orally daily
  • Levofloxacin 500 or 750 mg orally once daily
  • Moxifloxacin 400 mg orally once daily

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

Children first-line is Amoxicillin-clavulanate 45 mg/kg per day in 2 divided doses if uncomplicated acute bacterial sinusitis

  • Treat for 10–14 days in children if uncomplicated bacterial rhinosinusitis
  • Third-generation cephalosporin (eg, cefpodoxime or cefdinir) in children with penicillin allergy
  • If there is no improvement after 72 hours switch to a second-line agent
osmosis Osmosis
Picmonic
Rhinosinusitis and treatments

Rhinosinusitis is the inflammation of the sinuses. It’s usually preceded by an upper respiratory infection. Diagnosis is usually based on symptoms including nasal drainage, facial pain, retroorbital pain, or a fever if worsening.

Rhinosinusitis assessment
Play Video + Quiz
Beta lactamase inhibitors
Play Video + Quiz
Cephalosporins
Play Video + Quiz

Question 1
A 20 year-old woman presents with a 3-day history of sneezing, watery nasal discharge, and a nonproductive cough. Her throat was sore for the first 2 days, and she now complains of fatigue and difficulty breathing because of her "stuffy nose." Which of the following is most likely to improve this patient's status?
A
Ascorbic acid
Hint:
Ascorbic acid is of no proven benefit in the treatment of viral URI.
B
Amoxicillin
Hint:
The use of antibiotics is inappropriate for viral infections.
C
Pseudoephedrine
D
Chlorpheniramine
Hint:
An antihistamine may relieve the sneezing, but it may thicken secretions, making them difficult to clear.
Question 1 Explanation: 
A decongestant will relieve the nasal congestion and stuffy nose symptoms.
Question 2
A 53 year-old woman complains that she has not been able to smell for several weeks. Prior to an upper respiratory infection 3 weeks ago, her sense of smell was "just fine." The most likely cause of the anosmia is
A
intranasal obstruction
Hint:
Intranasal obstruction is common with acute bacterial or viral infections, but anosmia resolves when the obstruction resolves.
B
destruction of the olfactory neuroepithelium
C
thickened mucus covering the olfactory cilia
Hint:
Thickened mucus does not inhibit odorants from reaching the neuroepithelium.
D
depletion of the G-protein in the ciliary membrane
Hint:
G-protein is not depleted in viral URIs.
Question 2 Explanation: 
The olfactory epithelium is destroyed by viral infections and chronic rhinitis.
Question 3
A 2 year-old female presents with purulent nasal discharge bilaterally with fever and cough for several days. Her mom had taken her out of daycare for a similar occurrence 2 months ago, that was treated with Amoxicillin. Exam further reveals halitosis and periorbital edema. Treatment should be initiated with which of the following?
A
Antihistamines
Hint:
Antihistamines and intranasal corticosteroids have not been adequately studied in children to prove they make a difference in treating recurrent sinusitis.
B
Ribavirin (Rebetol)
Hint:
Ribavirin is approved for the treatment of RSV infection.
C
Intranasal corticosteroids
Hint:
See A for explanation.
D
Amoxicillin-clavulanate (Augmentin)
Question 3 Explanation: 
High dose amoxicillin-clavulanate is the treatment of choice for resistant bacterial sinusitis, especially in children presenting with risk factors (daycare attendance, previous antibiotic treatment 1-3 months prior, age younger than 2 years).
Question 4
A 26 year-old male presents with headache, sinus pressure, and sinus congestion for over a month. He has a thick nasal discharge in the mornings, but this improves as the day goes on. He is afebrile. On exam, there is tenderness over the face. TMs have normal light reflex. Nasal mucosa reveals thick yellowish discharge. Neck is supple, without lymphadenopathy. Which of the following is the diagnostic study of choice?
A
transillumination of sinuses
Hint:
Transillumination is used in the initial evaluation of chronic or acute sinusitis, but is not sensitive or specific.
B
routine sinus films
Hint:
See C for explanation.
C
CT scan of sinuses
D
nasal culture
Hint:
Nasal culture is not indicated in the evaluation of chronic sinus infections.
Question 4 Explanation: 
CT scan is more sensitive than plain films for the diagnosis and management of chronic sinusitis, and is considered the gold standard for sinus imaging.
Question 5
Which of the following is the most common etiologic agent associated with acute bacterial sinusitis in the adult population?
A
Staphylococcus aureus
Hint:
See B for explanation.
B
Streptococcus pneumoniae
C
Pseudomonas aeruginosa
Hint:
See B for explanation.
D
Mycoplasma pneumoniae
Hint:
See B for explanation.
Question 5 Explanation: 
The typical pathogens associated with acute bacterial sinusitis are Streptococcus pneumoniae, other streptococci species, and Haemophilus influenzae. Moraxella catarrhalis and Staphylococcus aureus are less common causes. Pseudomonas is a less common cause and would be associated with nosocomial infection often in a critically ill patient. Mycoplasma is not a typical cause of bacterial sinusitis.
Question 6
A 33 year-old presents with sinusitis unresponsive to three various antibiotics over the past four months. Sinus puncture is performed with culture positive for Aspergillus fumigatus. What is the most appropriate treatment for this patient?
A
Amphotericin (Amphotericin B)
B
Amoxicillin/Clavulanate (Augmentin)
Hint:
See A for explanation.
C
Ofloxacin (Floxin)
Hint:
See A for explanation.
D
Cefuroxime (Ceftin)
Hint:
See A for explanation.
Question 6 Explanation: 
Aspergillus fumigatus is a fungal organism therefore this patient would be most appropriately treated with Amphotericin B which is an antifungal medication.
Question 7
An otherwise healthy college student presents with complaints of cough, malaise, fever, sore throat, yellow-green nasal discharge, and headache for the past 3 weeks. She complains of facial pain over the cheeks and while chewing. On examination, the nasal turbinates are erythematous and edematous nearly obstructing the nares bilaterally. Her face is tender to palpation over the maxillary sinuses. She has not been previously evaluated. Which of the following is the next best step in the management of this patient?
A
Prescribe amoxicillin/clavulanate (Augmentin)
B
Prescribe azithromycin
Hint:
Both azithromycin and TMP-SMX are associated with high rates of bacterial resistance (because of overuse in patients with viral sinusitis ), and should only be used in patients who fail initial therapy or are allergic to penicillins.
C
Prescribe trimethoprim-sulfamethoxazole (TMP-SMX)
Hint:
Both azithromycin and TMP-SMX are associated with high rates of bacterial resistance (because of overuse in patients with viral sinusitis ), and should only be used in patients who fail initial therapy or are allergic to penicillins.
D
CT Head
Hint:
Imaging cannot differentiate viral from bacterial URI and generally does not change management in uncomplicated cases. It can be useful, though, in complicated cases or patients unresponsive to initial therapy.
E
Sinus aspiration
Hint:
Sinus aspiration is the gold standard for diagnosing a sinus infection as bacterial. However, it is invasive, time-consuming, painful for patients, and wholly unnecessary to diagnose and properly treat bacterial sinusitis.
Question 7 Explanation: 
Amoxicillin - clavulanate is the recommended first-line treating agent (for a 5-7 day course in uncomplicated cases) in treating bacterial rhinosinusitis. The diagnosis of acute bacterial sinusitis should be entertained under either of the following circumstances: presence of symptoms or signs of acute rhinosinusitis 10 days or more beyond the onset of upper respiratory symptoms, and worsening of symptoms or signs of acute rhinosinusitis within 10 days after an initial improvement. First-line therapy is amoxicillin with or without clavulanate.
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