PANCE Blueprint EENT (7%)

Acute and chronic sinusitis (ReelDx + Lecture)

VIDEO-CASE-PRESENTATION-REEL-DX

Sinusitus

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 deg F (37.8 deg C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min. 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 cattarrhalis
  • 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

  • CT is the GOLD STANDARD

Waters View

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

Adults first-line is Amoxicillin-clavulanic acid (Augmentin) 875 BID, consider doxycycline 100 BID, reserve levofloxacin for resistant or severe cases of sinusitis.

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

  • Treat for 5–7 days in adults if uncomplicated bacterial rhinosinusitis.
  • Treat for 10–14 days in children if uncomplicated bacterial rhinosinusitis.
  • If there is no improvement after 72 hours switch to a second line agent.
  • Don't forget the basics: Hydration, Steam inhalation 20–30 minutes TID, Saline irrigation (Neti pot) or nose drops, Sleep with head of bed elevated.

 

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. What is the most appropriate antibiotic for this patient?
A
Amoxicillin/clavulanate (Augmentin)
B
Amoxicillin
Hint:
Amoxicillin alone would not be appropriate management as many isolates of S. pneumoniae, H. influenzae, and M. catarrhalis have been shown to be beta-lactamase positive and therefore nonsusceptible to amoxicillin.
C
Ampicillin-sulbactam
Hint:
Ampicillin-sulbactam provides coverage against oral anaerobes and is appropriate empiric management of pyogenic odontogenic infections, peritonsillar abscess, and Ludwig’s angina. It is not used in the management of acute bacterial rhinosinusitis.
D
Clindamycin
Hint:
For penicillin-allergic patients who can tolerate cephalosporins, clindamycin 150 mg or 300 mg every six hours plus a third-generation oral cephalosporin (cefixime 400 mg daily or cefpodoxime 200 mg twice daily) is another option.
E
Levofloxacin
Hint:
Levofloxacin may be used as second-line therapy for ABRS in patients with an allergy to penicillin, but amoxicillin-clavulanic acid would be the most appropriate initial choice in this patient.
Question 7 Explanation: 
This patient presents with a 3-week history of fever, headache, sore throat, purulent mucus draining from the nares, and tenderness of the maxillary sinuses, which suggests a diagnosis of acute bacterial rhinosinusitis. The best initial treatment is amoxicillin-clavulanic acid. The most common causative organisms of acute bacterial rhinosinusitis (ABRS) are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Due to high rates of beta-lactamase positivity, the first-line therapy for ABRS is amoxicillin-clavulanic acid. Levofloxacin should be used for patients with an allergy to penicillin.
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