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Questions and Answers
Questions and Answers
A patient presents with symptoms suggestive of acute rhinosinusitis. Which anatomical sinus is MOST commonly involved in sinus infections?
A patient presents with symptoms suggestive of acute rhinosinusitis. Which anatomical sinus is MOST commonly involved in sinus infections?
- Sphenoid sinus
- Posterior ethmoidal sinus
- Frontal sinus
- Maxillary sinus (correct)
A patient with a history of asthma and seasonal allergies presents with suspected acute rhinosinusitis. Which of the following is LEAST likely to be a contributing risk factor for their condition?
A patient with a history of asthma and seasonal allergies presents with suspected acute rhinosinusitis. Which of the following is LEAST likely to be a contributing risk factor for their condition?
- Well-controlled allergic rhinitis (correct)
- Swimming in a chlorinated pool
- Exposure to cigarette smoke
- Recent dental procedure
A patient complains of a persistent cough that worsens when lying down, alongside nasal congestion and a purulent nasal discharge. Which symptom is MOST indicative of rhinosinusitis?
A patient complains of a persistent cough that worsens when lying down, alongside nasal congestion and a purulent nasal discharge. Which symptom is MOST indicative of rhinosinusitis?
- Nasal congestion
- Cough worsening in prone position
- Sore throat
- Purulent nasal discharge (correct)
A patient presents with pain between and behind their eyes. Which sinus is MOST likely affected?
A patient presents with pain between and behind their eyes. Which sinus is MOST likely affected?
A clinician suspects acute bacterial rhinosinusitis (ABRS) in a patient. Which pathogen is LEAST likely to be a causative agent of ABRS?
A clinician suspects acute bacterial rhinosinusitis (ABRS) in a patient. Which pathogen is LEAST likely to be a causative agent of ABRS?
During a physical examination for suspected rhinosinusitis, which finding is MOST indicative of nasal obstruction?
During a physical examination for suspected rhinosinusitis, which finding is MOST indicative of nasal obstruction?
A patient is diagnosed with uncomplicated acute rhinosinusitis (ARS). Under what circumstances should a CT scan of the sinuses be considered?
A patient is diagnosed with uncomplicated acute rhinosinusitis (ARS). Under what circumstances should a CT scan of the sinuses be considered?
A patient with acute rhinosinusitis is prescribed fluticasone nasal spray. What is the PRIMARY mechanism by which this medication improves symptoms?
A patient with acute rhinosinusitis is prescribed fluticasone nasal spray. What is the PRIMARY mechanism by which this medication improves symptoms?
A patient with viral rhinosinusitis asks about the benefits of using decongestants. What is the MOST appropriate response?
A patient with viral rhinosinusitis asks about the benefits of using decongestants. What is the MOST appropriate response?
After how many days without symptom improvement should antibiotics be considered for a patient with suspected acute bacterial rhinosinusitis (ABRS)?
After how many days without symptom improvement should antibiotics be considered for a patient with suspected acute bacterial rhinosinusitis (ABRS)?
A patient with a severe penicillin allergy requires antibiotic treatment for ABRS. Which antibiotic is MOST appropriate?
A patient with a severe penicillin allergy requires antibiotic treatment for ABRS. Which antibiotic is MOST appropriate?
What is the recommended duration of antibiotic treatment for adults with mild to moderate ABRS?
What is the recommended duration of antibiotic treatment for adults with mild to moderate ABRS?
A patient presents with periorbital edema, altered mental status and a severe headache in addition to symptoms of sinusitis. What is the MOST appropriate course of action?
A patient presents with periorbital edema, altered mental status and a severe headache in addition to symptoms of sinusitis. What is the MOST appropriate course of action?
A patient is diagnosed with chronic rhinosinusitis (CRS). Which duration of symptoms is MOST indicative of CRS?
A patient is diagnosed with chronic rhinosinusitis (CRS). Which duration of symptoms is MOST indicative of CRS?
Which underlying factor is MOST associated with chronic rhinosinusitis (CRS)?
Which underlying factor is MOST associated with chronic rhinosinusitis (CRS)?
What is the recommended initial treatment for chronic rhinosinusitis (CRS)?
What is the recommended initial treatment for chronic rhinosinusitis (CRS)?
When should a specialist referral be considered for a patient with rhinosinusitis?
When should a specialist referral be considered for a patient with rhinosinusitis?
What is the MOST appropriate follow-up timeline for a patient with sinusitis after initiating antibiotic therapy?
What is the MOST appropriate follow-up timeline for a patient with sinusitis after initiating antibiotic therapy?
A patient with Chronic Sinusitis states that their asthma is significantly worse. What could be the correlation between these 2 diagnoses?
A patient with Chronic Sinusitis states that their asthma is significantly worse. What could be the correlation between these 2 diagnoses?
A patient reports year-round congestion, runny nose, and postnasal drip. They mention the symptoms are significantly worse indoors, especially when cleaning. Which allergic trigger is MOST likely contributing to their chronic rhinosinusitis?
A patient reports year-round congestion, runny nose, and postnasal drip. They mention the symptoms are significantly worse indoors, especially when cleaning. Which allergic trigger is MOST likely contributing to their chronic rhinosinusitis?
Questions and Answers
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Flashcards
Flashcards
Rhinosinusitis
Rhinosinusitis
Inflammation of the nasal sinuses, most commonly caused by a viral upper respiratory infection.
Rhinosinusitis Risk Factors
Rhinosinusitis Risk Factors
Allergies, asthma, dental issues, smoking, contaminated water exposure, and nasal abnormalities.
Cardinal Symptoms of Rhinosinusitis
Cardinal Symptoms of Rhinosinusitis
Purulent nasal discharge, nasal obstruction, and facial pain/pressure/fullness
Maxillary Sinusitis Pain
Maxillary Sinusitis Pain
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Causes of Rhinosinusitis
Causes of Rhinosinusitis
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Common Viral Pathogens in Rhinosinusitis
Common Viral Pathogens in Rhinosinusitis
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Common Bacterial Pathogens in ABRS
Common Bacterial Pathogens in ABRS
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Clinical Signs of Rhinosinusitis
Clinical Signs of Rhinosinusitis
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First-Line Treatment for ARS
First-Line Treatment for ARS
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Intranasal Corticosteroid Example
Intranasal Corticosteroid Example
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Watchful Waiting for Rhinosinusitis
Watchful Waiting for Rhinosinusitis
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When to Consider Antibiotics
When to Consider Antibiotics
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First-Line Antibiotic for ABRS
First-Line Antibiotic for ABRS
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Complications of Rhinosinusitis
Complications of Rhinosinusitis
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Urgent Referral Symptoms for Sinusitis
Urgent Referral Symptoms for Sinusitis
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Chronic Rhinosinusitis (CRS)
Chronic Rhinosinusitis (CRS)
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Key Symptoms of Chronic Sinusitis
Key Symptoms of Chronic Sinusitis
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Signs of Chronic Sinusitis on Examination
Signs of Chronic Sinusitis on Examination
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Underlying Conditions Associated with CRS
Underlying Conditions Associated with CRS
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Treatment for Chronic Sinusitis
Treatment for Chronic Sinusitis
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Study Notes
Study Notes
- Rhinosinusitis is commonly caused by viral upper respiratory tract infections (URIs).
- Most sinus infections affect the maxillary and anterior ethmoidal sinuses.
- The maxillary sinus, the largest, has a superiorly placed ostium into the nose.
Rhinosinusitis Risk Factors
- Allergies
- Asthma
- Tooth abscesses, dental infections, or procedures
- Cigarette smoking
- Swimming in contaminated water
- Conditions causing swollen nasal mucous membranes (e.g., common cold, allergic rhinitis)
- Anatomical abnormalities like nasal polyps or a deviated septum
Rhinosinusitis Symptoms
- URI symptoms
- Postnasal drip (often with a bad taste)
- Cough, particularly when prone
- Congestion
- Fever
- Ear fullness/pressure
- Sore throat from nasal drip
- Hyposmia/anosmia
- Fatigue
- Cardinal symptoms include purulent nasal discharge, nasal obstruction, and facial pain/pressure/fullness.
- Acute frontal sinusitis causes pain in the forehead and above the eyebrows.
- Maxillary sinus infections produce pain and tenderness over the cheek (toothache).
- Ethmoid sinus infection causes pain/pressure behind or between the eyes.
Rhinosinusitis Pathogens
- Viral (Majority of Cases): Rhinovirus, Coronavirus, Influenza A and B, Parainfluenza virus, Respiratory syncytial virus
- Bacterial (About 2% of Cases): Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
Rhinosinusitis Clinical Presentation
- Fever
- Nasal turbinate edema, erythema, and discharge; discharge may be purulent/bloody
- Hyponasal speech indicates nasal obstruction.
- Check for patency of bilateral nares and inspect symmetry of nose; check for structural abnormalities
- Reddened throat/signs of postnasal drip
- Eye examination
- Palpation and percussion of frontal/maxillary sinuses
- Examination and tapping of teeth
- Transillumination of front/maxillary sinuses (not always accurate)
Rhinosinusitis Diagnostics
- Acute sinusitis can be diagnosed based on symptoms and physical exam, typically without diagnostics.
- CT imaging is not appropriate for uncomplicated acute rhinosinusitis.
- CT scans are reserved for severe headache, facial swelling, or cranial nerve palsies, after maximal medical therapy, or in cases of orbital complications, neurological defects, or immunodeficiency.
Rhinosinusitis Treatment
- Analgesics, intranasal corticosteroids, and saline nasal irrigations manage symptoms.
- NSAIDs or acetaminophen manage fever, facial pain, or headache.
- Acetaminophen 650 mg PO every 4-6 hours PRN
- Ibuprofen 400mg-800mg PO Q-8 hours PRN
- Intranasal steroids (e.g., fluticasone) improve symptoms.
- Fluticasone (Flonase) 1 spray in each nostril BID
- Saline nasal irrigation improves mucociliary clearance.
- Decongestants and antihistamines are not effective for bacterial sinusitis.
- Viral rhinosinusitis is self-limited; management targets symptom relief and avoids unnecessary antibiotics
- For viral symptoms, a "watchful waiting" approach is advised before antibiotics.
- Advise patients to avoid environmental irritants and manage allergic rhinitis.
Rhinosinusitis Antibiotics
- Symptoms lasting over 10 days warrant antibiotics
- Consider antibiotics if onset includes high fever (> 39 degrees Celsius), purulent nasal discharge, facial pain > 3-4 days, or worsening symptoms after a viral URI > 5-6 days
- Mild to moderate disease in adults – treat for 5-7 days:
- Amoxicillin/clavulanate (Augmentin 875 mg po BID)
- Amoxicillin 875 mg po BID
- If non-type 1 PCN/Cephalosporin allergy (flat rash): Cefuroxime 500 mg po BID
- If severe PCN/ Cephalosporin allergy : Doxycycline hyclate 100 mg po BID, OR Levofloxacin (Levaquin) 750 mg po daily
- Use humidified air, increase fluid intake, and sleep with head elevated.
- Educate patients on the disease process and rationale for delayed antibiotics.
- For Acute Bacterial Rhinosinusitis (ABRS) with risk of resistance or antibiotic failure, treatment duration is 7-10 days:
- Amoxicillin/clavulanate 2 g PO BID
- Levofloxacin 750 mg PO once daily
- Moxifloxacin 400 mg PO once daily
Rhinosinusitis Complications
- Periorbital cellulitis, orbital cellulitis, meningitis, intracranial abscess, central venous thrombosis
- Urgent referral needed for:
- High, persistent fevers >102°F
- Periorbital edema, inflammation, or erythema
- Cranial nerve palsies
- Abnormal extraocular movements, proptosis; vision changes (double vision or impaired vision)
- Severe headache
- Altered mental status
- Meningeal signs
Chronic Sinusitis (CRS)
- Often missed by healthcare providers, it is an inflammatory condition with acute exacerbations.
- Examination reveals polyps, edema, or purulent mucus, with usually an underlying condition
- The presence of two or more of the following signs and symptoms for > 12 weeks is highly sensitive for diagnosing CRS
- Nasal obstruction
- Facial Congestion-pressure-fullness
- Discolored nasal discharge
- Hyposmia
- About 1 in 5 chronic rhinosinusitis patients also have asthma; CRS worsens asthma.
- Allergies (especially year-round, poorly controlled allergies like dust mites, animal dander, molds, and cockroaches)
- Exposure to tobacco smoke or airborne irritants
- Conditions such as cystic fibrosis, immunodeficiency, and ciliary dyskinesia
- Deviated septum is a common cause of nasal blockage potentially blocking one or both nostrils.
- Viral infections can lead to chronic rhinosinusitis.
- Focus on treating the underlying cause
- Saline irrigation (over-the-counter, not saline spray)
- Intranasal steroids for 8-12 weeks
- Follow up in 3-5 days after antibiotics if symptoms are unresolved or worse.
- Refer to ENT for recurrent infections after maximum medical therapy, if chronic sinusitis is suspected, or if infections are resistant to treatment.
- Specialist consultation is recommended to clarify the allergic or immunologic basis for sinusitis.
- Refer to EMERGENCY CARE if meningitis is suspected
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