Sinusitis

Question 1

What are the 2 key types of sinusitis?

Answer 1

Acute and chronic

Question 2

What is the definition of sinusitis?

Answer 2

Symptomatic inflammation of the paranasal sinuses

Question 3

What causes acute sinusitis?

Answer 3

Triggered by a viral upper respiratory tract infection and is defined by symptoms that last for less than 12 weeks

Question 4

What is the time frame of acute vs chronic sinusitis?

Answer 4

Acute <12 weeks, chronic >12 weeks

Question 5

When is acute sinusitis diagnosed in adults vs in children?

Answer 5

• adults: presence of nasal blockage or nasal discharge with facial pain/ pressure (or headache) and/or reduction of the sense of smell
• children: presence of nasal blockage or discoloured nasal discharge with facial pain/ pressure and/or cough

Question 6

What are 7 things that examination may reveal in acute sinusitis?

Answer 6

1. inflammation
2. purulent discharge
3. mucosal oedema
4. polyps
5. septal deviation
6. tenderness over the sinuses
7. fever

Question 7

What are 5 features that would make you suspect acute bacterial sinusitis?

Answer 7

1. Symptoms >10 days
2. Discoloured or purulent nasal discharge
3. Severe local pain (with unilateral predominance)
4. Fever >38^oC
5. Deterioration after initial mild illness

Question 8

What are 2 factors needed to diagnose chronic sinusitis?

Answer 8

1. Lasts >12 weeks
2. Objective evidence of sinonasal inflammation on examination

Question 9

How is the diagnosis of chronic sinusitis made in adults vs children?

Answer 9

1. Adults: presence of nasal blockage or nasal discharge (anterior/posterior nasal drip) with facial pain or pressure (or headache) and/or reduction of the sense of smell
2. Children: presence of nasal blockage or nasal discharge with facial pain (or pressure) and/or cough

i.e. same as acute

Question 10

What are 3 signs on examination that support a diagnosis of chronic sinusitis?

Answer 10

1. Nasal inflammation
2. Mucosal oedema
3. Mucopurulent nasal discharge

Question 11

When should you make a non-urgent referral to an ENT specialist in suspected sinusitis? 8 situations

Answer 11

1. If signs and symptoms are not typical of sinusitis and diagnosis in doubt
2. Treatment failure after extended course of antibiotics
3. Frequent recurrent episodes (more than 3 requiring abx a year)
4. Unusual or resistant bacteria
5. Anatomic defect(s) causing obstruction
6. Immunocompromise
7. Suspected allergic or immunological cause
8. Comorbidities complicating management such as nasal polyps

Question 12

When should you make an urgent referral to ENT for acute sinusitis (2 key features)?

Answer 12

If neoplasm suspected e.g.:

1. unilateral polyp or mass
2. bloody nasal discharge

Question 13

What are 6 situations when you should refer urgently to ENT in chronic sinusitis?

Answer 13

1. If unilateral symptoms
2. Epistaxis
3. Blood-stained discharge
4. Crusting
5. Orbital symptoms e.g. diplopia or reduced visual acuity
6. Neurological symptoms or signs

Question 14

What are 4 aspects of the management of acute sinusitis?

Answer 14

1. Advice about natural course and cause of infection
2. Recommending measures to relieve symptoms e.g. analgesia for pain or fever
3. Considering need for antibiotics
4. Considering high-dose intranasal corticosteroids in adults with more severe or prolonged symptoms

Question 15

What are 5 aspects of the management of chronic sinusitis?

Answer 15

1. Managing any associated disorder e.g. allergic rhinitis or asthma
2. Advice on avoiding exacerbating factors such as allergic triggers
3. Recommending measures to relieve symptoms, such as nasal irrigation with saline solution
4. Considering the need for intranasal corticosteroids (especially if there’s suspicion of allergic cause)
5. Considering need for long-term antibiotics (and starting treatment only after discussing this with a specialist)

Question 16

What is the course of acute sinusitis over time?

Answer 16

Increase in symptoms after 5 days, or persistence of symptoms beyond 10 days, but less than 12 weeks

Question 17

What are 3 further symptoms of acute sinusitis in addition to the diagnostic features?

Answer 17

1. Altered speech indicating nasal obstruction
2. Tenderness, swelling or redness over the cheekbone or periorbital areas
3. Cough

Question 18

How should you perform examination in suspected sinusitis?

Answer 18

• Inspect and palpate maxillofacial area to elicit sweling or tenderness
• Perform anterior rhinoscopy (using largest speculum of otoscope or head light and nasal speculum)

Question 19

What are 3 predisposing factors to chronic sinusitis?

Answer 19

1. Allergic rhinitis (symptoms include sneezing; watery nasal discharge; nasal itching; itchy, watery eyes)
2. Asthma
3. Immunosuppression

Question 20

What are 6 differentials for sinusitis?

Answer 20

1. URTI
2. Allergic rhinitis
3. Nasal foreign body
4. Adenoiditis and tonisillitis
5. Sinonasal tumour
6. Migraine

Question 21

What are 3 situations when you should refer sinusitis for urgent hospital admission?

Answer 21

1. Severe systemic infection
2. Intraorbital or periorbital complications, including periorbital oedema or cellulitis, displaced eyeball, double vision, ophthalmoplegia, newly reduced visual acuity
3. Intracranial complications, including swelling over frontal bone, symptoms or signs of meningitis, severe frontal headache, focal neurological signs

Question 22

What are 6 symptoms suggestive of orbital involvement in sinusitis?

Answer 22

1. Peri-orbital oedema
2. Peri-orbital cellulitis
3. Displaced eyeball
4. Double vision
5. Ophthalmoplegia
6. Reduced visual acuity

Question 23

What are 4 symptoms suggestive of intracranial involvement in sinusitis?

Answer 23

1. Severe frontal headache
2. Swelling over frontal bone
3. Symptoms or signs of meningitis
4. Focal neurological signs

Question 24

What should you do in the community for a patient with sinusitis needing hospital admission?

Answer 24

Offer immediate antibiotic prescription (phenoxymethylpenicllin/co-amoxiclav/doxycycline/clarithromycin) or further appropriate investigation and management in line with NICE guidance on self-limiting resp tract infections

Question 25

What are 5 things to do if a person has had acute sinusitis symptoms for **\<10 days?**

Answer 25

1. Do not offer antibiotic prescription 2. Advise that acute sinusitis usually caused by **virus** and only complicated by bacterial infection in about 2 in 100 cases. takes 2-3 weeks to resolve, most will get better without abx 3. Symptoms can be managed with self care: paracetamol, ibuprofen, nasal saline/ nasal decongestants (lack of evidence for these though). NHS website for instructions on using salt water to ease congestion 4. No evidence for oral decongestants, antihistamines, mucolytics, steam inhalation, warm face packs 5. Seek medical advice if rapid worsening or don't improve after 3 weeks, or become systemically very unwell

Question 26

What are 4 aspects to management of acute sinusitis that has lasted **\>10 days?**

Answer 26

1. Prescribe **high dose nasal corticosteroid** for **14 days** for adults and children \>12y e.g. **mometasone** **200mcg** **bd** 2. Consider no abx or back up prescription 3. If back up prescription given, advice about managing symptoms with self care, use prescription if worsen rapidly or significantly, or don't improve within 7 days 4. Advise to seek medical advice if develop complications, symptoms rapidly deteriorate, don't improve within 3-5 days of initial treatment, or stop abx treatment because not tolerated

Question 27

What is the suggested regime for nasal corticosteroid for acute sinusitis lasting \>10 days (adults and children \>12y)?

Answer 27

Mometasone 14 days, 200micrograms twice a day

Question 28

What are 3 things to remember when prescribing nasal steroids for acute sinusitis \>10 days?

Answer 28

1. It may improve symptoms but not likely to affect **how long symptoms** last 2. Could cause **systemic** effects, paticularly in people already taking another corticosteroid 3. May be difficult for people to **use correctly**

Question 29

What are 4 things to remember when deciding whether to prescribe antibioitics for acute sinusitis lasting \>10 days?

Answer 29

1. Evidence that antibiotics make little difference to how long symptoms last, or proportion of people with improved symptoms 2. Withholding antibiotics is unlikely to lead to complications 3. Possible adverse effects, particularly diarrhoea and nausea 4. Factors that might make bacterial cause more likely - symptoms \>10days, discoloured/purulent discharge, fever \>38 etc

Question 30

What are 2 things to advise patients about if a back up antibiotic prescription is given for sinusitis?

Answer 30

1. Managing symptoms with self-care measures 2. Using back-up prescription if symptoms worsen rapidly or significantly, or do not improve within 7 days

Question 31

What are 3 things to consider when reassessing patients?

Answer 31

1. Alternative diagnoses such as dental infection 2. Signs or syptoms of more serious illness or condition 3. Previous antibiotic use, which may lead to resistant organisms

Question 32

What are the recommended antibiotics and course for acute sinusitis in adults?

Answer 32

* ***Phenoxymethylpenicillin**, 500mg qds 5 days* * systemically very unwell/ signs of more serious illness/ high risk of complications: **co**-**amoxiclav** 500/125mg tds 5 days * allergy: **doxycycline** 200mg on first day then 100mg od for 4 days (5 day course) _or_ * **clarithromycin** 500mg bd for 5 days * Pregnant and allergic or intolerant to penicillin: **erythromycin** 250mg to 500mg qds 5 days

Question 33

What are the recommended antibiotics and course for acute sinusitis in children \<18 years?

Answer 33

* **Phenoxymethylpenicillin** first line: see dosing based on age * Systemically very unwell/ more serious illness/high risk of complications: **co**-**amoxiclav** (dosing based on age) * Allergy: **Clarithromycin** (dosing based on body mass) * **Doxycycline** can be given 12-17y but contraindicated if \<12y. 200mg first day, then 100mg od 4 days (5 day course)

Question 34

If phenoxymethylpenicillin hasn't worked to treat acute sinusitis, what is second line?

Answer 34

Co-amoxiclav If penicillin allergy, seek advice from local microbiologist For children, seek advice from local microbiologist

Question 35

What are 7 pieces of verbal advice to give to a patient with chronic sinusitis?

Answer 35

1. May last for several months 2. Good control of allergic rhinitis or asthma likely to benefit symptoms 3. Offer written advice e.g. ENT UK publication on sinusitis 4. Avoid allergic triggers 5. stop smoking 6. good dental hygiene 7. avoid underwater diving if prominent symptoms 8. consider nasal irrigation with saline solution to relieve congestion and discharge

Question 36

What treatment can be offered to patients with chronic sinusitis in primary care?

Answer 36

Course of intranasal steroids e.g. mometasone or fluticasone for up to 3 months, especially if suspicion of allergic cause

Question 37

What should you do if considering nasal corticosteroids in a child?

Answer 37

Seek specialist advice

Question 38

What should you do if considering long-term antibiotics to treat chronic sinusitis and why?

Answer 38

seek specialist advice first, as evidence for this approach is limited

Question 39

What are 7 situations when you should refer chronic sinusitis to the appropriate specialist?

Answer 39

1. Unilateral symptoms - consider urgent, suspicion of neoplasia 2. Persistent despite **3 months of treatment** 3. Nasal polyps complicating assessment or treatment, particularly if present in children 4. Recurrent episodes of **otitis media** and **pneumonia** in child 5. Unusual opportunistic infections 6. Symptoms that might significantly interfere with functioning and quality of life 7. Allergic or immunologic risk fators that need investigating

Question 40

What is generally the first line antibiotic to treat acute sinusitis if indicated?

Answer 40

phenoxymethylpenicillin 500mg qds 5 days

Question 41

What antibiotic regimen is recommended for acute sinusitis if the patient is systemically unwell?

Answer 41

co-amoxiclav 500/125mg tds 5 days

Question 42

What are 2 options for the antibiotic management of acute sinusitis when there is penicillin allergy?

Answer 42

1. Doxycycline initial dose 200mg then 100mg for 4 days (5 day coruse) 2. Clarithromycin 500mg bd for 5 days

Question 43

What antibiotic regimen is recommended for acute sinusitis in pregnancy when there is allergy/intolerance to penicillin?

Answer 43

erythromycin 250 to 500mg qds 5 days