Rhinosinusitis - Diagnosis and Management Summary
Acute (<1mo) vs. subacute (1-3mo) vs. chronic (>3mo, usually w/ anaerobes); recurrent (4 or more annual episodes)
Dx: rhinorrhea (viral - clear, bact - purulent) + nasal obstruction or facial pressure/pain/fullness. A/w anosmia, ear fullness, cough, H/A
• S. pneumo (41%), H. flu (35%), M. catarrhalis (4%), S. aureus (3%), anaerobes (7%), strep (7%)
• Time Frame: >10 days, or worsening within 10 days after initial improvement (“double worsening”)
• Tx: Watchful waiting* in pts w/ good followup vs. Augmentin 875mg BID** (Doxy 100mg BID in PCN-allergic) x 5-7d
• Time Frame: 7-10 days
• Tx: Symptom control, oral decongestant
• Mucor (invasive) in DM, immunocompromised
• Acute(invasive) to more chronic (>3mo)
• Tx: Surgical removal of fungal mucin or “fungal ball” (mycetoma). ENT emergency if invasive (destruction of sinus, erosion into orbit or brain)
Dx: ONLY if concern for complications or other etiology suspected: CT scan with contrast +/- MRI
Complications: Meningitis, periorbital/orbital cellulitis (pain, edema, proptosis, painful eye movement, diplopia), subperiosteal/intracranial/epidural abscess, osteomyelitis of the sinus bones, septic cavernous sinus thrombosis.
Alarm symptoms: persistent fevers >102F; periorbital edema, inflammation, or erythema; CN palsies; abnormal extraocular movements; proptosis; vision changes (diplopia, impaired vision); severe headache; AMS; meningeal signs.
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