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AIP: Headache > Sinusitis > Flashcards

Sinusitis Flashcards

1
Q

What are the 2 key types of sinusitis?

A

Acute and chronic

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2
Q

What is the definition of sinusitis?

A

Symptomatic inflammation of the paranasal sinuses

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3
Q

What causes acute sinusitis?

A

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

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4
Q

What is the time frame of acute vs chronic sinusitis?

A

Acute <12 weeks, chronic >12 weeks

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5
Q

When is acute sinusitis diagnosed in adults vs in children?

A
  • 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
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6
Q

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

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

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

A
  1. Symptoms >10 days
  2. Discoloured or purulent nasal discharge
  3. Severe local pain (with unilateral predominance)
  4. Fever >38oC
  5. Deterioration after initial mild illness
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8
Q

What are 2 factors needed to diagnose chronic sinusitis?

A
  1. Lasts >12 weeks
  2. Objective evidence of sinonasal inflammation on examination
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9
Q

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

A
  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

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10
Q

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

A
  1. Nasal inflammation
  2. Mucosal oedema
  3. Mucopurulent nasal discharge
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11
Q

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

A
  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
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12
Q

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

A

If neoplasm suspected e.g.:

  1. unilateral polyp or mass
  2. bloody nasal discharge
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13
Q

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

A
  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
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14
Q

What are 4 aspects of the management of acute sinusitis?

A
  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
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15
Q

What are 5 aspects of the management of chronic sinusitis?

A
  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)
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16
Q

What is the course of acute sinusitis over time?

A

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

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17
Q

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

A
  1. Altered speech indicating nasal obstruction
  2. Tenderness, swelling or redness over the cheekbone or periorbital areas
  3. Cough
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18
Q

How should you perform examination in suspected sinusitis?

A
  • Inspect and palpate maxillofacial area to elicit sweling or tenderness
  • Perform anterior rhinoscopy (using largest speculum of otoscope or head light and nasal speculum)
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19
Q

What are 3 predisposing factors to chronic sinusitis?

A
  1. Allergic rhinitis (symptoms include sneezing; watery nasal discharge; nasal itching; itchy, watery eyes)
  2. Asthma
  3. Immunosuppression
20
Q

What are 6 differentials for sinusitis?

A
  1. URTI
  2. Allergic rhinitis
  3. Nasal foreign body
  4. Adenoiditis and tonisillitis
  5. Sinonasal tumour
  6. Migraine
21
Q

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

A
  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
22
Q

What are 6 symptoms suggestive of orbital involvement in sinusitis?

A
  1. Peri-orbital oedema
  2. Peri-orbital cellulitis
  3. Displaced eyeball
  4. Double vision
  5. Ophthalmoplegia (paralysis of EOMs)
  6. Reduced visual acuity
23
Q

What are 4 symptoms suggestive of intracranial involvement in sinusitis?

A
  1. Severe frontal headache
  2. Swelling over frontal bone
  3. Symptoms or signs of meningitis
  4. Focal neurological signs
24
Q

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

A

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

25
Q

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

A
  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
26
Q

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

A
  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
27
Q

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

A

Mometasone 14 days, 200 micrograms twice a day

28
Q

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

A
  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
29
Q

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

A
  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
30
Q

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

A
  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
31
Q

What are 3 things to consider when reassessing patients?

A
  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
32
Q

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

A
  • 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
33
Q

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

A
  • 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)
34
Q

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

A

Co-amoxiclav

If penicillin allergy, seek advice from local microbiologist

For children, seek advice from local microbiologist

35
Q

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

A
  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
36
Q

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

A

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

37
Q

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

A

Seek specialist advice

38
Q

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

A

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

39
Q

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

A
  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
40
Q

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

A

phenoxymethylpenicillin 500mg qds 5 days

41
Q

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

A

co-amoxiclav 500/125mg tds 5 days

42
Q

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

A
  1. Doxycycline initial dose 200mg then 100mg for 4 days (5 day coruse)
  2. Clarithromycin 500mg bd for 5 days
43
Q

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

A

erythromycin 250 to 500mg qds 5 days

44
Q

When are intranasal corticosteroids indicated for acute sinusitis?

A

symptoms >10 days

45
Q

When are antibiotics indicated for acute sinusitis?

A

severe presentations, evidence of bacterial infection

46
Q

What is meant by double-sickening in acute sinusitis?

A

viral infection worsening due to secondary bacterial infection

47
Q

What can cause cough in sinusitis?

A

post-nasal drip

AIP: Headache (10 decks)

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