sinusitis, tonsilitis, epistaxis Flashcards
• Suspect acute bacterial sinusitis when several of the following features are present:
○ Symptoms for more than 10 days
○ Discoloured or purulent nasal discharge (with unilateral predominance).
○ Severe local pain (with unilateral predominance).
○ A fever greater than 38°C.
○ A marked deterioration after an initial milder form of the illness (so-called ‘double-sickening’).
Elevated ESR/CRP (although the practicality of this criterion is limited).
sinutisis treatment
mometasone 300ug bd for 14 days
sinusitis ABs
• For adults aged 18 years and older:
○ If no life-threatening symptoms — phenoxymethylpenicillin 500 mg four times a day for 5 days.
○ If systemically very unwell, symptoms or signs of a more serious illness or condition are present, or there is a high risk of complications — co-amoxiclav 500/125 mg three times a day for 5 days.
○ If allergic or intolerant to penicillin — doxycycline 200 mg on the first day, then 100 mg once daily for 4 days (a 5-day course in total), or clarithromycin 500 mg twice a day for 5 days.
○ If pregnant and allergic or intolerant to penicillin — erythromycin 250 mg to 500 mg four times a day or 500 mg to 1000mg twice a day for 5 days.
• Doxycycline is contraindicated in children under 12 years old
complications acute and chronic sinusitis
• Acute
○ Orbital complications: orbital cellulitis, orbital abscess, cavernous sinus thrombosis
○ Intracranial complications: meningitis, encephalitis, abscess, venous thrombosis
○ Bony complications: osteomyelitis
○ Progression to chronic sinusitis
• Chronic: significant impact on quality of life
○ Extra sinus symptoms such as sleep problems, fatigue and depression
○ impact on employment: absenteeism, reduced effectiveness and productivity
○ Reduction in social functioning
High healthcare usage
chronic sinusitis treatment
- Symptoms may last months and if they have associated allergic rhinitis or asthma should be controlled to help symptoms
- Consider nasal irrigation with saline solution to relieve congestion and nasal discharge.
Consider a course of intranasal corticosteroids (for example, mometasone or fluticasone) for up to 3 months
• Seek specialist advice before prescribing long-term antibiotics, as the evidence for this approach is limited.
referral sinusitis
○ Unilateral symptoms (consider urgent referral as this increases suspicion of neoplasia).
○ Persistent symptoms despite compliance with 3 months of treatment.
○ Nasal polyps complicating assessment or treatment, particularly if present in children.
○ Recurrent episodes of otitis media and pneumonia in a child.
○ Unusual opportunistic infections.
○ Symptoms that significantly interfere with functioning and quality of life.
○ Allergic or immunologic risk factors that need investigating.
prediction score to determine likelihood of streptococcal infection
• The FeverPAIN criteria are: score 1 point for each (maximum score of 5)
○ Fever over 38°C.
○ Purulence (pharyngeal/tonsillar exudate).
○ Attend rapidly (3 days or less)
○ Severely Inflamed tonsils
○ No cough or coryza
○ A score of 0 or 1 is associated with a 13% to 18% likelihood of isolating streptococcus. A score of 2 or 3 is associated with a 34% to 40% likelihood of isolating streptococcus. A score of 4 or 5 is associated with a 62% to 65% likelihood of isolating streptococcus.
• Centor criteria
○ Tonsillar exudate
○ Tender anterior cervical lymphadenopathy or lymphadenitis
○ History of fever (over 38°C)
○ Absence of cough
○ Each of the Centor criteria score 1 point (maximum score of 4). A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus. A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.
if they score 4/5 FPAIN or 3/4 in Centor and are at risk of rheumatic fever prescribe ABs
arrange a rapid antigen test for group A streptococcus. A negative antigen test in a person (particularly a child) with suspected GAS should be followed up with a throat culture.
tonsillectomy
7 episodes per year for one year, 5 per year for 2 years, or 3 per year for 3 years, and for whom there is no other explanation for the recurrent symptoms)
treatment for candidal pharyngitis
nystatin for mild to moderate cases
fluconazole if more widespread
symptoms suggestive of a tumour
nasal obstruction, rhinorrhoea, facial pain, hearing loss, persistent lymphadenopathy, and/or evidence of cranial neuropathy
most common in people older than 50 years of age, in those with occupational exposure to wood dust or chemicals, and (for nasopharyngeal cancer) in people of South Chinese or North African family origin.
epistaxis treatment when bleeding stop
Naseptin: nostrils four times daily for 10 days
mupirocin: two to three times a day for 5–7 days.
recurrent epistaxis
○ Angiofibroma (rare benign nasal tumour, usually in males aged 12–20 years of age) — suggested by nasal obstruction and severe epistaxis.
○ Cancer — suggested by nasal obstruction, facial pain, hearing loss, eye symptoms (proptosis or double vision), and/or persistent lymphadenopathy.
§ Be aware that nasal, sinus, and nasopharyngeal cancers are most common in people older than 50 years of age, in those with occupational exposure to wood dust or chemicals, and (for nasopharyngeal cancer) in people of South Chinese or North African family origin.
○ Telangiectasia — suggested by red or purple spots on the fingertip pads, lips, lining of the nose, and occasionally the ears and face. There may be a family history of hereditary haemorrhagic telangiectasia.
