Acute and chronic rhinosinusitis — formative SAQs

SAQ 1 (10 marks)

A 5-year-old presents with a twelve-day history of thick nasal discharge and a daytime cough following a viral upper-respiratory infection. The symptoms have not improved. For the last two days the child has had a return of fever and the discharge has become more purulent. The child is systemically well, with no orbital or neurological signs and a normal examination apart from bilateral mucopurulent nasal discharge. [1]

Question: Outline the diagnosis, the investigations, and the stepwise management of this child, including the antibiotic regimen and the safety-net. (10 marks) [1]

Model answer

Diagnosis and recognition (2 marks). The diagnosis is acute bacterial rhinosinusitis. The child meets the AAP criteria in two ways — persistent symptoms (nasal discharge and daytime cough) beyond ten days without improvement, and a double-worsening course with return of fever and more purulent discharge after initial illness. Rhinosinusitis is inflammation of the nasal cavity and the paranasal sinuses, which share a continuous mucosa; acute bacterial disease complicates an estimated five to ten per cent of viral colds after ostial obstruction impairs mucociliary clearance. [1] [2]

Investigations (2 marks). No routine investigation is required. Acute bacterial rhinosinusitis is a clinical diagnosis; plain sinus radiographs are unhelpful because mucosal thickening and opacification are present in most uncomplicated viral colds, and nasal cultures are unreliable because of contaminating flora. Contrast CT of the sinuses is reserved for a suspected orbital or intracranial complication, failure to respond, or diagnostic uncertainty — none of which is present here. [1] [11]

Antibiotic regimen (3 marks). Give first-line high-dose amoxicillin-clavulanate 90 mg per kilogram per day of the amoxicillin component in two divided doses (maximum amoxicillin 4 g per day) for ten to fourteen days. The high dose overcomes penicillin-resistant Streptococcus pneumoniae and the clavulanate covers the beta-lactamase-producing nontypeable Haemophilus influenzae and Moraxella catarrhalis that, with pneumococcus, cause most cases. For a penicillin allergy, use cefdinir or cefuroxime, or clindamycin with consideration of a third-generation cephalosporin in a severe beta-lactam allergy. Add an intranasal corticosteroid and continue saline irrigation as adjuncts. [1] [2]

Supportive care and safety-net (3 marks). Prescribe saline irrigation, analgesia and antipyretics, and review at forty-eight to seventy-two hours; if there is no improvement, reconsider the diagnosis, ensure adherence to the saline and corticosteroid, and image if a complication is suspected. Give a clear, specific safety-net for the red flags of orbital and intracranial spread — periorbital or eyelid swelling, eye pain, double vision, reduced vision, severe headache, neck stiffness, vomiting, photophobia, drowsiness, a fit, or a worsening illness — each of which would mean urgent reassessment and imaging. Most children recover fully with appropriate antibiotics. [1] [11]

SAQ 2 (10 marks)

Question: A 3-year-old with a febrile cold develops right periorbital swelling, redness and eye pain over twenty-four hours. On examination there is proptosis, the eye is displaced downward and outward, eye movement is painful and restricted, and visual acuity is reduced. (a) What complication has developed, and which investigation confirms it? (b) Outline the medical and surgical management. (c) Name the organisms to cover and the antibiotic regimen. (10 marks) [9]

Model answer

(a) The complication and its investigation (4 marks). The child has an orbital complication of ethmoiditis — a post-septal orbital cellulitis with, given the downward-and-out displacement of the globe and the vision compromise, a likely subperiosteal abscess (Chandler stage 3) or orbital abscess (stage 4). Infection has spread from the ethmoid sinus through the paper-thin lamina papyracea into the orbit. Contrast-enhanced computed tomography of the sinuses and orbits is the investigation of choice and should be obtained urgently; it shows the rim-enhancing subperiosteal or orbital collection, the sinus opacification and any bony erosion. An ophthalmology and ENT review is required at once, and the reduced visual acuity is the trigger for urgent imaging and surgical assessment. [3] [9]

(b) Medical and surgical management (3 marks). Admit, establish intravenous access, and start broad-spectrum intravenous antibiotics after blood cultures. Refer urgently to ENT and ophthalmology. A subperiosteal abscess classically needs surgical drainage; a carefully selected small medial abscess in a young child with improving vision and no intracranial feature may be managed with intravenous antibiotics and close observation, with a low threshold to operate if vision deteriorates, the abscess is large, or there is no prompt improvement. The prognostic-cohort study confirmed that age, abscess size and the clinical state guide the medical-versus-surgical decision. An orbital abscess (stage 4) with reduced vision, and cavernous sinus thrombosis (stage 5), are surgical and intensive-care emergencies. Monitor and document the visual acuity and eye movements serially. [9] [12]

(c) Organisms and antibiotic regimen (3 marks). Cover the streptococci and staphylococci of complicated sinus disease together with anaerobes given the orbital extension. A reasonable empiric regimen is intravenous ceftriaxone 50 mg per kilogram (maximum 2 g) once daily plus metronidazole 7.5 mg per kilogram (maximum 500 mg) every eight hours, adding vancomycin for suspected methicillin-resistant Staphylococcus aureus or critical illness. De-escalate when culture and susceptibility results return, and complete a prolonged course guided by the clinical response and imaging. [2] [9]