Acute Sinusitis


Article Author:
Derek DeBoer


Article Editor:
Edward Kwon


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/15/2019 8:03:41 AM

Introduction

Acute sinusitis is an inflammation of the sinuses. Because sinus passages are contiguous with the nasal passages, rhinosinusitis is often a more appropriate term. Acute rhinosinusitis is a common diagnosis, accounting for approximately 30 million primary care visits and $11 billion in healthcare dollars spent annually. It is also a common reason for antibiotic prescriptions in the United States. Due to recent guidance covering concerns for antibiotic resistance and the judicious use of antibiotics, it is essential to have clear guidelines available for such a common diagnosis.[1][2]

Rhinosinusitis can be classified into the following groups (based more on consensus rather than research) [3]:

  1. Acute - symptoms lasting less than 4 weeks
  2. Subacute - symptoms last between 4 and 12 weeks
  3. Chronic - symptoms lasting more than 12 weeks
  4. Recurrent - four episodes lasting less than 4 weeks with symptom resolution between episodes

Etiology

Viruses most commonly cause acute rhinosinusitis. The most common causes of viral rhinosinusitis (VRS) include rhinovirus, adenovirus, influenza virus, and parainfluenza virus. The most common causes of acute bacterial rhinosinusitis (ABRS) are Streptococcus pneumoniae (38%), Haemophilus influenzae (36%), and Moraxella catarrhalis (16%).[4] Although rare, fungal infections can also cause acute rhinosinusitis.  These are more likely to occur in immunocompromised patients. Typical species include Mucor, Rhizopus, Rhizomucor, and Aspergillus.  

Epidemiology

Acute rhinosinusitis accounts for 1 in 5 antibiotic prescriptions for adults, making it the fifth most common reason for an antibiotic prescription. Approximately 6% to 7% of children with respiratory symptoms have acute rhinosinusitis. An estimated 16% of adults are diagnosed with ABRS annually. Given the clinical nature of this diagnosis, there is a possibility of overestimation.

An estimated 0.5 to 2.0% of viral rhinosinusitis (VRS) will develop into bacterial infections in adults and 5 to 10% in children.[1][2]

Pathophysiology

Sinuses function to filter out pollutants, microorganisms, dust, and other antigens. Sinuses drain into the meatus' via small channels called ostia. The maxillary, frontal, and anterior ethmoid sinuses drain into the middle meatus, creating a congested area called the osteomeatal complex. The posterior ethmoid and sphenoid sinuses drain into the superior meatus. Tiny hairs called "cilia" line within the mucous membrane work in an integrated and coordinated fashion to carry out this function. Rhinosinusitis occurs when the sinuses and nasal passages cannot effectively clear out these antigens, leading to an inflammatory state. This condition usually results from three key factors: obstruction of the sinus ostia (i.e., anatomic causes such as a tumor or septal deviation), dysfunction of the cilia (i.e., Kartagener syndrome), or thickening of sinus secretions (cystic fibrosis). When this occurs, bacteria can remain in, gain access to, and proliferate within the usually sterile para-sinuses. Complications occur when the sinus infection spreads to surrounding structures, such as the brain and orbit, via the valve-less diploic veins. These are veins located within the inner cancellous bone layer of the skull.

Adults have four developed and paired sinus cavities. The ethmoid, sphenoid, frontal, and maxillary sinuses. In children, only the ethmoid and maxillary sinuses are present at birth. The ethmoid sinus separates from the orbit by only a thin layer of bone. Thus, orbital infections typically arise from the ethmoid sinus, which occurs more often in younger children. The frontal sinuses do not appear to develop until 5 to 6 years of age and do not reach full development until after puberty. Intracranial complications typically arise from the frontal sinuses and thus occur more often in older children. The sphenoid sinus starts to pneumatize at 5 years of age but does not fully develope until 20 to 30 years of age.   

Histopathology

Healthy sinuses are composed of pseudostratified columnar epithelium, which uses cilia to clear the sinuses of debris, mucus, and other substances. The mucosal edema, infiltration of granulocytes and lymphocytes, squamous metaplasia, and fibroblast proliferation from acute rhinosinusitis disrupts this process.[5]

History and Physical

Acute rhinosinusitis is a clinical diagnosis. Three “cardinal” symptoms that are most sensitive and specific for acute rhinosinusitis are purulent nasal drainage accompanied by either nasal obstruction or facial pain/pressure/fullness. 

When cardinal symptoms persist beyond ten days or if they worsen after an initial period of improvement (“double worsening”), one may diagnose ABRS. Other symptoms associated with acute rhinosinusitis include cough, fatigue, hyposmia, anosmia, maxillary dental pain, and ear fullness or pressure.[3]  

Children have a slight variance in the clinical presentation of ABRS.  In addition to the 10-day duration, cardinal symptoms, and “double worsening,” children are more likely to present with fevers. Nasal discharge may initially be watery, then turn purulent. A viral upper respiratory infection precedes approximately 80% of acute bacterial sinusitis.[6]

Severe symptoms are more indicative of a bacterial cause.  These include high fevers (over 39 C or 102 F) accompanied by purulent nasal discharge or facial pain for 3 to 4 consecutive days at the beginning of the illness. Viral illnesses typically resolve after three days.  

Antibiotic resistance factors should also merit consideration. These include [4]:

  • Antibiotic use within the last month
  • Hospitalization within the previous five days
  • Healthcare occupation.

Lastly, one should assess whether a patient is at higher risk.  These characteristics include [3]:

  • Comorbidities (i.e., cardiac, renal, or hepatic disease)
  • Immunocompromised states
  • Age under 2 years or over 65 years

Fungal acute rhinosinusitis is most commonly associated with fevers and facial pain.  Refractory or severe symptoms in an immunocompromised patient should prompt consideration of this diagnosis.

Evaluation

As mentioned above, acute rhinosinusitis is a clinical diagnosis. The clinician most commonly needs to distinguish between VRS and ABRS, which is crucial to ensure the responsible usage of antibiotics. Local resistance patterns and prevalence of penicillin non-susceptible Strep. pneumoniae requires elucidation.

Conventional diagnostic criteria for rhinosinusitis in adults is the patient having at least two major or one major plus two or more minor symptoms. The criteria in children are similar except that there is more of an emphasis on nasal discharge (rather than nasal obstruction).Major symptoms: 1. Purulent anterior nasal discharge2. Purulent or discolored posterior nasal discharge3. Nasal congestion or obstruction 4. Facial congestion or fullness 5. Facial pain or pressure 6. Hyposmia or anosmia 7. Fever (for acute sinusitis only) 

Minor symptoms: 1. Headache 2. Ear pain or pressure or fullness 3. Halitosis 4. Dental pain 5. Cough 6. Fever (for subacute or chronic sinusitis) 7. Fatigue

ABRS can be differentiated from VRS using the following clinical guidance[4][6][1][3]:

  • Duration of symptoms for more than ten days
  • High fever (over 39 C or 102 F) with purulent nasal discharge or facial pain that last for 3 to 4 consecutive days at the beginning of the illness
  • Double sickening of symptoms within the first ten days

Routine laboratory assessment is generally not necessary. Evaluation for cystic fibrosis, ciliary dysfunction, or immunodeficiency are considerations for intractable, recurrent, or chronic rhinosinusitis.  There is some evidence that an elevated ESR and CRP may be associated with a bacterial infection.

The culture of endoscopic aspirates with greater than or equal to 10 CFU/mL is considered the gold standard. However, this is not necessary for diagnosis and not done for the vast majority of cases of ABRS. Nasal and nasopharyngeal cultures are of low utility due to their poor correlation with endoscopic aspirates. Referral for endoscopic aspiration can, however, be an option for refractory cases.  

Imaging is not necessary unless there is a clinical concern for a complication or alternative diagnosis. Sinus plain films are generally not useful in detecting inflammation. They may show air-fluid levels. However, this does not help differentiate viral versus bacterial etiologies. If a complication or alternative diagnosis is suspected, then sinus CT imaging should be obtained to assess for bone, soft tissue, and anatomical abnormalities. Sinus CT may show air-fluid levels, opacification, and inflammation. A thickened sinus mucosa over 5 mm is indicative of inflammation.  It can also effectively assess bony erosion or destruction. However, these findings are also not helpful in differentiating viral versus bacterial etiologies. MRI offers more detail than sinus CT to evaluate soft tissue or help elucidate a tumor. Thus, MRI may be helpful to determine the extent of complications in cases such as an orbital or intracranial extension. Given the importance of early identification and treatment of complications, if there is a clinical concern for them, it may be necessary to obtain both a CT and MRI.[7]

Treatment / Management

Treatment of ABRS consists of either antibiotic therapy or a period of watchful waiting as long as the certainty of reliable follow-up.  There are slight variations between different expert committee guidelines.[8]

The American Academy of Otolaryngology Adult Sinusitis 2015 updated guideline recommends amoxicillin with or without clavulanate in adults as first-line therapy for a period of 5 to 10 days in most adults. Treatment failure is noted if symptoms do not decrease within 7 days or worsen at any time.  

The Infectious Disease Society of America Guidelines for Acute Bacterial Rhinosinusitis recommends amoxicillin with clavulanate in adults as first-line therapy for 10 to 14 days in children and 5 to 7 days in adults. Treatment failure is noted if symptoms do not decrease after 3 to 5 days or worsen after 48 to 72 hours of therapy.  

The American Academy of Pediatrics Clinic Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged to 18 Years recommends amoxicillin with or without clavulanate as first-line therapy. The duration of treatment is unclear, however treating for an additional seven days after symptoms resolve was their suggestion. The criteria for treatment failure is if symptoms do not decrease or worsen after 72 hours of therapy. If the patient cannot tolerate oral fluids, then the patient can receive ceftriaxone 50m/kg. If the patient can tolerate oral fluids the next day and improves, then the patient can transition to an oral antibiotic course thereafter. A separate article recommended amoxicillin with clavulanate as initial therapy in children to adequately cover beta-lactamase-producing pathogens.[9]

Local antibiotic resistance patterns, the patient's risk level, risk factors for antibiotic resistance, and severity of symptoms help determine whether to add clavulanate or whether high-dose amoxicillin (90mg/kg/day versus 45mg/kg/day) should be used in children.  

For patients allergic to penicillin, a third-generation cephalosporin plus clindamycin (for adequate coverage of non-susceptible Strep. pneumoniae) or doxycycline could be therapeutic possibilities. Third-generation cephalosporins alone have variable efficacy rates against Strep. pneumoniae. Fluoroquinolones could also be considered but are associated with a higher rate of adverse events. Doxycycline and fluoroquinolones should be used with more caution in children. There are higher rates of Strep. pneumoniae and Hemophilus influenzae resistance to second-generation cephalosporins, trimethoprim/sulfamethoxazole, and macrolides.

Evidence has also shown that antibiotic therapy does not necessarily shorten symptom duration or complication rates in adults. Many cases of ABRS may also spontaneously resolve within two weeks.[10]

Clinicians can offer symptomatic treatments; however, clear evidence is lacking overall. Nasal steroids and nasal saline irrigation are the most common recommendations in guidelines. Intranasal steroids may help by reducing mucosal swelling, which can help relieve the obstruction. A small number of trials indicated that higher doses of intranasal steroids could help improve the time to symptom resolution at 2 to 3 weeks.[11] Nasal saline irrigation can also help reduce obstruction. Antihistamines are not a recommendation unless there is a clear allergic component as they potentially thicken nasal secretions.

Suspicion for the invasive form of acute fungal rhinosinusitis should prompt urgent evaluation and referral to otolaryngology, neurosurgery, and/or ophthalmology. These patients may require combined medical and surgical management (debridement).[12]

Differential Diagnosis

It is most important to differentiate between acute viral versus bacterial rhinosinusitis. Allergic rhinitis is also a common condition requiring elucidation. Fungal infections may also cause rhinosinusitis. Invasive fungal sinusitis is a serious form of this infection that is more common in immunocompromised patients. It is associated with a high mortality rate. Other less common diagnoses to consider in the differential diagnosis include:

  1. Nasal foreign body
  2. Enlarged or infected adenoids
  3. Structural abnormalities, i.e., deviated septum, sinonasal neoplasm
  4. Disorders affecting ciliary function, i.e., primary ciliary dyskinesia, cystic fibrosis
  5. Referred pain, i.e., dental infection or abscess

Prognosis

Acute bacterial rhinosinusitis is most commonly viral. The large majority of cases will either resolve spontaneously or can be effectively treated with antibiotics. Invasive fungal rhinosinusitis is a rare, serious form of the infection that can occur in immunocompromised patients. It is associated with a high morbidity and mortality rate. [12]

Complications

Complications are rare, occurring in about 1 out of every 1000 cases.[1] Sinus infections may spread to the orbit, bone, or intracranial cavities.  Eighty percent of orbitocranial complications occur in the orbit. These complications can come with significant morbidity and mortality. The orbit is the most common site due to the very thin ethmoid bone that separates infections from the ethmoid to the orbit. The Chandler classification is the most common method or grading orbital complications of sinusitis infection (listed from least to most severe)[13]:

  1. Preseptal cellulitis
  2. Orbital cellulitis
  3. Subperiosteal abscess
  4. Orbital abscess
  5. Cavernous sinus thrombosis

Intracranial complications can also occur.  These include the development of a subdural hematoma, epidural hematoma, meningitis, or a subdural empyema (the latter comes with a high mortality rate). Pott puffy tumor is a subperiosteal abscess of the frontal bone, usually associated with osteomyelitis. Both complications typically arise from frontal sinus infections, via hematogenous spread through the valveless diploic vein system. 

Acute fungal sinusitis can occur in a noninvasive and invasive form.[14] The invasive form can spread to surrounding structures. Early identification of this complication is vital to avoiding potentially devastating outcomes.[12]

Consultations

Referral to an otolaryngologist is rarely needed since most cases are viral and will resolve spontaneously. Acute uncomplicated bacterial sinusitis can have treatment with antibiotics. However, if a complication is suspected, prompt referral to an otolaryngologist, ophthalmologist, and/or neurosurgeon is required to avoid the potentially catastrophic effects of intracranial and orbital extension. Reasons for urgent referral include:

  • Mental status changes
  • Cranial nerve abnormalities
  • Pain with extraocular movements
  • Periorbital edema
  • Severe or refractory symptoms in an immunocompromised patient

Routine referral to an otolaryngologist may also be done for any intractable or refractory case of rhinosinusitis to provide further evaluation.

Deterrence and Patient Education

Most causes of acute bacterial rhinosinusitis are viral. Most cases will resolve spontaneously. There is evidence that acute bacterial rhinosinusitis (ABRS) can also resolve spontaneously. The diagnosis of ABRS is clinical.

Enhancing Healthcare Team Outcomes

Acute rhinosinusitis is among the most common primary care conditions.  To avoid high morbidity, an interprofessional team should manage the disorder. The critical thing which clinicians need to be aware of is that most cases result from viruses and are self-limiting.  As such, it is crucial to be able to identify the three cardinal symptoms for acute bacterial rhinosinusitis. Clinicians should only prescribe antibiotics for the patient who exhibits prolonged symptoms without improvement for 10 days, “double-worsening,” or those with severe symptoms. Amoxicillin with or without clavulanate should be first-line therapy. Local antibiotic resistance factors, risk factors for antibiotic resistance, and the overall risk level of the patient should be a consideration. An infectious disease certified pharmacist can be a valuable resource, as they will often have the latest antibiogram data, can suggest antimicrobial alternatives if necessary, and check for drug interactions.

Imaging is not helpful except in cases where there a complication or alternative diagnosis is suspected. If complications are suspected, then urgent imaging and referral to otolaryngology, ophthalmology, and/or neurosurgery should be done to avoid potentially catastrophic outcomes. The nurse and the pharmacist should educate the patient on avoidance of smoking and getting the flu vaccine annually, as this may lower the risk of viral rhinosinusitis. Finally, the patient should understand that routine use of antibiotics is not necessary, as most cases resolve spontaneously; this is another area where nursing staff can guide the patient and answer any questions. However, referral to otolaryngology for a culture of endoscopic aspirates merits consideration for refractory cases. Open communication between interprofessional team members will inevitably lead to improved outcomes. [Level V]

"The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, Department of the Air Force, Department of Defense, or the U.S. government." 


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Acute Sinusitis - Questions

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A 67-year-old female presents to the emergency department with fever and purulent nasal discharge for the last five days. She reports worsening symptoms for the last two days. On examination, she appears ill and fatigued. Her vital signs reveal a temperature of 102 degrees Fahrenheit. Which of the following is most consistent with the suspected diagnosis?



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A 65-year-old male presents to the emergency department with a 2-week history of purulent nasal discharge and facial pain. He denies any fever. He has not used any antibiotics since his symptoms started. He reported feeling better after initial couple days of symptoms but now feels they symptoms are getting worse. His vital signs are normal. Mild maxillary tenderness is noted bilaterally. Which of the following radiographic findings are consistent with the suspected diagnosis?



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A 56-year-old male with uncontrolled diabetes presents to the clinician with a vague, dull headache and fever. Three weeks ago, he was diagnosed with acute viral sinusitis and discharged home with Tylenol, nasal steroids, and home rest. However, his nasal discharge and sinus pain progressed. He did not return to the clinic and therefore, was not treated with antibiotics. He has now developed a vague, dull headache, fevers, nasal discharge, blurry vision, and slight neck stiffness. Vital signs reveal a blood pressure of 130/90 mmHg, heart rate of 130 beats per minute, respiratory rate of 24 breaths per minute, oxygen saturation 95%, and a temperature of 99 degrees Fahrenheit. Physical examination reveals round, reactive, and equal pupils, bilateral cervical lymphadenopathy, normal tympanic membranes, mild maxillary sinus tenderness, clear lungs bilaterally, and normal heart auscultation. Neurologic examination reveals bilateral and symmetric upper extremity and lower extremity strength at 4/5 with sensations intact. What is the most common clinical finding of this patient's condition?



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A 17-year-old male presents to the clinic with a 2-week history of worsening purulent nasal discharge, facial pain, and nasal obstruction. He denies any fever. On examination, his vitals are normal. He does have bilateral maxillary sinus tenderness. During treatment planning, he reports a history of anaphylaxis to penicillin. Which of the following is the best alternative treatment for this patient?



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A 40-year-old male presents to the clinician with complaints of progressively worsening nasal sinus obstruction for the past 2-3 weeks, nasal discharge, and newly developing subjective fevers. He has developed mild photophobia and a little redness around his eyes. He also reveals a past history of uncontrolled diabetes. His medications include Metformin 1000 mg twice daily, Asprin 81 mg once daily, Crestor 10 mg once daily, and Glargine 20 units nightly. He admits to not taking his medications regularly. Vital signs include a blood pressure of 150/95 mmHg, a heart rate of 100 beats per minute, respiratory rate of 20 breaths per minute, oxygen saturation of 96%, and a temperature of 100.0 degrees Fahrenheit. Physical examination reveals mild periorbital erythema, mild pain with extraocular movements, mild cervical lymphadenopathy, and normal-appearing pharynx. The lungs are clear bilaterally, and normal heart sounds are noted. What is the most likely mechanism by which this patient's complication has developed?



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A 45-year-old female presents to the clinician with a 3-week history of worsening nasal discharge, malaise, and a worsening vague frontal headache. She adds that she is also experiencing a feeling of “fullness” along her maxillary sinuses. She now is complaining of some pain in her eyes. She has not received prior care other than some Sudafed and sinus rinses. She has a history of uncontrolled diabetes and hypertension and is taking Metformin and Lisinopril. Vital signs include a blood pressure of 110/70 mmHg, heart rate of 96 beats per minute, respirations of 20 breaths per minute, oxygen saturation of 97% and a temperature of 99.6 degrees Fahrenheit. Her physical examination reveals mild photophobia and pain with eye movements. The rest of the physical examination is unremarkable. What is the next best step in the management of this patient?



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A 17-year-old male presents to the emergency department with a 2-week history of facial pain and purulent nasal discharge. He reported feeling better a few days ago, but he feels his symptoms are worsening again. He does not report any fevers. On examination, he appears fatigued but nontoxic. Vital signs are normal. Mild tenderness is present on maxillary sinus palpation bilaterally. What is the next step in the management of this patient?



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A 14-year-old male child presents to the clinician with his mother. The mother states that her child has had painful sinuses with associated purulent and watery nasal discharge for the past ten days. The symptoms have not improved, and he has missed two days of school. He has only tried over-the-counter nasal sprays which have not helped. Physical examination reveals a blood pressure of 100/60 mmHg, a temperature of 100 degrees Fahrenheit, a heart rate of 80 beats per minute, a respiratory rate of 20 breaths per minute, and oxygen saturation of 99%. His maxillary sinuses are mildly tender. His head and neck exam reveal mild bilateral submandibular lymphadenopathy. Otoscopic examination of his tympanic membrane is normal. His lung and heart exams are unremarkable. What is the best next step in the management for this patient?



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A 17-year-old healthy male presents with 14 days of progressive nasal obstruction, nasal discharge, and malaise. He has tried some over-the-counter nasal saline rinses and pseudoephedrine which has had minimal relief. He is leaving for college in 3 weeks and would like to get better as soon as possible. He has no known drug allergies. Vital signs reveal a blood pressure of 118/70 mmHg, heart rate of 80 beats per minute, respiratory rate of 16 breaths per minute, a temperature of 97.9 degrees Fahrenheit, and oxygen saturation 98%. His physical examination reveals mild bilateral cervical lymphadenopathy, normal tympanic membranes bilaterally, and pupils round and reactive to light bilaterally without photophobia. His lung and heart exams are within normal limits. What is the best treatment option for this patient?



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A 40-year-old male, known HIV (human immunodeficiency virus) positive presents to the clinician seven days after being treated for acute bacterial sinusitis. He has been treated with a 10-day course of amoxicillin and clavulanate. He reports continued worsening of his nasal obstruction and still feels subjective fever. He is on antiretroviral therapy and meets with his infectious disease specialist regularly. His medical history is otherwise unremarkable. On exam, his blood pressure is 140/90 mmHg, the pulse is 81 beats per minute, respiratory rate is 16 breaths per minute, the temperature is 99.9 degrees Fahrenheit, and oxygen saturation is 98%. The rest of the physical examination is unremarkable except for mild maxillary sinus tenderness. He has already obtained a sinus CT to rule-out alternate diagnoses. Which is the best next step in the management of this patient?



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A 16-year-old male presents to the emergency department complaining of facial pain and purulent nasal discharge. He reports symptoms started about ten days ago. He reports initial improvement without any antibiotic therapy but subsequently feeling "a lot worse." He now has subjective fevers, facial pain, and purulent discharge. He is otherwise healthy with no other medical problems. Vital signs are within normal limits. He is fatigued, but not ill-appearing. There is mild bilateral maxillary sinus tenderness. The exam is otherwise unremarkable. Which is the next step in the management of this patient?



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A 33-year old male presents to the provider's office for a 3-week history of progressive nasal obstruction, nasal discharge, and now intermittent subjective fevers. He is otherwise healthy. He has had no prior treatments or medical evaluations for these complaints. Physical exam reveals blood pressure 120/80mmHg, heart rate 90b/min, respiratory rate 16/minute, temperature 99.9 degrees Fahrenheit, O2 saturation 98%. His eye exam reveals mild photophobia, pain with eye movements, and pupils round and reactive to light bilaterally. His throat and tympanic membranes are normal. His lung and heart exams are also within normal limits. Other than treatment options, about which complication is the provider most concerned?



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A client with acute viral sinusitis is being discharged home from the emergency department. What home instructions will the registered nurse reinforce the during discharge teaching? Select all that apply.

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A 20-year-old man presents to the office with 3 days of nasal obstruction, nasal discharge, and malaise. He has no history of allergies but has had acute sinusitis in the past. His physical exam reveals a blood pressure of 130/80 mmHg, pulse 80/min, respiratory rate 16/min, temperature 98.6 F, and SpO2 99%. The exam is otherwise normal. He has an important meeting for work next week and wishes to be better by then. What is the next best step in the management of this patient?



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Acute Sinusitis - References

References

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Aring AM,Chan MM, Current Concepts in Adult Acute Rhinosinusitis. American family physician. 2016 Jul 15;     [PubMed]
DeMuri G,Wald ER, Acute bacterial sinusitis in children. Pediatrics in review. 2013 Oct;     [PubMed]
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Kirsch CFE,Bykowski J,Aulino JM,Berger KL,Choudhri AF,Conley DB,Luttrull MD,Nunez D Jr,Shah LM,Sharma A,Shetty VS,Subramaniam RM,Symko SC,Cornelius RS, ACR Appropriateness Criteria{sup}®{/sup} Sinonasal Disease. Journal of the American College of Radiology : JACR. 2017 Nov     [PubMed]
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