Acute sinusitis; acute tonsillitis

Question 1

The sinuses are usually sterile - the most common infectious agents seen in acute sinusitis are [3].

Answer 1

The sinuses are usually sterile - the most common infectious agents seen in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses.

Question 2

There are four sets of paranasal sinuses. What are they? [4]

Answer 2

• Frontal sinuses (above the eyebrows)
• Maxillary sinuses (either side of the nose below the eyes)
• Ethmoid sinuses (in the ethmoid bone in the middle of the nasal cavity)
• Sphenoid sinuses (in the sphenoid bone at the back of the nasal cavity)

Question 3

What are predisposing factors for acute sinusitis? [4]

Answer 3

Predisposing factors include:
* nasal obstruction e.g. Septal deviation or nasal polyps
* recent local infection e.g. Rhinitis or dental extraction
* swimming/diving
* smoking

Question 4

Clinical features of acute sinusitis? [3]

Answer 4

Features
* facial pain: typically frontal pressure pain which is worse on bending forward
* nasal discharge: usually thick and purulent
* nasal obstruction

Question 5

Management of acute sinusitis? [+]

Answer 5

Management of acute sinusitis

People presenting with symptoms for around 10 days or less:
- No abx
* analgesia
* intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited

People presenting with symptoms for around 10 days or more with no improvement
- NICE recommend that intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days

Patients with systemic infection or sepsis require admission to hospital for emergency management.

Question 6

NICE recommend for patients with acute sinusitis symptoms that are not improving after 10 days, the options of [2]

Answer 6

High dose steroid nasal spray for 14 days (e.g., mometasone 200 mcg twice daily)

A delayed antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin first-line)

Question 7

Management options for chronic sinusitis are [3]

Answer 7

• Saline nasal irrigation
• Steroid nasal sprays or drops (e.g., mometasone or fluticasone)
• Functional endoscopic sinus surgery (FESS)

Question 8

How do you distinguish between viral and bacterial cause of tonsillitis? [4]

Answer 8

CENTor: Sore throat (99%) with
Can’t cough
Exudates (tonsillar)
Nodes
Temperature

• More likely to be bacterial - in which case need Abx

Question 9

Which nodes swell in tonsilitis and where do you find them? [2]

Answer 9

There may be anterior cervical lymphadenopathy, which refers to swollen, tender lymph nodes in the anterior triangle of the neck (anterior to the sternocleidomastoid muscle and below the mandible).

The tonsillar lymph nodes are just behind the angle of the mandible (jawbone).

Question 10

Apart from 3+ score on Centor score, what are other NICE indications for Abx tx of acute tonsillitis? [4]

Answer 10

• features of marked systemic upset secondary to the acute sore throat
• unilateral peritonsillitis
• a history of rheumatic fever
• an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
• patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present

Question 11

Describe the mx of tonsilitis [+]

Answer 11

Consider prescribing antibiotics if the Centor score is ≥ 3, or the FeverPAIN score is ≥ 4.
- Also, consider antibiotics if they are at risk of more severe infections, such as young infants, immunocompromised patients or those with significant co-morbidity, or a history of rheumatic fever.

Delayed prescriptions can be considered. This involves educating patients or parents about the likely viral nature of the sore throat and providing a prescription to be collected only if the symptoms worsen or do not improve in the next 2 – 3 days.

Question 12

What are main common complications of tonisillits? [3]

Answer 12

Acute otitis media
* Common, benign and self-limiting.
* Antibiotics reduce the risk.

Peritonsillar abscess (quinsy) or neck abscess
* Usually in the first 2 months after acute tonsillitis episode.
* Presents with spiking fever, neck pain and dysphagia.

Acute sinusitis
* In 0.4% of untreated patients.
* Antibiotics reduce the risk.

Question 13

If a patient has peritonsillar abscess - what treatment is always indicated? [1]

Answer 13

• Antibiotics reduce the risk. Drainage required.

Question 14

Rare (but important) complications of tonisillitis [4]?

Answer 14

Scarlet fever
Presents as a blanching erythematous papular rash, a strawberry tongue and circumoral pallor.

Acute rheumatic fever
Extremely rare (< 1:100,000).
Causes widespread inflammation throughout the body.
Presents with arthritis, subcutaneous nodules, erythema marginatum, chorea and carditis.
Antibiotics reduce the risk.

Acute post-streptococcal glomerulonephritis:
Exceedingly rare.
Presents with haematuria, oedema, vomiting and anorexia.

Streptococcal toxic shock syndrome:
Very rare but life-threatening.
Presents with progressive multiple organ failure and shock.
Due to exaggerated inflammatory response to streptococcal antigens.

Question 15

Abx of choice for tonsillitis? [2]

Answer 15

Penicillin V (also called phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes.

Clarithromycin is the usual first-line choice in true penicillin allergy.