Rhinosinusitis

Question 1

What is it?

3 types

Answer 1

Inflammation of the paranasal sinuses

Infectious, allergic or autoimmune

Question 2

What is acute sinusitis classed as?

What usually precedes it?

Answer 2

< 12 wks

Usually from viral URTI or bacterial infection

Question 3

What is chronic rhinosinusitis classed as?

What may it be due to?

How is it sub-classified?

Answer 3

> 12 wks

Acute infection or due to recurrent infection, allergy or anatomical abnormality

Presence or absence of nasal polyps

Question 4

Rhinitis vs sinusitis

Answer 4

Allergic rhinitis, or hay fever, happens when you breathe in something to which you are allergic, and the inside of your nose becomes inflamed and swollen. Sinusitis is an inflammation of the lining inside the sinuses which can be acute or chronic.

Question 5

Name the 4 sinuses

Answer 5

Maxillary
Frontal
Ethmoidal
Sphenoidal

Question 6

What would you ask about in the history?

Answer 6

Nasal obstruction (nasal block) - bi/unilateral

Nasal discharge? bi/unilateral? discharge clear or discoloured?

Facial pain? What is the nature of the pain?

Do you have any bleeding from the nose? (epistaxis)

Have you noticed any change in the shape of your nose?

Have noticed any change in your sense of smell.

Question 7

Risk factors:

• Seasonal
• Anatomical
• Respiratory disease
• Others

Answer 7

Allergic rhinitis

Nasal polyps, facial injury, congenital abnormality

Asthma, CF

Immunodeficiency
Pregnancy
Smoking

Question 8

How to tell difference between polyp and concha on endoscopy?

Answer 8

This can be difficult, but polyps are paler and have no sensory fibers. Therefore gentle touching the polyp with a probe will cause no sensation.

Question 9

S+S:

Pain:

Where?
What is a more subtle presentation of pain?
Where does it radiate to? - 2
What exacerbates the pain? - 2

Answer 9

Pain and tenderness over sinus areas

Facial fullness especially if chronic

Frontal headache
Teeth

Straining
Bending forward

Question 10

Other S+S

Answer 10

Red nose, cheeks or eyelids

Blocked nose, postnasal drip, hyposmia

Persistent cough

Question 11

Features suggesting bacterial infection

Answer 11

Purulent discharge
Severe or persistent (>10 days)
Fever
Mild illness which then becomes worse

Question 12

Nasal polyps

What are they?

When is an urgent ENT referral needed for malignancy?

What may it cause? - 3

Answer 12

Non-tender, grey lumps in contrast to the tender, red nasal turbinates.

If unilateral and bleeding

Nasal obstruction
Hyposmia (reduced sense of smell)
Snoring

Question 13

Management - usually resolves in 2 wks without Rx

Other options - 4

Answer 13

Intranasal decongestants (max 1 wk)
Simple analgesia
Saline nasal irrigation
Warm face packs

Question 14

Management

What do you give if symptoms have persisted for > 10 days?

What antibiotic is given if someone has severe symptoms or individual has CF or is immunodeficient ?

Answer 14

Nasal corticosteroids (Fluticasone)

Phenoxymethlpenicillin

Co-amoxiclav (if systemically unwell)

Question 15

Why do you not use decongestants long term?

Answer 15

They can make the stuffiness worse.

Question 16

Complications:

Periorbital or orbital cellulitis:

• what is it?
• how is it managed?

Subperiosteal or orbital abscess:

• Pathophysiology
• Rx?

Meningitis:
-symptoms

Subdural abscess:

• pathophysiology
• main symptom

Cavernous sinus thrombosis

• symptoms
• orbital sign

Answer 16

Periorbital or Orbital cellulitis
Both present with erythema and swelling around the eye
Managed in hospital with antibiotics.

Subperiosteal or orbital abscess
Occur when orbital cellulitis progresses and requires surgical intervention

Meningitis 
Rare 
Severe headache 
Neck stiffness 
Photophobia 

Subdural Abscess
Direct extension of infection from sinuses
Headache

Cavernous Sinus Thrombosis
Very rare
Severe headache
Orbital swelling – bilateral