Rhinosinusitis (ENT)

Question 1

Define rhinosinusitis (AKA sinusitis).

Answer 1

Symptomatic inflammation of the mucosal lining of the nasal cavity (rhinitis) and paranasal sinuses, presenting with purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both (for </=4 weeks if acute)

Question 2

Which groups does rhinosinusitis tend to occur in? (2)

Answer 2

• F>M
• peak incidence tends to occur in colder months

Question 3

What are the two types of causes of rhinosinusitis and examples of each?

Answer 3

• viruses:
  
  • rhinovirus
  • coronavirus
  • adenovirus
• bacteria:
  
  • Streptococcus pneumoniae
  • Haemophilus influenzae

Question 4

What are the three categories of rhinosinusitis based on how long it lasts?

Answer 4

• acute </=4 weeks
• subacute 4-12 weeks
• chronic >/=12 weeks

Question 5

What are the clinical features of rhinosinusitis? (8)

Answer 5

• purulent nasal discharge (discoloured mucus)
• nasal obstruction
• facial pain/pressure (frontal, worse on bending forwards)
• cough
• myalgia
• sore throat
• hyposmia/anosmia
• oedematous turbinate

Question 6

How do we know the cause of rhinosinusitis based on symptom duration?

Answer 6

• symptoms <10 days = acute viral sinusitis
• symptoms >10 days but <4 weeks (and severe symptoms at onset) = acute bacterial sinusitis

Question 7

What are some risk factors for rhinosinusitis? (5)

Answer 7

• viral URTI (can lead to superimposed bacterial infections)
• allergic rhinitis (hayfever) / other atopic conditions e.g. asthma
• GORD
• nasal obstruction
• smoking

Question 8

What is the main way we diagnose rhinosinusitis?

Answer 8

Clinical diagnosis

Question 9

What do we do if we suspect complications of rhinosinusitis and what might we see? (1 + 4)

Answer 9

CT sinuses (with contrast)

• opacification
• mucosal thickening
• air-fluid levels
• soft tissue swelling

Question 10

What other visualising investigation is there for rhinosinusitis (apart from sinus CT)?

Answer 10

Nasal endoscopy - provides good visualisation for the nasal cavity and sinuses –> mucosal erythema, purulent discharge

Question 11

What investigation can help in planning appropriate management for rhinosinusitis?

Answer 11

Sinus culture - not required for diagnosis but can be helpful especially if refractory to empirical Abx

Question 12

What is the first-line treatment for acute viral rhinosinusitis?

Answer 12

Supportive therapy - analgesics or antipyretics (paracetamol/ibuprofen)

Question 13

What is the first-line treatment for acute bacterial rhinosinusitis? (2)

Answer 13

• immunocompromised/severe illness: Abx therapy (co-amoxiclav, phenoxymethylpenicillin)
• immunocompetent/not severe: watchful waiting for up to 10 days (bacterial>10d) / immediate commencement of Abx + supportive therapy

Question 14

What else can we give for acute rhinosinusitis (apart from supportive care + Abx if bacterial)? (4)

Answer 14

• decongestant (e.g. oxymetazoline)
• intranasal corticosteroid - if >10 days
• ipratropium (anticholinergic)
• nasal irrigation with intranasal saline

Question 15

What is the first-line treatment for acute invasive fungal rhinosinusitis / recurrent rhinosinusitis?

Answer 15

ENT specialist referral

Question 16

What are some complications of rhinosinusitis? (6)

Answer 16

• chronic sinusitis
• bacterial meningitis
• subdural abscess
• peri-orbital or orbital cellulitis
• subperiosteal or orbital abscess
• cavernous sinus thrombosis

Question 17

Describe the prognosis of rhinosunisitis.

Answer 17

• generally self-limiting and resolves within 1 month
• complications more seen in paediatric population and occur due to direct extension of the infection into neighbouring structures