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]}