Acute and chronic rhinosinusitis — branching viva

Opening question

Examiner: Take me through this child. What is your diagnosis, and what is your frame for managing it? ^[1]

Candidate: The first stage is acute bacterial rhinosinusitis, and then an orbital complication. The twelve days of thick nasal discharge and daytime cough without improvement, with the return of fever and the biphasic worsening, meet the AAP criteria for acute bacterial rhinosinusitis. The periorbital swelling, redness and painful eye that have followed mark the orbital complication — post-septal orbital cellulitis with, given the eye is displaced and vision is affected, a likely subperiosteal or orbital abscess. My frame is layered: make the clinical diagnosis, give the right antibiotic, and then recognise that this child has crossed into a sight- and potentially life-threatening complication that needs admission, intravenous antibiotics, urgent contrast CT, and ENT and ophthalmology review. ^{[1] [9]}

Examiner: How do you distinguish bacterial rhinosinusitis from a simple viral cold? ^[1]

Candidate: The nasal and sinus mucosa are one continuous lining, so almost every viral cold briefly involves the sinuses — acute viral and early bacterial rhinosinusitis are clinically indistinguishable for the first ten days. The AAP criteria separate them: persistent symptoms beyond ten days without improvement; a double-worsening course after initial improvement; or a severe onset with fever and purulent discharge for three or more consecutive days. Any one pattern supports the bacterial diagnosis. This child has the persistent and the double-worsening patterns. ^{[1] [2]}