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Using Sx to diagnose Acute Bacterial Rhinosinusitis (ABRS)?
- Need 2 major symptoms,
- 1 must be O or D – nasal obstruction or discharge
More than 7 days symptoms of sinusitis or suddent worsening of Sx after 5-7 days (biphasic illness)(Consider ABRS under any one of the following conditions:1. worsening after 5-7 days (biphasic illness) with similar symptoms- 2. symptoms persist more than 7 days without improvement
3. presence of purulence for 3-4 days with high fever
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Red flags in ARDS for urgent referral?
- Altered mental status
- Headache
- Systemic toxicity
- Swelling of the orbit or change in visual acuity
- Hard neurological findigns
- Signs of meningeal irritation
- Suspected intracranial complications: meningitis, intracranial abscess, cavernous sinus thrombosis
- Involvement of associated structures – periorbital cellulitis, pott’s puffy tumor
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Symptoms of sinusitis? (major Sx)
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Major symptoms: PODS
- P – facial Pain/pressure/fullness (pain)
- O – nasal Obstruction
- D – nasal purulence/discoloured postnasal Discharge
- S – hyposmia/anosmia (Smell)
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Treatment of mild to moderate rhinosinusitis/ABRS?
May use INCS (intranasal corticosteroids) as monotherapy. If no improvement after 72 hours, use antibiotics.
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Treatment of severe ABRS?
ICNS + antibiotics
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First line choice of Abx? In Pen allergic Pt?
- Amoxicillin
- Pen-allergic - Septra (TMP/SMX) or a macrolide
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2nd line Abx if treatment failure or concerned with resistence?
- Fluoroquinolone or Amox-Clav combo.
- Resistance more likely if:
- recent abx use (<3 months)
- daycare exposure
- chronic symptoms
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When is treatment failure?
- After 72 hours of treatment with no improvement.
- Change class of abx if treatment failure.
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Adjuncts in ABRS?
- analgesics (tylenol, NSAIDS)
- INCS
- Saline irrigation
- Decongestants
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Prevention strategies?
handwashing, education, environmental awareness
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When to consider referral?
- No response to 2nd line abx therapy
- Suspected chronicity
- persistent severe Sx
- Repeated bouts with clearing b/w episodes
- More than 3x/ year (recurrent)
- Immunocompromised host
- Allergic rhinitis evaluation for immunotherapy
- Anatomic defect causing obstruction
- Nosocomial infection
- Assumed fungal or neoplasm
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Why wait until 7 days?
- More likely to be a viral infection
- Abx side effects:
- diarrhea
- interferes with contraception
- allergy
- yeast infections
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What to do for recurrent ABRS?
CT scan/refer for expert assessment.
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How to stratify ABRS symptoms?
- • Mild: occasional limited episode
- • Moderate: steady symptoms but easily tolerated
- • Severe: hard to tolerate and may interfere with activity or sleep.
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What is objective criteria for ABRS on imaging?
- presence of an air/ fluid level or complete opacification.
- Mucosal thickening
- alone is not considered diagnostic.
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