CASE PRESENTATION

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CASE PRESENTATION

• Dr Oredein

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CASE PRESENTATION

• 17yrs old M.S
• Seen on 11th Sept 2000
• C/o Headaches 4/7
• pain on the forehead

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CASE PRESENTATION

• HPC
• Cough productive of yellow sputum for 4/7
• Associated headache which is mainly frontal in
  location
• Headache partially relieved by panadol.
• Fever h/o migraine photophobia vomiting
  runny nose visual symptoms

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CASE PRESENTATION

• O/E
• Comfortable young man in no distress
• Pallor, T 37C, anicteric
• RS clinically clear
• ABDfull and soft, tenderness masses LSK
• CNS grossly normal
• E.N.T nad
• Forehead .Slight swelling b/w the eyebrows
• .Tenderness over the forehead

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CASE PRESENTATION

• Impression
• R/o Frontal Sinusitis
• Investigation/Rx
• X-Rays sinuses
• I.M Voltaren 75mg stat

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CASE PRESENTATION

• X-Ray

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CASE PRESENTATION

• ENT Referral
• Admitted to B8
• FBC
• IV Augmentin 625mg 8hrly

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CASE PRESENTATION

• Discharged after 2 days of IV medication
• Clinic follow-up
• Repeat X-Rays

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Acute Sinusitis

• Definitions
• Acute sinusitis (1 day-3wks )
• Subacute sinusitis (3wks-12wks)
• Chronic sinusitis (gt12wks)

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Acute Sinusitis

• Epidemiology
• 31 mill. have sinus disease yearly
• 16 mill. Physician visits
• 5 of viral URTI are complicated by sinusitis
• Adults average 2-3 colds per year
• More than 150 million is spent per year on OTC.

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Acute Sinusitis

• Etiology
• Strept. Pneumoniae
• H.Influenza
• B.Catarrhalis
• Anaerobes and staph (chronic)
• P.Aeruginosa (HIV, Cystic fibrosis)

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Acute Sinusitis

• Predisposing factors
• Nasal septum deviation
• Traumas and fractures
• Septal spurs
• Rhinitis medicamentosa
• Hypertrophic turbinate
• Barotraumas, foreign bodies, instrumentation
• Nasal polyps, tumors
• Infections from adjacent tissues

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Acute Sinusitis

• Pathophysiology
• Paranasal sinuses
• Frontal
• Maxillary
• Ethmoid
• Sphenoid

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Mucociliary pathways
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Acute Sinusitis

• Pathophysiology
• Viral URTI and allergic rhinitis ? ostial
  obstruction ? ?intrasinus pressure ?stagnation of
  secretion
• Ciliary abnor./immobility ?drainage inhibition ?
  ?
• resorption of air within the sinus ? ? O2
  tension/ ?pH
• ? ?inflammation and bacteria overgrowth

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Acute Sinusitis

• Clinical Presentation
• Preceding URTI
• Mucopurulent rhinorrhea
• Postnasal drip
• Nasal congestion/obstruction
• Cough, fever, nausea
• Facial pain or headache over involved sinus.

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Acute Sinusitis

• Clinical Presentation
• Maxillary
• Malar facial pain
• Referred ear pain
• Maxillary dental pain
• Retro ocular pain
• Purulent nasal discharge
• Conjunctivitis
• Low grade fever

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Acute Sinusitis

• Clinical Presentation
• Frontal
• Pain /tenderness over lower forehead
• Purulent discharge
• ? Fever

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Acute Sinusitis

• Clinical Presentation
• Ethmoidal
• Mainly disease of children
• Retro orbital pain and fever
• Swelling tenderness over the medial aspect of
  the nose
• Purulent discharge

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Acute Sinusitis

• Clinical Presentation
• Sphenoidal
• Uncommon disease
• Non-specific signs and symptoms
• Hx of recent nasotracheal intubations
• Pain over occiput, vertex or mastoid
• gt50 present with neurologic or ophthalmologic
  complications

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Sites of referred pain
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Acute Sinusitis

• Independent predictors (LRA)
• Maxillary toothache
• Abnormal sinus transillumination
• Poor response to nasal decongestant or
  antihistamine.
• Colored nasal discharge
• Mucopurulence seen on examination

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Acute Sinusitis

• Physical Examination/Signs
• Best done after topical decongestant
• ? nasal airway
• Mucosal erythema
• ? Purulent discharge from nasal meatus
• Head positioning

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Acute Sinusitis

• ED Evaluation
• Transillumination
• Radiology
• Plain X-rays
• CT Scan
• MRI ( little role in ED)
• Culture
• Blood Test

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Acute Sinusitis

• Differential Diagnosis
• Rhinitis
• Tension headache
• Vascular headache
• Brain abscesses
• Meningitis
• Subdural empyema

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Acute Sinusitis

• Complications
• Orbital
• Facial cellulitis, Periorbital cellulitis
• Periorbital abscess, Orbital abscess, blindness
• Intracranial
• Meningitis, cavernous sinus thrombosis, epidural/
  subdural empyema, brain abscess
• Headache, ?sensorium, focal neurologic deficit

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Acute Sinusitis

• ED Management
• Therapeutic Goals
• Relieve obstruction
• Treat Infections
• Others

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Acute Sinusitis

• ED Management
• Relieve Obstruction
• Nasal Decongestants (Topical/Systemic)
• Oxymetazolin
• Phenylepherine hydrochloride
• Pseudoephedrine

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Mecca position for topical decongestant
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Acute Sinusitis

• ED Management
• Treat Infection
• Antibiotics
• Amoxicillin
• TMP and SMX
• Augmentin
• Clarithromycin

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Acute Sinusitis

• ED Management
• OTHERS
• Analgesia
• Warm soaks / steam to face
• Urgent treatment of complications
• Steroids/Anticoagulation/Antihistamines

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Acute Sinusitis

• Disposition
• Rx as OP- healthy pt. With uncomplicated sinus
  infection
• Frontal or sphenoid sinusitis with air-fluid
  levels requires hospitalization.
• Life threatening complications
• Consultations
• High-dose antibiotics
• Admission.

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Common Pitfalls

• Inadequate Treatment
• Failure of referral
• Inadequate radiographic studies
• Failure to consider rhino. Infec in high risk pts.

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Summary points

• Sinusitis is an important source of morbidity and
  loss of income.
• Acute sinusitis should be treated with
  decongestant and antibiotics for 10-14days.
• Check for and treat predisposing factors such as
  allergy, deviated nasal septum, intranasal
  polyps, especially in chronic sinusitis