Acute Rhinosinusitis

ARS Overview - Sinus Siege Starter

• Inflammation of nasal cavity & paranasal sinus mucosa.
• Types by duration:
  • Acute Rhinosinusitis (ARS): < 4 weeks; symptoms resolve completely.
    • Viral (AVRS): Common cold, typically < 10 days.
    • Post-viral ARS: Symptoms worsen after 5 days or persist > 10 days.
    • Acute Bacterial (ABRS): Often follows severe post-viral ARS.
  • Recurrent Acute (RARS): ≥ 4 episodes/year; symptom-free intervals.
• Affected sinuses: Maxillary, Ethmoid (anterior/posterior), Frontal, Sphenoid.
• Key drainage pathway: Ostiomeatal Complex (OMC).

  ⭐ Maxillary sinus is the most commonly affected sinus in adults.

Pathogenesis & Bugs - Nasty Nose Invaders

• Pathogenesis: Viral URI (commonest trigger) → mucosal inflammation → OsteoMeatal Complex (OMC) obstruction.
  • Leads to: Impaired mucociliary clearance → secretion stasis → bacterial superinfection.
  • Risk Factors: Allergic rhinitis, nasal polyps, septal deviation, dental infections, immunodeficiency.
• Common Bugs:
  • Viral: Rhinovirus, Influenza.
  • Bacterial (Acute Bacterial Rhinosinusitis - ABRS): 📌 S.M.H.
    • Streptococcus pneumoniae (Most common)
    • Haemophilus influenzae
    • Moraxella catarrhalis

⭐ Obstruction of the Osteomeatal Complex (OMC) is pivotal for maxillary, frontal, and anterior ethmoid sinusitis.

Symptoms & Signs - The Snotty Story

• Major Criteria (Need ≥2):
  • Nasal blockage/congestion
  • Purulent nasal discharge (ant/post)
  • Facial pain/pressure
  • Hyposmia/anosmia (↓ smell)
• Minor Criteria (Supportive):
  • Headache, fever, halitosis, fatigue, dental pain, cough, ear fullness/pain.
• Differentiating Features:
  • Viral ARS: Symptoms <10 days, peak 3-5 days, then improve.
  • Bacterial ARS: Symptoms >10 days OR "double sickening" (worsening after 5-7 days initial improvement) OR severe onset (fever ≥39°C + purulent discharge/facial pain for ≥3-4 consecutive days).

⭐ "Double sickening" (biphasic illness pattern) is a key indicator for bacterial rhinosinusitis.

Diagnosis, Dangers & Alerts - Spotting Sinus Storms

• Diagnosis (EPOS based): Sudden onset ≥2: nasal block/discharge, facial pain/pressure, ±anosmia. Duration < 12 wks.
  • Viral ARS: Symptoms < 10 days, not worsening.
  • Bacterial ARS (ABRS): ≥3 signs: discolored discharge (esp. unilateral) AND severe local pain (esp. unilateral); fever > 38°C; 📌 "Double Sickening" (worsening after initial improvement/5 days); ↑ESR/CRP.
• CT Scan: Not routine. Use for: suspected complications, severe/recurrent ARS, immunocompromised patients, pre-operative planning.

• ⚠️ Red Flags (Urgent Action!):
  • Orbital: Proptosis, diplopia, ↓vision, ophthalmoplegia.
  • Intracranial: Severe headache, altered mental status, meningism, focal neurological deficits.
  • Other: Frontal swelling (Pott's puffy tumor), persistent high fever > 39°C, no improvement after 48-72h antibiotics.

⭐ Pott's Puffy Tumor: Frontal bone osteomyelitis with subperiosteal abscess. A critical complication of frontal sinusitis needing urgent surgery & IV antibiotics.

Treatment Toolkit - Blockage Busters

• Core Symptom Relief:
  • Nasal saline irrigation.
  • Analgesics (Paracetamol/NSAIDs).
  • Decongestants: Oral; Topical (Oxymetazoline/Xylometazoline) for max 3-5 days. 📌 OXY-XYL for 3-5!
  • Intranasal Corticosteroids (INCS): Fluticasone, Mometasone - cornerstone for ABRS.
• ABRS Antibiotic Choice:
  • Amoxicillin (875mg BD) or Amoxicillin-Clavulanate (875/125mg BD).
  • Penicillin allergy: Doxycycline or Respiratory Fluoroquinolone.

⭐ Amoxicillin-clavulanate is often preferred first-line for ABRS due to increasing resistance.

• Refer if: Severe symptoms, complications, no response to 2 antibiotic courses, or ≥4 episodes/year.

High‑Yield Points - ⚡ Biggest Takeaways

• Viral infections (Rhinovirus) are the primary cause of ARS.
• Bacterial superinfection typically involves S. pneumoniae, H. influenzae.
• Key symptoms: nasal obstruction, purulent discharge, facial pain/pressure, hyposmia.
• ARS < 4 weeks; bacterial if symptoms >10 days, severe, or double sickening.
• Orbital cellulitis is most common complication; Pott's puffy tumor (frontal sinusitis).
• Amoxicillin is first-line for uncomplicated bacterial ARS; consider Augmentin.
• Waters view for maxillary sinus; CT scan gold standard for complications/chronic ARS or suspected intracranial spread.