EN4.32 | Acute and Chronic Sinusitis with Complications — Summary & Reflection

KEY TAKEAWAYS

Rhinosinusitis is classified by duration: acute (≤4 weeks), subacute (4–12 weeks), and chronic (>12 weeks with objective mucosal disease). Acute rhinosinusitis is viral in >90% of cases; bacterial ARS is indicated by 'double sickening,' symptoms beyond 10 days, severe fever ≥38.5°C, or unilateral purulent pain. Bacterial pathogens in ARS are S. pneumoniae, H. influenzae, and M. catarrhalis. Antibiotics are NOT indicated for viral ARS; amoxicillin/co-amoxiclav is first-line for bacterial ARS. CRS is managed stepwise: topical steroids + saline (12 weeks) → systemic steroids or macrolides → FESS for refractory disease. The most dangerous complications of sinusitis are orbital (Chandler I–V) and intracranial (meningitis, epidural abscess, subdural empyema, brain abscess, cavernous sinus thrombosis). Proptosis, restricted eye movements, or reduced visual acuity in a sinusitis patient = emergency CT and likely surgical drainage. Pott's puffy tumour (frontal bone osteomyelitis + forehead subperiosteal abscess) is a frontal sinusitis complication. Invasive fungal sinusitis (mucormycosis) in a diabetic or immunocompromised patient with black nasal necrosis = surgical and antifungal emergency.

REFLECT

A 28-year-old IT professional presents to you with a 3-day history of 'sinus infection' and demands antibiotics, saying 'I get this every year and antibiotics always fix it quickly.' His current symptoms are bilateral nasal congestion, clear discharge, and mild facial pressure — classic viral ARS at day 3. How would you manage this consultation? Reflect on the tension between the patient's well-established health belief (antibiotics work for his sinuses), the scientific evidence (antibiotics have marginal benefit at best in viral ARS), and the public health imperative (antibiotic stewardship). What communication strategies would you use to decline the prescription without damaging the therapeutic relationship or leaving the patient dissatisfied?