ExploreCME: Diving deep into PANCE Prep!
Daily podcast covering topics geared towards PANCE sucess.
ExploreCME: Diving deep into PANCE Prep!
Sinusitis, Simplified
Welcome back to the deep dive. Today we are cutting right through the noise to tackle a really critical high-yield topic: acute and chronic sinusitis. For those of you studying up, this one falls squarely in the EAT content area: eyes, ears, nose, and throat, which is a pretty big player on those entry-level exams. It is, yeah.
SPEAKER_01:And you know, before we even start talking about assessment or management, you really have to nail the fundamentals. Okay. With rhinosinusitis, duration is everything. I mean, it's the primary determinant for everything that comes next. We classify these things strictly by how long symptoms last.
SPEAKER_00:Aaron Powell, so lay out those duration rules for us because those cutoffs basically dictate the whole treatment plan.
SPEAKER_01:Aaron Powell Absolutely. So the vast majority of what we see is acute rhinosinositis. That just means symptoms have been around for less than four weeks. Trevor Burrus, Jr.
SPEAKER_00:And that's usually the common cold, right? The congestion, the pressure.
SPEAKER_01:Exactly. Now, if those symptoms stick around, we move into what's called subacute rhinosatositis. That's the middle ground, so four to twelve weeks. But the second you cross that three-month mark, you are dealing with chronic rhinosinusitis or CRS. And that's defined as symptoms lasting longer than 12 weeks.
SPEAKER_00:Aaron Powell And that can be with or without acute flare-ups, right?
SPEAKER_01:Aaron Powell That's right. Understanding those time frames is just it's essential. It decides whether you're reaching for supportive care, an antibiotic, or maybe even something more.
SPEAKER_00:So our mission today is to help you navigate all of those crucial decision points from history and physical straight through to management of both the common forms and, well, the life-threatening ones. Let's start with assessment. It's so interesting because with acute sinusitis, the most powerful tool is often just a good patient history, not a fancy lab test.
SPEAKER_01:Aaron Powell That's scot on. We spend so much time just trying to differentiate the two main culprits, viral versus bacterial. Let's uh let's look at the viral one first.
SPEAKER_00:Aaron Powell Okay. So what are we listening for in the viral history?
SPEAKER_01:Aaron Powell The time frame. That's the key giveaway. If the symptoms have been going on for less than 10 days, the odds are very, very high that this is viral.
SPEAKER_00:Aaron Powell And what are they telling you?
SPEAKER_01:They'll report nasal congestion, watery rhinoa, you know, that classic clear, drippy nose, maybe a decreased sense of smell, and sneezing.
SPEAKER_00:Aaron Powell And on physical exam for that viral cold, what does the inside of the nose look like?
SPEAKER_01:It's typically red and swollen, erythematis and edibitis, and you'll see that watery, clear discharge. The crucial thing is purity and discharge is generally absent.
SPEAKER_00:Okay, so that 10-day marker is our first real red flag. When do we start to pivot from thinking it's just a cold to actively suspecting acute bacterial rhinosinusitis or ABRS?
SPEAKER_01:Aaron Powell You need one of two things to happen. First, the symptoms have to persist for more than 10 days without any sign of improvement. That failure to clear is the most common trigger.
SPEAKER_00:Aaron Powell And the second one, the more dramatic one.
SPEAKER_01:Ah, that is the famous double sickening pattern.
SPEAKER_00:Right.
SPEAKER_01:The patient tells you they were getting better, maybe days five to seven felt okay, and then wham, their symptoms suddenly got way worse. Higher fever, more pain, all within that initial 10-day window.
SPEAKER_00:That pattern is such a strong clinical clue. What about other uh high yield things in the history that make you think, okay, this is probably bacterial?
SPEAKER_01:Right. So listen for the patient reporting a foul odor. We call it cacosmia.
SPEAKER_00:A bad smell that no one else can smell.
SPEAKER_01:Exactly. It suggests there's infected trap fluid in there. Another really strong predictor is dental pain, especially in the upper jaw. The roots of those teeth are just so close to the sinus floor.
SPEAKER_00:So we've got the history. On the exam for ABRS, we're now looking for that shift from clear, watery discharge to that thick, purulent, yellow-green stuff, correct?
SPEAKER_01:Aaron Powell Exactly. Plus, you'll often find localized facial tenderness when you palpate right over the affected sinus. And you know, it's worth saying for you, the learner, that only about 2% of viral cases actually become bacterial.
SPEAKER_00:Only 2%.
SPEAKER_01:Yeah. We have to keep that lone number in mind when we start talking about antibiotics later.
SPEAKER_00:Aaron Powell That context is vital. Now let's talk anatomy. The location of the pain can tell us which sinus is actually causing the problem. Aaron Powell Right.
SPEAKER_01:Maxillary sinusitis is by far the most common. Patients will describe unilateral facial fullness, pressure, cheek tenderness, and because the trigeminal nerve is involved, that pain often refers to the upper teeth.
SPEAKER_00:Aaron Powell And what if it's the ethmoid sinuses? Where is the pain then?
SPEAKER_01:With ethmoiditis, you're looking at pressure high on the side of the nose, often right between the eyes. It can even radiate towards the orbit. Aaron Powell Okay.
SPEAKER_00:And frontal is pretty straightforward, I assume.
SPEAKER_01:Usually, yeah. Pain and tenderness right over the forehead. The one that can trick you is sphenoid sinusitis.
SPEAKER_00:Ah, the deep one.
SPEAKER_01:Yes. The headache is described really vaguely, like in the middle of my head. Sometimes they'll literally point to the very top of their skull. You have to ask about that specifically, or you can miss it.
SPEAKER_00:That is essential for building your differential. Okay, now we have to talk about the terrifying outlier, the true emergency, invasive fungal sinusitis.
SPEAKER_01:This is a critical distinction. This happens almost exclusively in highly immunocompromised patients.
SPEAKER_00:So who are we talking about?
SPEAKER_01:Think patients with uncontrolled diabetes, especially if they're in DKA, or someone undergoing chemo or with advanced renal disease.
SPEAKER_00:And the initial symptoms might look like a bad bacterial infection, but what are the red flags that push this into the emergency category?
SPEAKER_01:The facial pain is usually way out of proportion. It's severe. And you might see early signs of vision changes. But the cardinal sign, the one that should make you pick up the phone immediately, is a black esher on the middle turbinate.
SPEAKER_00:Black escher, necrotic tissue. That's unforgettable.
SPEAKER_01:It means the fungus is invading blood vessels and killing tissue. And the crazy thing is the nasal drainage might be clear or straw colored. So if you're only looking for pus, you could have a fatal delay. You have to look for that esher.
SPEAKER_00:Given that we can diagnose viral and bacterial cases so well with just history and physical, when do we actually pull the trigger and order imaging? Because I mean, ordering a CT for every cold is definitely not the right move.
SPEAKER_01:No, that's the crux of it, right? The general rule is simple. Routine x-rays are not recommended for acute, uncomplicated sinusitis. The diagnosis is clinical.
SPEAKER_00:So when do we image?
SPEAKER_01:We save imaging for specific scenarios. A non-contrast CT scan is your go-to when you suspect a complication.
SPEAKER_00:So if they're not getting better on antibiotics.
SPEAKER_01:Exactly. If they fail therapy, or most critically, if you suspect orbital or intracranial extension of the infection. Okay. But here's the clinical reality you have to remember. CT is super sensitive, but it's not specific at all. A lot of patients with a simple viral cold will still have sinus abnormalities on a CT.
SPEAKER_00:So don't let the imaging override a classic 10-day history.
SPEAKER_01:Never. The history is king.
SPEAKER_00:And when would we ever escalate to an MRI?
SPEAKER_01:MRI is really for when you need better soft tissue detail. So if you're worried about a tumor, deep intracranial spread, or again that fungal infection, MRI is great at telling the difference between a tumor and just fluid, which is vital in those emergencies.
SPEAKER_00:And for diagnosing that invasive fungal type, imaging alone isn't enough, is it?
SPEAKER_01:Absolutely not. The definitive early diagnosis for invasive fungal sinusitis requires a biopsy.
SPEAKER_00:Okay.
SPEAKER_01:They'll do it endoscopically. Get a piece of that tissue and look for those classic broad non-septate hyphae on a silver stain.
SPEAKER_00:Got it. Let's shift our focus to management now, from diagnosis to intervention, starting with the most common scenario that viral rhinosinositis.
SPEAKER_01:Management here is purely supportive. We're talking rest, hydration, over-the-counter analgesics, and especially saline irrigation. It really helps.
SPEAKER_00:What about medications for symptoms?
SPEAKER_01:Sure. Oral decongestants like pseudoephedrine and intranasal corticosteroids like mometazone can be very helpful for relief.
SPEAKER_00:And what about those common nasal sprays that everyone grabs from the pharmacy? That's where we run into that really common self-inflicted problem. Ugh, yes.
SPEAKER_01:We have to be so firm on this. Those sprays like oxymedazaline should be limited to three days, four at the absolute most.
SPEAKER_00:Why is that?
SPEAKER_01:Because of rhinitis medicamentosa. It's this awful rebound congestion. The sprays work by constricting blood vessels, but when they wear off, the body overcompensates and the congestion comes back even worse. It creates a vicious cycle.
SPEAKER_00:Yeah.
SPEAKER_01:And of course, antibiotics are completely useless here.
SPEAKER_00:Aaron Ross Powell Right. So moving to ABRS, we know that a lot of these bacterial cases actually clear up on their own. So how do we practice good antibiotic stewardship?
SPEAKER_01:Aaron Ross Powell We have to be strict. We reserve antibiotics for patients with severe symptoms, high fever, really bad facial pain, swelling, or if they definitively meet that time criteria we talked about.
SPEAKER_00:The more than 10 days or the double sickening.
SPEAKER_01:Exactly. If these symptoms are mild and the patient is healthy, watchful waiting for seven to ten days is often the best plan.
SPEAKER_00:So once the decision is made to treat a pretty standard, uncomplicated adult patient, what's our first line choice?
SPEAKER_01:Standard dose amoxicillin clavulinate. It covers the usual suspects.
SPEAKER_00:Aaron Powell, but what if that patient is considered high risk? Say they're over 65 or we're recently in the hospital.
SPEAKER_01:Then we immediately jump to the high dose regimen of amoxicillin clavulinate. No messing around. We're trying to overcome potential resistance and just hit the infection hard and fast.
SPEAKER_00:And what if we have a true penicillin allergy?
SPEAKER_01:Doxycycline is an excellent second line option. Another good one is clindamycin plus a cephalosporin lyxafixin.
SPEAKER_00:And what should we not use?
SPEAKER_01:Great question. Macroites and TMP SMX, they're not recommended for empiric therapy anymore.
SPEAKER_00:Why not?
SPEAKER_01:Just due to really high rates of bacterial resistance. Using them just significantly increases your risk of treatment failure. You have to avoid them.
SPEAKER_00:Let's touch on chronic rhinocinositis briefly, the one that lasts over 12 weeks. Management is usually long-term corticosteroids, but are there any newer treatments we should know about?
SPEAKER_01:Yes. For chronic rhinosinositis with nasal polyps, the big advance has been biologic therapy, specifically dupalumab. It's a monoclonal antibody that targets the inflammatory pathways. It's been a game changer for severe cases.
SPEAKER_00:Wow. Okay, now let's go back to that invasive fungal emergency. We said immediate action is required. What does that mean exactly?
SPEAKER_01:It means a two-pronged attack, and you do it immediately and at the same time. First, prompt and wide surgical debridment. You have to get all of that dead infected tissue out. And second, concurrent four feet antifungal therapy. Vorconazole is often the primary agent.
SPEAKER_00:And what's the single most critical step that's not a drug?
SPEAKER_01:Reversing the underlying immune compromise. It is absolutely critical. If the patient's diabetic, you have to get that hyperglycemia under control aggressively. The best drugs in the world will fail if the host's defenses are still down.
SPEAKER_00:That is such a crucial point. Speaking of which, let's wrap up with health maintenance and patient education. What are the key messages we need to get across?
SPEAKER_01:You have to reiterate that antibiotics are rarely necessary for a simple sinus infection, and remind them that viral symptoms are supposed to last up to 10 days. Setting that expectation saves a lot of trouble.
SPEAKER_00:And again, that warning about the nasal sprays and rhinitis medicamentosa.
SPEAKER_01:Absolutely. And finally, you have to know how to recognize complications. This is where patient safety really comes into play.
SPEAKER_00:Where do most of these life-threatening extensions come from?
SPEAKER_01:They often spread directly through a thin bone called the lamina piporachia, which separates the ethmoid sinuses from the orbit.
SPEAKER_00:Leading to orbital complications.
SPEAKER_01:Right. And you have to look for proptosis, a bulging eye gaze restriction, and sudden severe orbital pain.
SPEAKER_00:And if you see those signs?
SPEAKER_01:Immediate CT scan and an emergency referral to ophthalmology or ENT, that patient is getting admitted, period.
SPEAKER_00:What about bony extensions?
SPEAKER_01:That's osteomyelitis of the frontal sinus. It presents as this tender, localized swelling on the forehead. Classically, it's called a pot puffy tumor.
SPEAKER_00:Sounds harmless, but it's not.
SPEAKER_01:Not at all. It's a severe bone infection.
SPEAKER_00:And the most severe category intracranial complications.
SPEAKER_01:Any sign of meningitis, brain abscess, or the dreaded cavernous sinus thrombosis. You look for eye movement problems, swelling of the conjunctiva, rapid vision loss. Any patient with facial cellulitis, sudden vision changes, or any change in mental status needs immediate admission and an aggressive workup. You just can't wait on those.
SPEAKER_00:That gives us such a clear roadmap for when a simple cold has become a crisis. Before we wrap, let's use that great analogy you shared to really lock in these concepts.
SPEAKER_01:Right. So think of the sinuses as rooms connected by narrow hallways. Viral rhinocinusitis is just swelling. The hallway walls are swollen shut, the rooms feel stuffy.
SPEAKER_00:And antibiotics can't fix swollen walls.
SPEAKER_01:Exactly. Now bacterial rhinocinusitis is when those hallways have been blocked long enough that 10-day mark for the stagnant fluid in the reams to get infected. That's when you might need the key, the antibiotic.
SPEAKER_00:And fungal.
SPEAKER_01:Invasive fungal sinusitis isn't a blocked hallway. The fungus is actively eating the walls of the rooms and the halls. It requires demolition. That's the surgery and heavy duty restoration, the IV antifungals.
SPEAKER_00:A perfect summary.
SPEAKER_01:And to leave you with a final thought. We stress that for invasive fungal sinusitis, you have to immediately reverse the immune compromise, like controlling hyperglycemia. We start the antifungal drug immediately, of course. But why is managing the patient's blood sugar just as critical as the drug itself? And how fast does that have to happen? Think about the environment that fungus needs to thrive and what you have to change first to save that patient's life.
SPEAKER_00:A perfect way to connect clinical management right back to the science. Thank you for diving deep with us today. We hope you feel ready to tackle any sinusitis presentation you encounter.