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Question:

A 4-year-old girl is brought to the office due to a worsening cough and nasal discharge. Two weeks ago, the patient developed nasal congestion and a runny nose, which initially improved over a few days. However, for the past 10 days she has had increasing amounts of thick, yellow-green nasal discharge. She stayed home from preschool for the past 2 days due to a worsening daytime cough and has also been waking up at night with a cough. She has no chronic medical conditions and takes no daily medications. Immunizations are up to date. Temperature is 37.2 C (99 F), pulse is 90/min, and respirations are 18/min. Pulse oximetry is 99% on room air. Examination shows an alert, active child with intermittent coughing. Thick, purulent mucus is present in the nares and visualized in the posterior oropharynx. Nasal turbinates are mildly erythematous and swollen. Bilateral tympanic membranes are translucent and mobile, and the lungs are clear on auscultation. Which of the following is the best next step in management of this patient?

Answers:

A.CT scan of sinuses

B. Intranasal corticosteroids

C. Observation and close follow-up

Correct answer:

D. Oral antibiotics

Your reply:

E. Oral antihistamines

F. A sinus fluid culture

G. Sinus x-rays

Explanation:

Choice A and G. ABRS is generally a clinical diagnosis. However, if the patient develops periorbital edema, vision abnormalities, or altered mental status, CT scan of the sinuses is recommended to identify suppurative complications (eg, orbital/preseptal cellulitis, brain abscess, cavernous sinus thrombosis). Sinus x-rays are less sensitive and not recommended in the diagnosis of sinusitis or its complications.

Choice B and E. Intranasal corticosteroids and oral antihistamines treat allergic rhinitis and are used only as adjunctive therapy for sinusitis with an allergic component. Allergic rhinitis presents with rhinorrhea that is clear, not purulent as in this patient.

Explanation

Educational objective: Acute bacterial rhinosinusitis is distinguished from a viral upper respiratory infection by the presence of severe, persistent, or worsening symptoms (eg, cough, nasal discharge). Treatment is with oral antibiotics.

Choice F. A sinus fluid culture is unnecessary for uncomplicated ABRS that responds to empiric antibiotics. If symptoms are refractory or complications occur, cultures may be obtained by sinus aspiration to better target antimicrobial therapy.

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