Describe acute rhinosinusitis with its diagnosis and management.

Nature and Pathogenesis

• Acute rhinosinusitis is inflammation of the nose and paranasal sinuses of less than 12 weeks duration, with complete resolution of symptoms.
• The term rhinosinusitis is preferred to "sinusitis", because the nasal and sinus mucosa are continuous and are always involved together.
• The pathogenesis IS A sequence that should BE recited.

Clinical Features and Management

• Diagnosis is clinical, and requires at least two symptoms, one of which must be nasal blockage or discharge:
• Nasal blockage or obstruction
• Nasal discharge, anterior or posterior, characteristically purulent
• Facial pain or pressure
• Reduction or loss of smell
• The site of pain suggests the sinus — maxillary: cheek pain, referred to the upper teeth; frontal: forehead pain, classically worse in the morning and easing by afternoon; ethmoid: pain between and behind the eyes, with periorbital oedema; sphenoid: deep-seated vertex or occipital pain.
• Examination — tenderness over the affected sinus; pus in the middle meatus on anterior rhinoscopy or endoscopy.
• Investigation IS not routinely required.
• Plain radiographs should not be used — they are insensitive, non-specific, and mucosal thickening is present in many normal people and in almost anyone with a cold
• CT is indicated only where there is suspected complication, failure to respond to treatment, immunocompromise, or planned surgery — not for diagnosis
• Management of viral and mild disease — symptomatic treatment alone: analgesia, saline irrigation, steam inhalation, adequate fluids and rest, and topical decongestant for NO more than 5 to 7 days
• Intranasal corticosteroid has good evidence in acute rhinosinusitis, reducing symptoms and speeding recovery, and is appropriate as first-line treatment in moderate disease
• Watchful waiting with symptomatic treatment is appropriate for the first 7 to 10 days in an otherwise well patient
• Antibiotics are indicated for — severe symptoms (high fever, severe pain); symptoms persisting beyond 10 days without improvement; double sickening; suspected complication; and immunocompromise or significant comorbidity
• First-line antibiotic is amoxicillin, or amoxicillin-clavulanate where there is recent antibiotic use, treatment failure or a high local resistance rate; with doxycycline or a macrolide in penicillin allergy, guided by local sensitivity. A course of 5 to 10 days is usual
• Adjuncts — mucolytics, whose evidence is weak; and antihistamines only where there is underlying allergy.
• Surgery is rarely needed in acute disease, and is reserved for a complication, or an unresolving collection — antral washout or endoscopic drainage
• The red flags demanding urgent assessment and imaging — periorbital swelling, redness or displacement of the eye; diplopia, reduced visual acuity or an afferent pupillary defect; severe unilateral or bilateral frontal headache; frontal swelling; signs of meningitis; and any neurological sign or reduced conscious level
• These features mean the patient is referred the same day, because orbital and intracranial complications progress in hours
• Double sickening is the most useful single sign, meaning improvement followed by deterioration after five or six days
• Most acute rhinosinusitis is viral and needs no antibiotic.
• Do not order plain sinus radiographs; mucosal thickening appears in almost anyone with a cold and changes nothing
• Pus in the middle meatus is the most useful sign, and is seen on anterior rhinoscopy or endoscopy after decongestion
• Two symptoms are required, one being blockage or discharge.
• The maxillary sinus is most often affected, because its ostium sits high and drainage depends entirely on cilia
• Sphenoid pain is vertex or occipital and deep-seated, and is the presentation most often misattributed
• Frontal pain is classically worse in the morning and eases through the afternoon as the sinus drains
• Maxillary pain refers to the upper teeth, which sends many patients to a dentist before an ENT surgeon
• Topical steroid has good evidence in acute disease, reducing symptoms and speeding recovery without an antibiotic
• Use decongestants for five to seven days at most, or rhinitis medicamentosa is created while treating the sinusitis