A 38-year-old woman presents with a 3-week history of nasal congestion, purulent nasal discharge, and facial pain over the maxillary region. She reports that symptoms began after an upper respiratory tract infection. On examination, she has tenderness over the maxillary sinuses and purulent secretions in the middle meatus. Nasal endoscopy shows edema and pus in the ostiomeatal complex. CT paranasal sinuses reveals opacification of the maxillary sinuses with air-fluid levels. Which of the following is the most appropriate next step in management?

Explanation

## Management of Acute Rhinosinusitis ### Clinical Presentation Analysis This patient has classic acute bacterial rhinosinusitis (ABRS) with: - Purulent nasal discharge in the middle meatus - Tenderness over maxillary sinuses - Air-fluid levels on CT (indicating bacterial infection) - Symptoms persisting >7 days post-URI ### Treatment Algorithm ```mermaid flowchart TD A[Acute Rhinosinusitis diagnosed]:::outcome --> B{Symptoms duration?}:::decision B -->|< 7 days| C[Supportive care only]:::action B -->|7-10 days| D[Start antibiotics + adjunctive therapy]:::action D --> E[Amoxicillin-clavulanate or respiratory fluoroquinolone]:::action E --> F[Add nasal saline irrigation + topical corticosteroids]:::action F --> G[Reassess at 2 weeks]:::decision G -->|Improved| H[Continue 7-10 days total]:::action G -->|No improvement| I[Consider imaging, specialist referral]:::decision I -->|Persistent disease| J[FESS if recurrent/chronic]:::action ``` ### Evidence-Based Management **Key Point:** Acute bacterial rhinosinusitis lasting 7–10 days warrants antibiotic therapy combined with adjunctive measures. | Intervention | Rationale | Evidence | |---|---|---| | Broad-spectrum antibiotics | Cover S. pneumoniae, H. influenzae, M. catarrhalis | First-line: amoxicillin-clavulanate 875/125 mg BD | | Nasal saline irrigation | Mechanical clearance of secretions, reduces bacterial load | Improves symptom resolution | | Topical nasal corticosteroids | Reduces ostiomeatal complex edema, improves drainage | Adjunctive benefit in ABRS | | Reassess at 2 weeks | Determines response and need for escalation | Standard of care | **High-Yield:** The ostiomeatal complex is the critical drainage pathway for maxillary and anterior ethmoid sinuses; edema here perpetuates infection. **Clinical Pearl:** Air-fluid levels on CT confirm bacterial infection and support antibiotic initiation, but do NOT mandate immediate surgery in uncomplicated ABRS. ### Why Not Immediate Surgery? - FESS is reserved for chronic sinusitis or acute sinusitis with complications (orbital cellulitis, intracranial extension) - First-line therapy is medical management with 2-week trial - Surgery after failed medical therapy is appropriate if symptoms persist >4 weeks or recur **Mnemonic:** **ABRS Management = ABC** - **A**ntibiotics (broad-spectrum) - **B**etter drainage (saline irrigation, topical steroids) - **C**heck response (reassess at 2 weeks) [cite:Bhattacharyya N, Villavisaor E. Textbook of Otolaryngology Ch 15]