doc_clotaire
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An 18-year-old white high school student comes to the office in late August because of a stuffy nose for 1 week. He reminds you that he
has had severe hay fever in the fall for the past 10 years. Review of his chart shows that he has positive skin tests to ragweed, dust and dust
mites, and he is receiving maintenance immunotherapy with extracts of these antigens. He also takes over-the-counter antihistamines for symptomatic relief. This regimen has not provided relief so far this season. Physical examination is normal, apart from clear rhinorrhea.
He is afebrile, and there is normal transillumination of the frontal and maxillary sinuses. In reviewing his medical records you note that smears of his nasal mucus contained large numbers of eosinophils. There is no record of any extensive immunologic work-up. You tell him that he now has either an early viral upper respiratory tract infection or the beginnings of his seasonal allergic rhinitis. You suggest that he use a corticosteroid nasal spray plus his usual antihistamines as needed. The appropriate treatment is undertaken, but 4 days later he returns because of a toothache and fever. On physical examination he has right facial fullness and pain below his eye when he leans forward. There is tenderness in the region of the upper premolar and molar teeth on the right side. His temperature is 38.7EC (101.6EF), orally. He has bloody, thick, green mucus coming from his right nostril. The remainder of his physical examination is normal. You suspect
maxillary sinusitis on the basis of the clinical findings.
1.-. Before beginning antibiotic treatment in this patient, it is necessary to first do which of the following?
(A) Confirm the diagnosis with CT films of the sinus
(B) Confirm the diagnosis with plain x-ray films of the sinus
(C) Confirm the diagnosis with transillumination of the sinus
(D) Request consultation with a dentist
(E) No additional steps are necessary
2. The appropriate steps are taken. In prescribing antibiotic therapy for this patient, it is most important to remember which of the following?
(A) Antibiotics are ineffective unless there is a concomitant surgical drainage procedure
(B) He is likely to be allergic to penicillin
(C) He needs to take medication for more than 7 days
(D) Only bactericidal antibiotics are effective
(E) Ordinarily at least two antibiotics are given
He is treated and initially feels much better. However, soon thereafter he developed a headache, right ear pain and painful stiff neck; he spikes a temperature to 39.3EC (102.7EF), orally. Extraocular movements are normal.
3. Which of the following is the most likely explanation for these new symptoms?
(A) Allergic reaction to the antibiotic(s)
(B) Associated meningeal inflammation or infection
(C) Development of cavernous sinus thrombosis
(D) Direct spread of infection from the maxillary to the mastoid sinus
(E) Obstruction of the orifice of the maxillary sinus with a mucous plug
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| Aashi
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E) No additional steps are necessary
C) He needs to take medication for more than 7 days
B) Associated meningeal inflammation or infection
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| 92306
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(E) No additional steps are necessary
maxillary sinusitis is a clinical diagnosis.
(C) He needs to take medication for more than 7 days
(B) Associated meningeal inflammation or infection --stiff neck,temperature to 39.3EC (102.7EF).
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| DrPak
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Complicated case!!
I think it's
B --> take X-ray to confirm
B ---> He's likely to be allergic, with his history of atopy
D ---> Spread to mastoid sinus.
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| robin082006
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(B) Confirm the diagnosis with plain x-ray films of the sinus
(C) He needs to take medication for more than 7 days
(B) Associated meningeal inflammation or infection
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| mjl1717
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were first suspecting either S.pneumo, H. flu, or Moraxaella.. I like translumination or palpating the sinuses like Dr. House.. Also in this case Amoxicillin /Clavulante ..Azithromycin has better compliance
Edited by mjl1717 on 03/05/07 - 01:05 PM
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| doc_clotaire
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1. The correct answer is E.
Sinusitis is a clinical diagnosis and for that reason, no
additional testing is mandated when therapy is to be undertaken. This patient has the
cardinal manifestations of acute sinusitis: tooth ache, sinus fullness, pain on palpation and
purulent discharge. He requires therapy aimed at the most common offending organisms
Streptococcus pneumonia and Haemophilus influenza type B.
A CT scan of the sinuses (choice A) is not necessary. This imaging test is usually
reserved for patients that are unable to be subjected to an adequate physical examination
such as patients in an ICU that have fever of unknown origin.
Plain films of the head (choice B) are not sensitive for opacification of the sinuses and
are therefore not routinely done.
Transillumination of the sinus (choice C) is not a confirmatory test since it is not 100%
sensitive (has some false negatives) or specific (has some false positives). In the setting
of a highly suspicious physical exam such as this patient’s, sinus trans-illumination, if
positive, further supports the diagnosis, but if negative, fails to detract from its likelihood.
Consultation with a dentist (choice D) is unnecessary since the patient does not have an
isolated tooth ache but it is in association with sinus tenderness and nasal discharge;
hallmarks of sinusitis.
2. The correct answer is C
. Sinusitis is an infection loculated within the chambers of
the sinuses and longer courses of therapy of 2-3 weeks are often necessary to achieve
sufficient penetration.
Surgery (choice A) is seldom required.
Rates of penicillin allergy (choice B) are generally only around 10%.
(Choice D) is wrong because many antibiotics such as macrolides like clarithromycin are
useful for sinusitis even though they are bacteriostatic, not bactericidal.
Two antibiotics (choice E) are seldom needed and usually only with refractory cases of
previously treated sinusitis.
3. The correct answer is B.
Headache, fever and stiff neck are all signs of meningeal
infection, choice B. Sinusitis is known to occasionally lead to meningitis.
There is no description of a rash such as would be found with an allergic reaction (choice
A) and this would be a rare cause of meningeal signs such as a stiff neck.
Cavernous sinus thrombosis (choice C) presents with gaze palsies from involvement of
the third, fourth and sixth cranial nerves, which are clearly described as normal here.
There is no description of involvement of the mastoid air cells (choice D) such as
tenderness over the mastoid process or lateral displacement of the pinna. In addition,
mastoid involvement alone does not give a stiff neck.
Obstruction of the maxillary sinus alone (choice E) does not result in the stiff neck or ear
pain.
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