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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Compare and contrast the clinical signs and symptoms of acute viral and bacterial rhinosinusitis in a given patient, noting the cardinal symptoms of acute rhinosinusitis.

  • Differentiate viral from bacterial etiology in rhinosinusitis based on a patient’s symptoms.

  • Identify the most common pathogens that cause acute bacterial rhinosinusitis.

  • Identify adult patients with a diagnosis of acute bacterial rhinosinusitis who may be candidates for observation without use of antibiotics.

  • Formulate a treatment plan for a patient with acute bacterial rhinosinusitis based on duration of symptoms, severity of symptoms, and history of previous antibiotic use.

  • Revise the treatment plan for a patient who fails the initially prescribed therapy.

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PATIENT PRESENTATION

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Chief Complaint

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“I feel awful and congested, and my head hurts. I think my sinus infection is back.”

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HPI

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Kyle Rhiner is a 49-year-old man who presents to his primary care physician with fever, purulent nasal discharge from the left naris, facial pain (L > R), nasal congestion, headache, and fatigue. He states that his symptoms began 8 days ago, but the symptoms initially improved over the first 4–5 days. However, the symptoms have become progressively worse over the last few days. He also complains of intense facial pressure when he bends forward to tie his shoes or to pick up something. He has noticed a decreased ability to smell and states that foods do not taste the same as before. He has experienced occasional episodes of nausea, dizziness, tremors, and palpitations for the last week and states that he has difficulty sleeping. He has been taking ibuprofen as needed and loratadine 5 mg/pseudoephedrine sulfate 120 mg every 12 hours but has received little relief from his symptoms. He denies vomiting, diarrhea, chills, diaphoresis, dyspnea, productive cough, or allergies. Mr Rhiner states that he was treated for a sinus infection about 3–4 weeks ago. When questioned further, he states that he presented to an urgent care clinic complaining of a runny nose, congestion, sneezing, cough, and a mild sore throat for 2–3 days. He was leaving the following day for a business trip and asked the physician for an antibiotic prescription. He told the physician that azithromycin has always worked for him so he was prescribed a Z-Pak. His symptoms slowly improved over several days, and he was symptom-free for a few days before his current symptoms began 8 days ago. He states that he only gets sick occasionally and has not had an infection in the last year prior to these episodes.

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PMH

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  • Sinus infection 3–4 weeks ago

  • Hypertension (well controlled with medication)

  • Hypercholesterolemia

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FH

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  • Father died of MI at 64 years of age.

  • Mother with hypertension and diabetes mellitus.

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SH

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Smokes cigars ...

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