Snapshot A 14-year-old boy presents with recurrent nasal congestion and left suborbital pain of 2 weeks duration. 1 week prior to the onset of these symptoms, he described having a "cold." On physical exam, there is pain over the left maxillary sinus. A CT of the head is shown.(Left maxillary sinusitis) Introduction Infection of the paranasal sinus due to undrained collection of pus maxillary sinuses most commonly involved but can involve any sinus can be bacterial (acute or chronic), or fungal Risk factors Kartagener's disease cystic fibrosis Wegener's granulomatosis smoking impairs ciliary function Acute sinusitis < 1 month Sudden onset most commonly caused by S. pneumoniae H. influenzae Moraxella cattarrhalis usually precipitated by an acute viral respiratory tract infection which is thought to lead to reduced clearance of mucus Inflammation can cause swelling of the mucosa of the nose or sinuses causing occlusion or obstruction of the sinus ostia mucociliary transport is reduced Chronic sinusitis > 12 consecutive weeks The role of bacteria is not well supported and the diagnosis criteria revolve around inflammation which predispose to ostia obstruction, further inflammation and infection Associated bacteria include S. aureus, anaerobs and gram-negatives Other risks include systemic disease, anatomic anomalies, mucociliary dusfunciton, trauma, noxious chemicals such as pollutants or smoke, medications. Invasive Fungal Rhinosinusitis Risks: immunosuppressed, diabetes, steroid use most commonly due to aspergillus followed by mucormycosis Suspect with fever, localization symptoms such as orbital swelling, changes in vision or significant facial pain or numbness, nasal bleeding. Endoscopy may show mucosal necrosis (indicative of mucormycosis). Mucormycosis grows rapidly and can invade vasculature causing ischemia. Noninvasive Fungal Rhinosinusitis fungus ball in sinuses Cuased by allergic or non-allergic reaction to fungus Presentation Symptoms fever facial pain headache that can radiates to the upper teeth purulent rhinorrhea congestion loss of smell Physical exam Classically, facial tenderness with palpation over the involved sinus Evaluation/Diagnosis Primarily a clinical diagnosis Imaging Plain radiographs have fallen out of favor due to poor sensitivity CT Nasal Endoscopy Invasive fungal rhinosinusitis Diagnosed with biopsy/histology. CT can be obtained to evaluate extent of disease. Fungal Ball appear dark, crumbly, possible sporulation histology (tangled hyphae) Allergic fungal rhinosinusitis histology shows inflammatory cells, eosinophils and charcot-leyden crystals, hyphae Treatment Acute sinusitis supportive therapy for 7 days analgesia (tylenol), nasal saline irrigation, decongestants, adequate hydration no antibiotics unless no clinical improvement during observation period or temperature >38.3 C antibiotic for 10-14 days amoxicillin-clavulanate is first line Chronic sinusitis Treatment in general is unclear. Some studies suggest improvement with antibiotics (such as macrolides) and topical or oral steroids. surgery if not responsive to antibiotic therapy to improve ventilation and drainage maxillary sinusotomy, ethmoidectomy, or sphenoid sinusotomy Invasive fungal rhinosinusitis If possible, reversal of immunocompromised state early aggressive medical (amphotericin B) and surgical debridement Fungus ball endoscopic removal Allergic fungal rhinosinusitis endoscopic removal of nasal polyps and inspissated muci prednisone taper Prognosis, Prevention, and Complications Prognosis Generally good in acute bacterial sinusitis can be fatal in diabetic or immunocompromised patients with invasive fungal disease Complications osteomyellitis mucocele meningitis epidural abcess cerebral abscess orbital/periorbital cellulitis cavernous sinus thrombosis
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + (M2.ET.4828) A 25-year-old man with a history of schizophrenia stable on his current antipsychotic regimen presents with a seizure. His mother noted that her son complained of a headache and feeling warm for the past ten days. The headache was exacerbated whenever he bent over. This morning, the mother brought him to the hospital after he fell from the top of the stairs and appeared to convulse his arms and legs. He takes quetiapine and a multivitamin. In the trauma bay, the patient appears to be breathing comfortably and follows the nurse's commands. His temperature is 100.9°F (38.3°C), blood pressure is 140/70 mmHg, pulse is 80/min, respirations are 15/min, and his oxygen saturation is 95% on room air. He complains of a headache over the top of his eyebrows. He has a few scrapes and bruises throughout his body. His left arm and leg are weaker than his right limbs. His cranial nerves are grossly intact bilaterally. Computed tomography of his head is shown in Figure A. Which of the following is the most likely cause of this patient's presentation? Review Topic QID: 109459 FIGURES: A 1 Budding yeast organisms with hyphae 20% (5/25) 2 Streptococcus species 28% (7/25) 3 Staphylococcus species 12% (3/25) 4 Bacteroides fragilis 0% (0/25) 5 Toxoplasma gondii cysts 40% (10/25) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M2.ET.4798) An 8-year-old female presents to her pediatrician with nasal congestion. Her mother reports that the patient has had nasal congestion and nighttime cough for almost two weeks. The patient’s 3-year-old brother had similar symptoms that began around the same time and have since resolved. The patient initially seemed to be improving, but four days ago she began developing worsening nasal discharge and fever to 102.6°F (39.2°C) at home. Her mother denies any change in appetite. The patient denies sore throat, ear pain, and headache. She is otherwise healthy. In the office, her temperature is 102.2°F (39.0°C), blood pressure is 96/71 mmHg, pulse is 128/min, and respirations are 18/min. On physical exam, the nasal turbinates are edematous and erythematous. She has a dry cough. Purulent mucous can be visualized dripping from the posterior nasopharynx. Her maxillary sinuses are tender to palpation. Which of the following organisms is most likely to be causing this patient’s current condition? Review Topic QID: 109214 1 Adenovirus 11% (6/54) 2 Moraxella catarrhalis 50% (27/54) 3 Pseudomonas aeruginosa 4% (2/54) 4 Staphylococcus aureus 19% (10/54) 5 Streptococcus pyogenes 17% (9/54) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M2.ET.4798) A 5-year-old male presents to the pediatrician with a 10-day history of cough that is worse at night. The patient has a history of mild intermittent asthma and has been using his albuterol inhaler without relief. He has also been complaining of headache and sore throat, and his mother has noticed worsening rhinorrhea. The patient’s past medical history is otherwise unremarkable, and he has no known drug allergies. In the office, his temperature is 101.8°F (38.8°C), blood pressure is 88/65 mmHg, pulse is 132/min, and respirations are 16/min. The patient has purulent mucus draining from the nares, and his face is tender to palpation over the maxillary sinuses. His pharynx is erythematous with symmetric swelling of the tonsils. On lung exam, he has moderate bilateral expiratory wheezing. Which of the following is the best next step in management? Review Topic QID: 109215 1 Amoxicillin 41% (11/27) 2 Amoxicillin-clavulanic acid 48% (13/27) 3 Ampicillin-sulbactam 11% (3/27) 4 Clindamycin 0% (0/27) 5 Levofloxacin 0% (0/27) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M2.ET.4798) A 54-year-old male presents to the emergency department with nasal congestion and sore throat. He also endorses ten days of fatigue, rhinorrhea and cough, which he reports are getting worse. For the last four days, he has also had facial pain and thicker nasal drainage. The patient’s past medical history includes obesity, type II diabetes mellitus, and mild intermittent asthma. His home medications include metformin and an albuterol inhaler as needed. The patient has a 40 pack-year smoking history and drinks 6-12 beers per week. His temperature is 102.8°F (39.3°C), blood pressure is 145/96 mmHg, pulse is 105/min, and respirations are 16/min. On physical exam, he has poor dentition. Purulent mucus is draining from his nares, and his oropharynx is erythematous. His maxillary sinuses are tender to palpation. Which one of the following is the most common risk factor for this condition? Review Topic QID: 109217 1 Asthma 6% (1/16) 2 Diabetes mellitus 12% (2/16) 3 Poor dentition 12% (2/16) 4 Tobacco use 19% (3/16) 5 Viral infection 44% (7/16) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (M2.ET.4694) A 30-year-old previously healthy male presents to your office with complaints of facial pressure and rhinorrhea for the past 3 weeks. The patient reports that several weeks prior, he had a “common cold” which resolved. However, he has since developed worsening facial pressure, especially over his cheeks and forehead. He reports over 1 week of green tinged rhinorrhea. His temperature is 100.1 deg F (37.8 deg C), blood pressure is 120/70 mmHg, pulse is 85/min, and respirations are 15/min. Nasal exam reveals edematous turbinates and purulent discharge. What is the most likely diagnosis? Review Topic QID: 107721 1 Acute viral rhinosinusitis 0% (0/0) 2 Acute bacterial rhinosinusitis 0% (0/0) 3 Subacute bacterial rhinosinusitis 0% (0/0) 4 Allergic rhinitis 0% (0/0) 5 Chronic rhinosinusitis 0% (0/0) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2