Acute rhinosinusitis, characterized by inflammation of the paranasal sinuses, is a common condition that can cause significant discomfort and affect daily life. While most cases can be managed at the primary healthcare level, certain red flags necessitate referral to a district hospital for further evaluation and treatment. In this article, we will explore the clinical scenarios, examination techniques, laboratory investigations, and management strategies for acute rhinosinusitis. We will also discuss the standard treatment workflow for chronic rhinosinusitis, emphasizing the importance of identifying exacerbating factors and considering surgical interventions when necessary.

I. Understanding Acute Rhinosinusitis:

Acute rhinosinusitis refers to the inflammation of the paranasal sinuses, often caused by viral or bacterial infections. It manifests as nasal obstruction, nasal discharge, facial pain, and reduced sense of smell. In most cases, conservative management at the primary healthcare level is sufficient. However, certain red flags indicate the need for referral to a district hospital.

II. Red Flags for Referral to District Hospital:

Known diabetic/immunocompromised individuals.

Suspicion of complications, such as orbital involvement or meningitis.

Non-resolution of symptoms with oral antibiotics for ten days.

Pointers of invasive fungal sinusitis, such as facial hypoesthesia and discoloration.

III. Clinical Examination:

A thorough clinical examination plays a crucial role in diagnosing and managing acute rhinosinusitis. Preliminary examination techniques include anterior rhinoscopy and oral examination. Nasal endoscopy is desirable for a comprehensive evaluation.

IV. Laboratory Investigations:

Laboratory investigations are essential in non-resolving or worsening cases despite antibiotic therapy. Endoscopy-guided nasal swabs and KOH smears can be performed. A CT scan of the paranasal sinuses may be necessary to assess suspected complications or non-resolving cases. Screening for diabetes and immunodeficiency is also recommended.

V. Management at PHC/Primary Level:

At the primary healthcare level, the following interventions are indicated:

Oral antibiotics, such as Amoxicillin or Co-amoxiclav, for 7-10 days.

Topical budesonide/mometasone nasal spray for symptomatic relief.

Normal saline nasal washes to clear secretions and enhance the effectiveness of topical medications.

Topical or oral decongestants for temporary relief.

Adequate hydration and steam inhalation.

Antihistamines for patients with co-existing allergies.

VI. District Hospital Interventions:

Referral to a district hospital may be necessary for the following scenarios:

Surgical interventions for underlying anatomical conditions causing recurrent acute sinusitis.

Ophthalmology referral for suspected intraorbital complications.

Dental deferral for suspected dental origin infection.

Invasive fungal sinusitis: initiation of antifungal medications, control of underlying immunocompromising co-morbidities, and consideration of debridement.

VII. Tertiary Level:

Patients with acute invasive fungal sinusitis, complicated acute bacterial sinusitis, or immunocompromised status may be referred to a tertiary level for management.

VIII. Standard Treatment Workflow for Chronic Rhinosinusitis:

When symptoms persist for more than 12 weeks, a diagnosis of chronic rhinosinusitis (CRS) should be considered. Treatment options for CRS include addressing etiology and exacerbating factors, allergy management, saline nasal washes, steam inhalation, stretching exercises, and the use of intra-nasal steroid sprays. Nasal endoscopy and CT scans may be performed if symptomatic relief is not achieved.

Acute rhinosinusitis is a prevalent condition that can significantly impact individuals' daily lives. While most cases can be effectively managed at the primary healthcare level, it is crucial to identify red flags that warrant referral to a district hospital. By understanding the clinical scenarios, conducting comprehensive examinations, and employing appropriate laboratory investigations, healthcare professionals can provide timely and effective management for patients with acute rhinosinusitis.

In addition, it is essential to follow a standardized treatment workflow for chronic rhinosinusitis (CRS) to ensure long-term symptom relief. This involves addressing the underlying causes, considering allergic rhinitis and co-existing conditions such as asthma, and employing appropriate medications and interventions. Surgical options should be considered in cases of nasal polyps or deviated nasal septum that contribute to CRS symptoms.

To optimize patient outcomes, it is crucial to educate patients about proper medication use, including the correct technique for using steroid nasal sprays and nasal irrigation. Adherence to nasal saline washes, regular physical activity, and prescribed medications is also emphasized. Moreover, healthcare providers should educate patients about the potential risks associated with prolonged use of topical nasal decongestants beyond the recommended duration.

By adopting a comprehensive approach that includes early identification of red flags, appropriate diagnostic investigations, and evidence-based management strategies, healthcare professionals can effectively address acute rhinosinusitis and chronic rhinosinusitis, leading to improved patient outcomes and quality of life.

References:

Indian Council of Medical Research. Treatment Guidelines for Antimicrobial Use in Common Syndromes. New Delhi, India, 2017.

Fokkens W, Lund V, Mullol J, et al. EPOS 2012: European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol 2012;50(Suppl 23):1-298.

Sharma V, Saxena RK, Sharma S, Sharma G, Dhasmana DC, Mishra KC. Comparative Efficacy and safety of various antimicrobials in patients of acute rhinosinusitis at tertiary-care hospital in Uttarakhand. Indian Jour Otol Head & Neck Surg, 2011, Oct; 63(4): 364-9.

Blomgren K, Eliander L, Hytönen M, Ylinen S, Laitio M, Virkkula P. How patients experience antral irrigation. Clin Med Insights Ear Nose Throat. 2015;8:13-7.