What is the next step in managing a patient with prolonged congestion and facial pain unresponsive to initial treatments?

From the Guidelines

For a patient with prolonged congestion and facial pain unresponsive to initial treatments, the next step should be referral to an otolaryngologist (ENT specialist) for evaluation of possible chronic rhinosinusitis. Before this referral, a trial of a more aggressive medical therapy is warranted, including a 10-14 day course of a broad-spectrum antibiotic such as amoxicillin-clavulanate (875/125 mg twice daily) or, if penicillin-allergic, doxycycline (100 mg twice daily) as recommended by 1. This should be combined with intranasal corticosteroids (such as fluticasone 50 mcg, 1-2 sprays per nostril daily) and saline nasal irrigation (using a neti pot or similar device twice daily with sterile saline) as suggested by 1. A short course of oral prednisone (20 mg daily for 5-7 days) may help reduce inflammation and improve drainage. If symptoms persist despite this regimen, imaging studies such as a non-contrast CT scan of the sinuses should be obtained to evaluate for anatomical obstruction, polyps, or chronic infection as recommended by 1. Persistent symptoms may indicate the need for endoscopic sinus surgery to improve drainage pathways and remove diseased tissue. This stepped approach addresses the underlying inflammation and potential infection while preparing for more definitive intervention if conservative measures fail, and is in line with the recommendations from 1 for managing sinusitis that does not improve with initial antibiotic treatment. Key considerations in managing this patient include:

• Distinguishing between viral and bacterial rhinosinusitis, as the treatment approach may differ 1
• Assessing for underlying conditions that may be contributing to the patient's symptoms, such as allergies or immune function disorders 1
• Considering the use of long-term macrolide therapy for patients with moderate or severe symptoms, as recommended by 1
• Evaluating the need for sinus surgery if medical therapy is unsuccessful, as suggested by 1

From the Research

Treatment Considerations for Chronic Sinusitis

The patient's prolonged congestion and facial pain unresponsive to initial treatments, including allergy meds, nasal sprays, and azithromycin, require further evaluation and management.

• The next step in managing this patient would be to consider diagnostic modalities such as nasal endoscopy and computed tomography (CT) scans to assess the extent of disease and anatomy 2, 3.
• Nasal endoscopy has been shown to be a cost-effective and time-saving option for diagnosing chronic rhinosinusitis, with a sensitivity of 78.08% and specificity of 66.67% compared to CT scans 2.
• A study comparing nasal endoscopy and CT scans found that nasal endoscopy was superior in detecting mucopurulent discharge, oedematous and polypoid infundibular mucosa, and other abnormalities in the osteomeatal area 3.
• The use of corticosteroids in functional endoscopic sinus surgery (FESS) has been shown to reduce operative time, estimated blood loss, and improve surgical field quality, as well as improve post-operative endoscopic scores and reduce recurrence rates in cases of chronic rhinosinusitis with nasal polyps (CRSwNP) 4.
• Coronal computed tomography (CT) scans are also an essential tool in the assessment of patients prior to FESS, allowing for accurate correlation of radiological and surgical anatomy and enhancing precision and safety during the procedure 5.

Diagnostic Evaluation

• A diagnostic evaluation of the patient should include a thorough clinical examination, followed by high-resolution computed tomography (HRCT) of the paranasal sinuses and diagnostic nasal endoscopy (DNE) 3.
• The diagnostic results of both modalities should be compared to determine the extent of disease and anatomy, and to guide further management.

Management Options

• Based on the diagnostic evaluation, management options may include functional endoscopic sinus surgery (FESS), medical therapy with corticosteroids and/or antibiotics, or a combination of both 4.
• The patient's symptoms, medical history, and diagnostic results should be taken into consideration when determining the best course of management.