What is the diagnosis and treatment for a patient with loss of smell, nasal swelling, and a large amount of green thick nasal discharge for three months?

Chronic Rhinosinusitis with Bacterial Superinfection

This patient has chronic rhinosinusitis (CRS) based on the three-month duration of symptoms, and the green thick nasal discharge suggests a superimposed acute bacterial infection requiring antibiotic therapy in addition to standard CRS management.

Diagnosis

The clinical presentation meets diagnostic criteria for chronic rhinosinusitis with likely bacterial superinfection:

• Duration: Symptoms persisting for 3 months (≥12 weeks) definitively establishes chronic rhinosinusitis 1
• Cardinal symptoms present:
  • Loss of smell (anosmia) 1
  • Nasal swelling/obstruction 1
  • Purulent nasal discharge (green, thick) 1

CRS requires at least 2 of 4 cardinal symptoms for ≥12 weeks: nasal blockage/obstruction, nasal discharge, facial pain/pressure, or reduction/loss of smell 1. This patient has three of these symptoms.

The green thick discharge indicates mucopurulent inflammation, which in the context of CRS suggests either active bacterial superinfection or chronic infectious sinusitis 1. Chronic infectious sinusitis is typically associated with neutrophil influx and may involve anaerobic bacteria, gram-positive streptococcus, bacteroides, Fusobacterium species, or S. aureus 1.

Objective Confirmation Needed

While the clinical diagnosis is strongly suggested, definitive diagnosis requires objective evidence through either:

• Nasal endoscopy showing mucopurulent discharge, edema, or mucosal obstruction in the middle meatus 1
• CT imaging demonstrating mucosal changes (though not required for initial management) 1

Imaging is not recommended initially unless complications are suspected, medical therapy fails, or surgery is being considered 1.

Treatment Algorithm

First-Line Therapy (Initiate Immediately)

1. Intranasal Corticosteroids - The cornerstone of CRS management 2, 3

• Fluticasone propionate 200 mcg daily (2 sprays per nostril once daily) 4
• Continue as maintenance therapy indefinitely 2, 3
• Maximum benefit may take several days to weeks 4

2. Nasal Saline Irrigation - Essential for mucociliary clearance 2, 3

• High-volume irrigation (not just spray) 1
• Perform twice daily 2

3. Antibiotics for Acute Bacterial Superinfection

• Amoxicillin or penicillin (beta-lactams) are most effective for acute bacterial rhinosinusitis 1
• Duration: Short-term course of 10-14 days for acute bacterial component 1
• Consider longer duration (up to 4 weeks) given the chronic nature, as chronic infectious sinusitis may require extended therapy targeting anaerobic pathogens 1, 3

Important Caveats

• Purulent discharge alone does not distinguish bacterial from viral infection in acute settings, but in the context of 3-month duration with loss of smell, bacterial involvement is likely 1
• Antibiotics are NOT effective for viral or post-viral rhinosinusitis and should not be used indiscriminately 1
• The green color of nasal discharge is not useful for differentiating bacterial from viral disease in acute rhinosinusitis 1, but persistent purulent discharge for 3 months suggests chronic bacterial involvement

Second-Line Options (If No Improvement in 3-5 Days)

• Switch to alternative antibiotic if no response to initial therapy 1
• Consider short course of oral corticosteroids (for exacerbations of CRS) 3
• Reassess for complications or alternative diagnoses 1

When to Refer to ENT

Refer to otolaryngologist if 1, 2:

• Symptoms persist despite appropriate medical therapy (intranasal corticosteroids + saline irrigation + up to 2 short courses of antibiotics or systemic corticosteroids) 1
• Recurrent acute bacterial sinusitis (≥3-4 episodes per year) 1
• Suspected complications (orbital involvement, intracranial extension) 1
• Consideration for functional endoscopic sinus surgery 2, 3

Additional Considerations

Evaluate for underlying causes 5:

• Allergic rhinitis (most common predisposing factor after viral infections) 1
• Gastroesophageal reflux 1, 5
• Immunodeficiency (if recurrent infections) 1
• Anatomical obstruction 5

Avoid common pitfalls:

• Do not use topical decongestants long-term (risk of rhinitis medicamentosa) 1
• Do not obtain imaging for uncomplicated acute bacterial sinusitis 1
• Do not prescribe antibiotics without evidence of bacterial infection 1