What is the appropriate treatment for a 54-year-old female smoker with facial swelling, congestion, dental issues, seasonal allergies, and a nighttime cough, who is experiencing throbbing facial pressure, low-grade fever, and is currently using acetaminophen, ibuprofen, albuterol nebulizer, and gummy marijuana?

Treatment Approach for Acute Rhinosinusitis with Dental Pathology and Cough

This patient requires antibiotic therapy with amoxicillin-clavulanate due to the presence of acute bacterial rhinosinusitis (ABRS) complicated by dental disease, along with symptomatic management for her cough and optimization of her underlying allergic rhinitis.

Diagnostic Confirmation

This patient meets criteria for ABRS based on the American Academy of Otolaryngology-Head and Neck Surgery guidelines 1:

• Purulent symptoms present for 2 days with facial swelling, pressure (6/10), and low-grade fever - while duration is short, the severity pattern with fever ≥38°C and purulent drainage suggests bacterial infection 1
• Critical red flag: Dental pathology - up to 20% of maxillary sinus infections originate from dental disease, making this odontogenic sinusitis requiring antibiotic coverage 1
• Unilateral facial swelling on the right side strongly suggests bacterial rather than viral etiology, particularly with concurrent dental issues 1

Primary Antibiotic Treatment

Prescribe amoxicillin-clavulanate 875 mg/125 mg twice daily for 10-14 days 1, 2:

• Amoxicillin-clavulanate is superior to amoxicillin alone when dental pathology is present due to coverage of β-lactamase producing oral anaerobes 1
• The twice-daily dosing (875/125 mg) is as effective and safe as three-times-daily dosing (500/125 mg) with better compliance 3
• Duration: 10-14 days minimum given the dental source and moderate severity 2, 4

For penicillin allergy:

• Non-type I hypersensitivity: Clindamycin 300 mg TID plus cefpodoxime 200 mg BID 1
• Type I hypersensitivity: Levofloxacin 500 mg daily or moxifloxacin 400 mg daily 1

Symptomatic Management

Pain Control

Continue acetaminophen and ibuprofen on a scheduled basis (not just once daily as currently taking) 1:

• Acetaminophen 650-1000 mg every 6 hours scheduled 1
• Ibuprofen 400-600 mg every 6-8 hours scheduled 1
• Avoid narcotics - over-the-counter analgesics are usually sufficient and narcotics should be discouraged 1

Nasal Congestion and Drainage

Intranasal corticosteroid spray (mometasone, fluticasone, or budesonide) twice daily 1, 5:

• Reduces mucosal inflammation and improves symptom resolution 1
• Particularly beneficial given her history of seasonal allergies 1
• Number needed to treat is 14 for modest but clinically important benefit 1

Hypertonic saline irrigation (3-5%) 2-3 times daily 1, 5:

• Superior anti-inflammatory effect compared to normal saline 1
• Helps thin mucus and improve mucociliary clearance 1

Oral decongestant (pseudoephedrine 30-60 mg every 4-6 hours) for short-term use 1, 2:

• Some evidence supports use for nasal congestion 1, 2
• Avoid topical decongestants beyond 3-5 days to prevent rhinitis medicamentosa 1, 6

Cough Management

Do NOT prescribe Tessalon Perles (benzonatate) as requested - the cough is due to postnasal drip from rhinosinusitis and will resolve with treatment of the underlying condition 6:

Instead, prescribe guaifenesin 400 mg every 4 hours as an expectorant for symptomatic relief 6:

• Evidence for clinical efficacy is limited but it is recommended by guidelines for productive cough 6
• The nighttime cough is from postnasal drip and should improve with intranasal corticosteroids and saline irrigation 6

Continue albuterol nebulizer as needed for her underlying reactive airway disease 7:

• Current use is appropriate given her 35-year smoking history 7
• Should not be used more frequently than recommended 7

Antihistamine for Allergic Rhinitis

Start a non-sedating antihistamine (cetirizine 10 mg daily, loratadine 10 mg daily, or fexofenadine 180 mg daily) 1:

• She has a history of seasonal allergies and is currently not taking an antihistamine 1
• This addresses an underlying contributing factor to her rhinosinusitis 1

Critical Follow-Up Instructions

Reassess in 7 days if symptoms worsen or fail to improve 1:

• 73-85% of patients with ABRS show clinical improvement by day 7 with antibiotics 1, 5
• If treatment failure occurs, consider resistant organisms and switch to respiratory fluoroquinolone 1

Immediate evaluation required if:

• Severe worsening headache or visual changes 5
• Periorbital swelling, erythema, or proptosis (orbital cellulitis) 5
• Altered mental status or neurological symptoms (intracranial complications) 5
• High fever with severe facial swelling 5

Dental Referral

Urgent dental evaluation within 1-2 weeks after completing antibiotics 1:

• The dental pathology is likely the source of infection and must be addressed 1
• Cannot wear lower partial due to swelling - this needs definitive dental treatment 1
• Failure to address dental source will result in recurrent sinusitis 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics without addressing the dental source - this will lead to treatment failure and recurrence 1
• Do not use topical decongestants >3-5 days - causes rebound congestion 1, 6
• Do not prescribe cough suppressants when the cough is from postnasal drip - treat the underlying rhinosinusitis instead 6
• Do not use amoxicillin alone when dental pathology is present - requires clavulanate for anaerobic coverage 1
• Do not obtain imaging unless complications are suspected or patient fails to respond to appropriate therapy 1

Smoking Cessation Counseling

Strongly advise smoking cessation given 35-year history 8:

• Smoking impairs mucociliary clearance and predisposes to recurrent sinusitis 8
• Increases risk of treatment failure 8
• Refer to smoking cessation program or prescribe pharmacotherapy (varenicline, bupropion, or nicotine replacement) 8