Family Nurse Practitioner Certification
Intensive Review
Acute bacterial rhino sinusitis treatment
treatment plan
two options
- symptomatic treatment without antibiotics if mild,
uncomplicated acute bacterial rhino sinusitis
(ABRs) in healthy patients. Treatment is oral fluids
and if needed, saline nasal irrigations. follow up in
10 days. (if better, no antibiotics needed). If
symptoms are worse (or have not resolved) on
follow up visit, initiate antibiotic regimen.
- treat with antibiotics if there are severe
symptoms (toxic, high fever, pain ,purulent nasal
or postnasal drip for >2-3 days. maxillary
toothache, unilateral facial pain, sense of bad odor
in nose (cacosmia), initial symptoms improved,
then worsening of symptoms), patient is
immunocompromised, symptoms present for > 10
days (or have worsened).
- most cases of adult acute rhino sinusitis are due
to viral infection. acute bacterial infection accounts
for only 0.5-2% of cases.
Antibiotic treatment
First line (adults)
,- Amoxicillin-clavulante (Augmentin) 1000/62.5mg
or 2000mg/125 mg one table orally BIDx 5-7 days.
PCN allergy or alternative antibiotics
- type 1 allergy (anaphylaxis, angioedema),
levofloxacin 750 mg PO daily or doxycycline BID x
5-7 days
- type 2 allergy (skin rash), Cefdinir, cefpodxime,
cefuroxime PO BID x 5-7 days.
Symptomatic or adjunct treatment (rhino sinusitis
or otitis media)
- pain or fever
> naproxen sodium (Anaprox DS) PO BID or
ibuprofen QID PRN.
> acetaminophen Q 4-6 hrs PRN
- Drainage
> increased oral fluids will thin mucus
> oral decongestants such as pseudoephedrine or
pseduphedrine combined with guaifenesin
(Mucinex D)
> Topical decongestants- use only for 3 days
maximum or will cause rebound
> saline nasal spray (ocean spray) one or twice
times every 2-3 hours PRN.
> steroid nasal spray (Flonase) if allergic rhinitis
> mucolytic (guaifenesin) and increase fluid to thin
mucus
,- cough
> dextromethorphan (robitussin) QID
> benzonatate prescription: swallow pills with
water, do not Crush, suck, or chew. toxic for
children younger than age 10 years (seizures,
cardiac arrest, death).
> increase intake of fluids avoid exposure to
cigarette smoke and alcohol
> the use of systemic steroids is not
recommended.
Treatment failure
if symptoms persist despite treatment (purulent
nasal drainage, sinus pain, nasal congestion, fever)
switch to another antibiotic. if on amoxicillin,
change antibiotic to augmentin PO Q12 hrs X 10-14
days or levofloxacin 750 mg daily. if recurrent
sinusitis, refer to otolaryngologist. nasal irrigation
may help use only sterile water (not tap water)
with saline packet.
serious complications of otitis media and rhino
sinusitis
- refer to ED stat
- MastoiditisL red and swollen mastoid that is
tender to palpation.
- preorbital or orbital cellulitis (more common in
children): swelling and redness at periorbital area,
, double vision or impaired vision, and fever.
abnormal EOM (extra orbital muscles) movement
of affected orbit (check CN's, EOM), altered LOC or
mental status change
- menignitis: acute onset of high fever, stiff neck,
severe headache, photophobia, toxicity, positive
Brudzinski or kernig sign.
- cavernous sinus thrombosis: patient complains of
acute onset of severe headache that interferes
with sleep, abnormal neurologic exam, confusion,
febrility, life-threatening emergency with high
mortality.
Disease review: Throat and sinuses: Otitis media
with effusion (serous otitis media)
may follow AOM, can also be caused by chronic
allergic rhinitis. patient complaints of ear pressure,
popping noises, and muffled hearing in affected
ear. sterile serous fluid is trapped inside the middle
ear.
objective findings
- TM may bulge or retract. Tympanogram abnormal
(flat line or no peak)
- TM should not be red
- a fluid level and/or bubbles may be visible inside
the TM.
Treatment plan
Intensive Review
Acute bacterial rhino sinusitis treatment
treatment plan
two options
- symptomatic treatment without antibiotics if mild,
uncomplicated acute bacterial rhino sinusitis
(ABRs) in healthy patients. Treatment is oral fluids
and if needed, saline nasal irrigations. follow up in
10 days. (if better, no antibiotics needed). If
symptoms are worse (or have not resolved) on
follow up visit, initiate antibiotic regimen.
- treat with antibiotics if there are severe
symptoms (toxic, high fever, pain ,purulent nasal
or postnasal drip for >2-3 days. maxillary
toothache, unilateral facial pain, sense of bad odor
in nose (cacosmia), initial symptoms improved,
then worsening of symptoms), patient is
immunocompromised, symptoms present for > 10
days (or have worsened).
- most cases of adult acute rhino sinusitis are due
to viral infection. acute bacterial infection accounts
for only 0.5-2% of cases.
Antibiotic treatment
First line (adults)
,- Amoxicillin-clavulante (Augmentin) 1000/62.5mg
or 2000mg/125 mg one table orally BIDx 5-7 days.
PCN allergy or alternative antibiotics
- type 1 allergy (anaphylaxis, angioedema),
levofloxacin 750 mg PO daily or doxycycline BID x
5-7 days
- type 2 allergy (skin rash), Cefdinir, cefpodxime,
cefuroxime PO BID x 5-7 days.
Symptomatic or adjunct treatment (rhino sinusitis
or otitis media)
- pain or fever
> naproxen sodium (Anaprox DS) PO BID or
ibuprofen QID PRN.
> acetaminophen Q 4-6 hrs PRN
- Drainage
> increased oral fluids will thin mucus
> oral decongestants such as pseudoephedrine or
pseduphedrine combined with guaifenesin
(Mucinex D)
> Topical decongestants- use only for 3 days
maximum or will cause rebound
> saline nasal spray (ocean spray) one or twice
times every 2-3 hours PRN.
> steroid nasal spray (Flonase) if allergic rhinitis
> mucolytic (guaifenesin) and increase fluid to thin
mucus
,- cough
> dextromethorphan (robitussin) QID
> benzonatate prescription: swallow pills with
water, do not Crush, suck, or chew. toxic for
children younger than age 10 years (seizures,
cardiac arrest, death).
> increase intake of fluids avoid exposure to
cigarette smoke and alcohol
> the use of systemic steroids is not
recommended.
Treatment failure
if symptoms persist despite treatment (purulent
nasal drainage, sinus pain, nasal congestion, fever)
switch to another antibiotic. if on amoxicillin,
change antibiotic to augmentin PO Q12 hrs X 10-14
days or levofloxacin 750 mg daily. if recurrent
sinusitis, refer to otolaryngologist. nasal irrigation
may help use only sterile water (not tap water)
with saline packet.
serious complications of otitis media and rhino
sinusitis
- refer to ED stat
- MastoiditisL red and swollen mastoid that is
tender to palpation.
- preorbital or orbital cellulitis (more common in
children): swelling and redness at periorbital area,
, double vision or impaired vision, and fever.
abnormal EOM (extra orbital muscles) movement
of affected orbit (check CN's, EOM), altered LOC or
mental status change
- menignitis: acute onset of high fever, stiff neck,
severe headache, photophobia, toxicity, positive
Brudzinski or kernig sign.
- cavernous sinus thrombosis: patient complains of
acute onset of severe headache that interferes
with sleep, abnormal neurologic exam, confusion,
febrility, life-threatening emergency with high
mortality.
Disease review: Throat and sinuses: Otitis media
with effusion (serous otitis media)
may follow AOM, can also be caused by chronic
allergic rhinitis. patient complaints of ear pressure,
popping noises, and muffled hearing in affected
ear. sterile serous fluid is trapped inside the middle
ear.
objective findings
- TM may bulge or retract. Tympanogram abnormal
(flat line or no peak)
- TM should not be red
- a fluid level and/or bubbles may be visible inside
the TM.
Treatment plan
