43 yo M presents with a two-week history of sinusitis as confirmed by XRAY on day 10. He was started in decongestants on day 4 of symptoms without relief, then at day 8 was started on Amoxicillin 500mg TID. He’s been on the antibiotics for 6 days without relief. He still complains of frontal face pain, at times purulent nasal discharge and congestion.
What would you do next?
Per Sanford’s Guide:
1.) With acute sinusitis, clinical failure is considered after 3 days of treatment.
2.) Persistent sinus pain, nasal congestion, purulent nasal discharge and, perhaps, fever
despite recommended therapy.
3.) Could result from:
- Infection due to an antibiotic resistant organism
- Obstruction of the ostium of one or more sinuses
- Sinusitis due to a non-infectious disease. e.g., granulomatosis with polyangiitis
Time for an ENT consult folks!
- Optional diagnostic methods: collection of sinus exudate for culture by either sinus puncture or direct sinus endoscopy.
- We must remember, common things happen commonly. Sinusitis for two weeks isn’t normal. Dig deeper. Horses are horses. Zebras initially look like horses.