1.    Usual pathogens in acute maxillary sinusitis include:

a.    Streptococcus pneumoniae
b.    Haemophilus influenzae
c.    Moxarella catarrhalis
d.    Oral anaerobes
e.    Staphylococcus aureus

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Answer: More than 70% of acute sinusitis in adults is caused by the gram-positive diplococcus Streptococcus pneumoniae, and Haemophilus influenzae, a gram-negative bacillus. Moxarella catarrhalis is another cause of acute sinusitis, especially in children. Oral anaerobes are typically associated with chronic sinusitis, not acute sinusitis, and Staphylococcus aureus is more often a nasal contaminant than an actual pathogen. (Answer: a, b, c)

2.    Which of the following statements about the presentation and diagnosis of acute sinusitis are true:

a.    Typical symptoms include purulent nasal discharge, headache, and pain over the infected sinus that is unaffected by movement
b.    Fever occurs in 75% of cases
c.    Transillumination and radiography of the sinuses are more useful for diagnosing chronic sinusitis than for acute sinusitis
d.    Sinus aspiration should be considered for immunocompromised hosts or treatment failures

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Answer: Purulent nasal discharge, headache, maxillary toothache, jaw pain on chewing are common manifestations of acute sinusitis. There is also facial pain over the infected sinus that worsens with movement, as well as percussion tenderness. Fever occurs in about 50% of patients with acute sinusitis and is uncommon in chronic sinusitis. Complete opacification of the affected sinus on transillumination or x-ray is highly suggestive of acute sinusitis, as are air-fluid levels and mucosal thickening on radiography or CT/MRI. These diagnostic tests are less useful for chronic sinusitis patients due to persistent mucosal abnormalities even after the infection is eradicated. Sinus aspiration is associated with a high yield of positive cultures in acute sinusitis, and should be considered for immunocompromised hosts or treatment failures. (Answer: d)

3.    All of the following are acceptable forms of initial empiric therapy for acute sinusitis except:

a.    Levofloxacin 500 mg (PO) q24h x 2 weeks
b.    Gatifloxacin 400 mg (PO) q24h x 2 weeks
c.    Moxifloxacin 400 mg (PO) q24h x 2 weeks
d.    Azithromycin 500 mg (PO) x 1 dose, then 250 mg (PO) q24h x 4 days

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Answer: Acute sinusitis can be treated IV or PO, depending on the severity of the infection and the ability to take oral medications. Levofloxacin, gatifloxacin, and moxifloxacin are effective at the dosages shown. Macrolides such as azithromycin predispose to resistant S. pneumoniae and should be avoided. Doxycycline can also be used to treat acute sinusitis, at a dose of 200 mg (PO) q12h x 3 days, followed by 100 mg (PO) q24h x 11 days. Treatment should be given for a full two weeks, not 7-10 days, to prevent relapses. (Answer: d)

4.    Which of the following statements about chronic sinusitis are true:

a.    Often presents as generalized headache
b.    Sinus tenderness by percussion is often a prominent finding
c.    2-3 weeks of antimicrobial therapy is usually adequate for most cases
d.    Referral to an ENT surgeon for intranasal endoscopic sinus surgery is recommended for appropriate treatment failures

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Answer: Chronic sinusitis typically presents as generalized headache and fatigue with little or no sinus tenderness by percussion in a patient with a history of acute sinusitis. The diagnosis is suggested by sinus films or head CT/MRI showing air-fluid levels and/or sinus mucosal thickening; head CT/MRI is also useful to rule out sinus tumor, which may present in a similar fashion. Antimicrobial therapy consists of a fluoroquinolone (levofloxacin, gatifloxacin, moxifloxacin) or doxycycline in the doses prescribed for acute sinusitis, but for 4 weeks, not 2 weeks. Therapeutic failure and relapse are usually due to inadequate antibiotic duration, dose, or tissue penetration. If symptoms persist after 4 weeks of therapy, referral to ENT for a surgical drainage procedure is recommended, to improve sinus drainage, remove infected/diseased tissue, help eradicate the infection, and prevent supparative complications (e.g., meningitis, osteomyelitis, subdural empyema, cavernous venous thrombosis). (Answer: a, d)

5.    All of the following statements about facial cellulitis are true except:

a.    Presents with the acute onset of warm, painless, facial rash
b.    Usual pathogens include Group A streptococci or Haemophilus influenzae
c.    If periorbital cellulitis is present, a head CT/MRI should be obtained to rule out underlying sinusitis/CNS involvement
d.    Preferred IV therapy consists of cefotaxime or ceftriaxone

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Answer: Facial cellulits presents with the acute onset of a warm, painful, facial rash without discharge, swelling, or pruritus, which may spread rapidly across the face. Usual pathogens include Group A streptococci and Haemophilus influenza, the latter of which may be suggested by a purplish hue appearance to the rash. If periorbital cellulitis is present, it is important to obtain head CT/MRI to rule out underlying sinusitis or CNS involvement. Preferred IV therapy includes cefotaxime 2 gm (IV) q6hx 2 weeks or ceftriaxone 1 gm (IV) q24hx 2 weeks; oral therapy consists of either a second- or third-generation cephalosporin, levofloxacin 500 mg (PO) q24h, or gatifloxacin 400 mg (PO) q24h x 2 weeks. Longer (3-week) courses of therapy may be needed in compromised hosts (chronic steroids, diabetics, SLE, etc.). Prognosis is good with early treatment, but worse if underlying sinusitis or CNS involvement is present. (Answer: a)