SCE ENT: Navigating Acute Rhinosinusitis Guidelines

As an aspiring specialist, mastering common conditions and their management according to national guidelines is paramount for success in the Specialty Certificate Examination (SCE). In the realm of Ear, Nose, and Throat (ENT), acute rhinosinusitis (ARS) is a highly prevalent condition that frequently appears in exam questions. This blog post will guide you through the essential guidelines for managing ARS, ensuring you are well-prepared for your SCE.

Why Acute Rhinosinusitis for SCE?

Acute rhinosinusitis, often simply called a "sinus infection," affects millions annually. Its high incidence means it's a condition you will undoubtedly encounter in your clinical practice, and therefore, it's a high-yield topic for the SCE. The examination assesses your ability to apply current clinical guidelines, differentiate between viral and bacterial causes, and make appropriate management decisions, particularly regarding antibiotic stewardship and referral criteria.

Understanding Acute Rhinosinusitis (ARS)

ARS is an inflammatory condition of the paranasal sinuses and nasal cavity, typically lasting less than 12 weeks. It is most commonly caused by a viral infection, often following an upper respiratory tract infection (URTI). Bacterial ARS, while less common, accounts for a significant proportion of persistent or worsening cases.

Key Distinctions:

• Viral ARS: Symptoms usually peak within 3-5 days and resolve spontaneously within 7-10 days.

• Bacterial ARS: Symptoms persist for more than 10 days without improvement, or worsen after initial improvement (known as "double sickening").

Clinical Presentation and Diagnosis

Patients typically present with nasal congestion, discharge (clear, purulent, or opaque), facial pain/pressure (often worse when bending forward), reduced sense of smell, headache, and sometimes fever.

Diagnosis is primarily clinical. Imaging (X-rays, CT scans) is generally not recommended for uncomplicated ARS, as it does not differentiate between viral and bacterial causes and may lead to unnecessary antibiotic prescriptions. Imaging is reserved for suspected complications or chronic cases.

Red Flags indicating potential complications (requiring urgent referral/imaging):

• Severe unilateral frontal headache

• Periorbital oedema, erythema, or pain

• Diplopia or other visual changes

• Proptosis

• Cranial nerve palsies

• Altered mental status

• Meningism

• Focal neurological signs

Management Strategies: Applying the Guidelines

The cornerstone of ARS management, especially for viral cases, is symptomatic relief and patient education. Adherence to antibiotic stewardship is crucial to combat antimicrobial resistance.

1. Symptomatic Relief (First-line for most cases):

• Analgesia: Paracetamol or NSAIDs for pain and fever.

• Nasal Saline Irrigation: Sprays or washes can help clear nasal passages and reduce mucosal swelling. This is a highly recommended and effective measure.

• Intranasal Corticosteroids (INCS): Can be considered for bothersome symptoms, particularly if symptoms are persistent or severe. There's some evidence for their benefit in reducing symptom duration.

• Oral Decongestants (e.g., pseudoephedrine, phenylephrine): Can offer short-term relief for nasal congestion but should be used cautiously, especially in patients with hypertension or cardiovascular disease. Avoid prolonged use due to risk of rhinitis medicamentosa.

2. Antibiotic Stewardship: When to Prescribe?

Antibiotics are generally NOT recommended for mild-to-moderate ARS, as most cases are viral. Over-prescription contributes to antibiotic resistance.

Consider antibiotics only if:

• Symptoms persist for more than 10 days without improvement.

• Symptoms significantly worsen after initial improvement ("double sickening").

• Patient is systemically unwell (e.g., high fever >38°C, signs of severe infection).

• Patient is immunosuppressed.

Recommended Antibiotic Choices (UK Guidelines):

• First-line: Phenoxymethylpenicillin or Amoxicillin for 5-7 days.

• Second-line/Penicillin allergy: Doxycycline or Clarithromycin (macrolides should be used cautiously due to increasing resistance).

• If severe infection or complications suspected: Co-amoxiclav (amoxicillin/clavulanic acid) or consider specialist advice.

3. Safety Netting and Patient Education

It's vital to educate patients on the self-limiting nature of most ARS, provide advice on symptomatic relief, and explain when to seek further medical attention (i.e., red flag symptoms or worsening/persistent symptoms).

4. Referral to Secondary Care (ENT Specialist)

Referral is indicated for:

• Suspected complications (e.g., orbital cellulitis, intracranial extension).

• Recurrent ARS (multiple episodes per year).

• Chronic rhinosinusitis (symptoms >12 weeks) not responding to primary care management.

• Diagnostic uncertainty or failure to respond to appropriate antibiotic therapy.

SCE Exam Tips

• Scenario-based questions: Be prepared for clinical vignettes describing patients with ARS. Focus on identifying typical viral vs. bacterial presentations and applying the correct management algorithm.

• Knowledge of guidelines: Questions will test your understanding of when to prescribe antibiotics, which ones, and for how long. Also, be aware of the contraindications for certain treatments (e.g., decongestants).

• Red flag recognition: Be adept at identifying the critical signs and symptoms that necessitate urgent referral or imaging.

• Antibiotic stewardship: Emphasise appropriate antibiotic use, as this is a key theme in many exams.

By thoroughly understanding the presentation, diagnosis, and guideline-based management of acute rhinosinusitis, you will confidently approach relevant questions in your SCE. Remember to always prioritise patient safety and prudent use of antibiotics.

Good luck with your preparation!