A 4-year-old girl is brought to the office due to a worsening cough and nasal discharge. Two weeks ago, the patient developed nasal congestion and a runny nose, which initially improved over a few days. However, for the past 10 days she has had increasing amounts of thick, yellow-green nasal discharge. She stayed home from preschool for the past 2 days due to a worsening daytime cough and has also been waking up at night with a cough. She has no chronic medical conditions and takes no daily medications. Immunizations are up to date. Temperature is 37.2 C (99 F), pulse is 90/min, and respirations are 18/min. Pulse oximetry is 99% on room air. Examination shows an alert, active child with intermittent coughing. Thick, purulent mucus is present in the nares and visualized in the posterior oropharynx. Nasal turbinates are mildly erythematous and swollen. Bilateral tympanic membranes are translucent and mobile, and the lungs are clear on auscultation. Which of the following is the best next step in management of this patient?

Question

A 4-year-old girl is brought to the office due to a worsening cough and nasal discharge.  Two weeks ago, the patient developed nasal congestion and a runny nose, which initially improved over a few days.  However, for the past 10 days she has had increasing amounts of thick, yellow-green nasal discharge.  She stayed home from preschool for the past 2 days due to a worsening daytime cough and has also been waking up at night with a cough.  She has no chronic medical conditions and takes no daily medications.  Immunizations are up to date.  Temperature is 37.2 C (99 F), pulse is 90/min, and respirations are 18/min.  Pulse oximetry is 99% on room air.  Examination shows an alert, active child with intermittent coughing.  Thick, purulent mucus is present in the nares and visualized in the posterior oropharynx.  Nasal turbinates are mildly erythematous and swollen.  Bilateral tympanic membranes are translucent and mobile, and the lungs are clear on auscultation.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d254_4e76_bc81_815d12510c94_MD0003_00 This patient has worsening daytime cough and purulent nasal discharge consistent with acute bacterial rhinosinusitis (ABRS), a common complication of viral upper respiratory infection (URI). Viral URI symptoms typically self-resolve in 7-10 days. In contrast, ABRS is diagnosed by any 1 of the following 3 criteria: Symptoms (eg, cough, congestion) persist for ≥10 days without improvement. OR OR Symptoms severe in onset (fever ≥39 C [102.2 F] + drainage) for ≥3 days. OR OR Symptoms worsen following initial improvement (ie, biphasic illness). Fever may be absent. Most cases are due to nontypeable Haemophilus influenzae or Streptococcus pneumoniae. Worsening symptoms (eg, progressive cough ± fever), as seen in this patient, are treated with oral antibiotics (eg, amoxicillin ± clavulanate) at the time of diagnosis. In contrast, in patients with persistent but not worsening symptoms and a milder course, oral antibiotics or a 3-day period of observation for clinical improvement are both acceptable treatment options (Choice C). (Choices A and G) ABRS is generally a clinical diagnosis. However, if the patient develops periorbital edema, vision abnormalities, or altered mental status, CT scan of the sinuses is recommended to identify suppurative complications (eg, orbital/preseptal cellulitis, brain abscess, cavernous sinus thrombosis). Sinus x-rays are less sensitive and not recommended in the diagnosis of sinusitis or its complications. (Choices B and E) Intranasal corticosteroids and oral antihistamines treat allergic rhinitis and are used only as adjunctive therapy for sinusitis with an allergic component. Allergic rhinitis presents with rhinorrhea that is clear, not purulent as in this patient. (Choice F) A sinus fluid culture is unnecessary for uncomplicated ABRS that responds to empiric antibiotics. If symptoms are refractory or complications occur, cultures may be obtained by sinus aspiration to better target antimicrobial therapy. Educational objective: Acute bacterial rhinosinusitis is distinguished from a viral upper respiratory infection by the presence of severe, persistent, or worsening symptoms (eg, cough, nasal discharge). Treatment is with oral antibiotics. References: Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. (http://www.ncbi.nlm.nih.gov/pubmed/23796742)

A 4-Year-Old Girl Is Brought to the Office Due to a Worsening