A 9-year-old girl is brought to the clinic for evaluation of persistent nasal congestion. Her symptoms began 2 weeks ago with fever, rhinorrhea, and congestion. Over the last week, the patient has developed a dry cough that is worse at night, and she has had to miss her daily swim practice. Her mother had been treating the symptoms with acetaminophen and an over-the-counter cough and cold medication. The fever has resolved, but nasal symptoms have not improved. The patient has no chronic medical conditions and takes no daily medications. Her father smokes cigarettes outside the house. Temperature is 37.2 C (99 F). Examination shows erythema and swelling of the nasal turbinates with purulent nasal drainage bilaterally. Mucopurulent discharge is present in the posterior pharynx. Bilateral tympanic membranes are clear and mobile. The lungs are clear to auscultation. Which of the following is the most common risk factor for development of this patient's current condition?
Acute bacterial rhinosinusitis | |
Clinical features |
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Diagnostic criteria (1 of 3) |
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Treatment |
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This patient has prolonged (≥10 days) nasal congestion suggestive of acute bacterial rhinosinusitis (ABRS), an infection of the paranasal sinuses most commonly due to nontypeable Haemophilus influenzae, Streptococcus pneumoniae, or Moraxella catarrhalis. Presenting symptoms often include cough, nasal discharge/congestion, facial pain, and headache. ABRS is defined by any 1 of the following 3 criteria:
Symptoms (eg, cough, nasal discharge/congestion) persisting for ≥10 days without improvement
Symptoms severe in onset (fever ≥39 C [102.2 F] + drainage) for ≥3 days
Symptoms worsening following initial improvement
The most common risk factor for ABRS is viral upper respiratory infection (URI); up to 10% of children with a viral URI develop ABRS. Thickened secretions and mucosal inflammation from the viral infection prevent sinus drainage and impair mucociliary clearance of contaminating bacteria, which can lead to secondary bacterial infection. Although less common than viral URI, mucosal inflammation due to allergic rhinitis can also predispose to ABRS. Diagnosis is usually clinical, and the first-line treatment is amoxicillin with or without clavulanate.
(Choices A and C) Adenoidal hypertrophy and nasal septal deformity can cause signs of nasal obstruction (eg, mouth breathing, sleep apnea) but are minor contributors to sinus disease. Viral URIs more commonly lead to ABRS.
(Choices B and D) Environmental irritants, such as cigarette smoke and pool chemicals, are common risk factors for asthma, which presents with wheezing (not seen in this patient). Environmental irritants can induce mucosal inflammation and lead to sinusitis but are less commonly implicated than viral URIs.
Educational objective:
Acute bacterial rhinosinusitis should be considered in children with cough or nasal discharge/congestion that persists for ≥10 days without improvement. The 2 most common risk factors are viral upper respiratory infections and allergic rhinitis.