Here are the key steps the emergency department would take after obtaining history and performing an examination: 1. Stabilize the patient. Given the high fever and altered mental status, immediate focus would be on stabilizing vital signs through IV fluids and antipyretics. Oxygen supplementation may also be needed. 2. Obtain imaging. A non-contrast head CT would be done urgently to evaluate for complications like abscess, thrombosis or meningitis. Contrast may be added based on findings. 3. Start empiric antibiotics. Broad spectrum IV antibiotics like vancomycin and piperacillin-tazobactam would be started immediately based on suspicion of orbital or intracranial infection.

1. Dr.AHMAD SALADDIN SULTAN
Specialist Emergency Medicine
Shamal Health Center-WIC

2. The four paired sinuses or air cavities can be referred to as:
- Ethmoid sinus cavities which are located between the eyes.
- Frontal sinus cavities which can be found above the eyes (more in the
forehead region).
- Maxillary sinus cavities are located on either side of the nostrils
(cheekbone areas).
- Sphenoid sinuses that are located behind the eyes and lie in the deeper
recesses of the skull.

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4. The presence of sinus cavities within the cranial bone (skull) is essential for
the following reasons:
- Sinus cavities allow for voice resonance.
- They help filter and add moisture to any air that is inhaled through the
nasal passages.
- Sinus Cavities provide a means to lighten the overall weight of the skull.

5. Acute Rhinosinusitis (ARS) :
Is defined as symptomatic inflammation of the
nasal cavity and paranasal sinuses lasting less than four
weeks. The term “Rhinosinusitis" is preferred to
"sinusitis" since inflammation of the sinuses rarely occurs
without concurrent inflammation of the nasal mucosa.

6. Acute rhinosinusitis (ARS) is a common problem. Each year, about
one in seven or eight persons in the United States and other Western
countries will have an episode of sinusitis. Incidence is higher in women
than men. Among adults, incidence is highest among those aged 45 to 64
years.
Risk factors for ARS include:
older age, smoking, air travel, exposure to changes in
atmospheric pressure (eg, deep sea diving), swimming, asthma and
allergies, dental disease, and immunodeficiency.

7. A-Classification of rhinosinusitis is based upon symptom duration:
-Acute rhinosinusitis – Symptoms for less than four weeks.
-Subacute rhinosinusitis – Symptoms for 4 to 12 weeks.
-Chronic rhinosinusitis – Symptoms persist greater than 12 weeks.
-Recurrent acute rhinosinusitis – Four or more episodes of ARS per year,
with interim symptom resolution.
B-ARS is further classified based on etiology and clinical manifestations:
-Acute viral rhinosinusitis (AVRS).
-Uncomplicated acute bacterial rhinosinusitis (ABRS) – ARS with bacterial
etiology without clinical evidence of extension outside the paranasal
sinuses and nasal cavity (eg, without neurologic, ophthalmologic, or soft
tissue involvement).
-Complicated acute bacterial rhinosinusitis – ARS with bacterial etiology
with clinical evidence of extension outside the paranasal sinuses and nasal
cavity.

8. In General Acute Rhinosinusitis:
Symptoms:
Nasal obstruction, anterior or posterior purulent nasal discharge, facial
pain and increase with bending forward, cough, decreased sense of smell.
Physical examination:
Findings may include altered speech (indicating nasal obstruction),
erythema or edema over the involved check bone or peri-orbital area,
cheek tenderness or tenderness with percussion of the upper teeth.

9. Acute viral rhinosinusitis Acute viral rhinosinusitis (AVRS) is diagnosed
clinically when patients have <10 days of symptoms consistent with ARS
that are not worsening.
Acute bacterial rhinosinusitis We use the following criteria to diagnose
acute bacterial rhinosinusitis (ABRS):
- Persistent symptoms or signs of ARS lasting 10 or more days without
evidence of clinical improvement or
- Onset of severe symptoms or signs of high fever (>39°C or 102°F) and
purulent nasal discharge or facial pain for at least three to four consecutive
days at the beginning of illness or
- Symptoms of a typical viral upper respiratory infection that are slowly
improving but then worsen again ("double-worsening") with more severe
symptoms and signs (new-onset fever, headache, nasal discharge) after
five to six days.

10. -Preseptal cellulitis.
-Orbital cellulitis.
-Subperiosteal abscess.
-Osteomyelitis of the sinus bones.
-Meningitis.
-Intracranial abscess.
-Septic cavernous sinus thrombosis.

11. In general no diagnostic evaluation is required and the diagnosis is
clinical based, but radiological evaluation and microbiology indicated in
cases listed below and should referred to the Emergency Department:
-Persistent, high fevers > (39°C).
-Severe and persistent headache.
-Periorbital edema, inflammation, or erythema.
-Vision changes (double vision or impaired vision).
-Abnormal extraocular movements.
-Proptosis.
-Ophthalmoplegia (pain with eye movement).
-Cranial nerve palsies.
-Altered mental status.
-Neck stiffness or other meningeal signs.
-Papilledema or other sign of increased intracranial pressure.

12. -Microbiologic testing :
The most common bacteria associated with ABRS are Streptococcus
pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, with the
first two comprising approximately 75 percent of cases of ABRS.

13. -Imaging:
Computed Tomography (CT; with contrast) or a Magnetic Resonance
Imaging (MRI; without and with contrast) of the head including the
paranasal sinuses.

15. Non-pharmacologic self-care:
- Warm moist air.
- Nasal saline.
- Hydration.
- Warm facial packs.
- Avoidance of nasal irritants (e.g. Cigarette smoke, indoor and outdoor air
pollutant).

16. • Symptomatic therapies:
Analgesics, Oral and topical decongestants, Saline nasal drops and Topical
Steroids.
• Antibiotic treatment depending on patient presentation and co-
morbidities. Initial empiric treatment with:
- Amoxicillin- clavulanate 625mg orally three times daily for seven days.
- Second – line empiric therapy: High dose Amoxicillin- clavulanate
(2000mg/125mgorally twice daily) or a respiratory fluoroquinolone
Levofloxacin 500mg orally once daily or Moxifloxacin 400mg orally once
daily) for five to seven days.
For penicillin- allergic patients, Doxycycline 100mg orally twice daily
or 200mg orally daily for five to seven days.
• Follow-Up Care: if not improved within 72 hours.

18. 23 years old male patient presented with history of two weeks of severe
headache, nasal blockage with purulent discharge, on examination found
to be sever tenderness at the frontal area, Vitals BP:120/78mmHg,
PR:95B/M, RR:18 and temp. 39.1C:
Important history points?
Investigations?
Provisional Diagnosis?
Treatments?
Disposition?

19. 38 Years female patient presented with clear nasal discharge for the last
six days with frontal headache increase with Sojood and decreased sense
of smell. Vitals is BP:110/76mmHg, PR:82B/M, RR:14, Temp.:37.7C:
Points of History?
Investigations?
Provisional Diagnosis?
Treatments?
Disposition?

20. 47 years old female brought by her son with history of breast cancer on
chemotherapy presented with complaining of sever headache specially at
frontal area since Eight days which intensity increase while bending forward,
purulent nasal discharge and repeated vomiting since 10 hours and also
report intolerance to perception of light,
Vital signs are: BP:140/98mmHg, PR:55 B/M, RR:21 Irregular, Temp.:39.5C:
Points of History?
Investigations?
Provisional Diagnosis?
Treatments?
Disposition?

21. After she reached Emergency what are steps they will do after taken history
and examinations: