Step 2 CK · Ophthalmology & ENT

Sinusitis, Epistaxis & Airway

Name: Sinusitis, Epistaxis & Airway
Creator: Veli Bakalov, MD

From Kiesselbach to the thumbprint sign

Ophthalmology & ENT·Nose, Mouth, Throat & Neck·4 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Most acute rhinosinusitis (under 4 weeks) is viral; give amoxicillin-clavulanate only for persistence beyond 10 days, severe onset (fever ≥39 °C with purulence or facial pain for 3 to 4 days), or double-worsening.
Chronic rhinosinusitis lasts 12 weeks or more (obstruction, discharge, pressure, hyposmia), often with polyps; nasal endoscopy, CT, and ENT referral; polyps + asthma + aspirin sensitivity = Samter triad.
Sinusitis emergencies: orbital cellulitis from the ethmoids (proptosis, painful eye movements), cavernous sinus thrombosis, Pott puffy tumor (frontal osteomyelitis), and intracranial spread.
A diabetic with facial pain and a black necrotic nasal eschar has mucormycosis: emergent surgical debridement plus amphotericin B.
Anterior epistaxis (about 90%, Kiesselbach plexus): lean forward and pinch 10–15 minutes with oxymetazoline → silver nitrate cautery → anterior packing.
Posterior epistaxis (sphenopalatine artery) is profuse and runs down the throat: posterior packing or balloon plus admission, then ligation or embolization if refractory; packing risks toxic shock syndrome.
Peritonsillar abscess: unilateral sore throat, hot-potato voice, trismus, uvula deviated away from the swelling; needle aspiration or I&D plus antibiotics for strep and anaerobes.
Epiglottitis: rapid fever, drooling, tripod posture, stridor with NO cough, thumbprint sign; secure the airway in a controlled setting, never depress the tongue, then IV ceftriaxone. Croup: barky cough, steeple sign, dexamethasone ± racemic epinephrine.
Ludwig angina (bilateral submandibular and sublingual cellulitis from a lower molar, tongue elevated) and retropharyngeal abscess (widened prevertebral space, risk of mediastinitis) are deep-space airway emergencies.

Acute and chronic rhinosinusitis

Most acute sinusitis is viral. Acute rhinosinusitis lasts under 4 weeks and is usually a self-limited viral illness, treated with analgesics, saline irrigation, and intranasal steroids. Bacterial disease (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) is suggested by the pattern over time, not by the color of the discharge. Imaging is not needed for uncomplicated acute sinusitis.

Viral versus bacterial rhinosinusitis

Feature	Viral	Bacterial (treat with antibiotics)
Duration	Under 10 days and improving	Persisting beyond 10 days without improvement
Severity	Mild, self-limited	Severe onset: fever ≥39 °C with purulent discharge or facial pain for 3 to 4 days
Course	Steady improvement	Double-worsening: initial improvement, then relapse
Treatment	Supportive care	Amoxicillin-clavulanate first-line (in children, high-dose amoxicillin with or without clavulanate)

Any one bacterial pattern justifies antibiotics.

Chronic rhinosinusitis lasts 12 weeks or more, with nasal obstruction, discharge, facial pressure, and hyposmia, and is often driven by nasal polyps or allergy. Evaluate with nasal endoscopy and CT and refer to ENT.

Nasal polyps plus asthma plus aspirin sensitivity form Samter triad (aspirin-exacerbated respiratory disease).

Complications of sinusitis

Orbital cellulitis spreads from the ethmoid sinuses: proptosis, painful eye movements, and ophthalmoplegia or reduced vision distinguish it from preseptal (eyelid-only) cellulitis. It is an emergency needing CT and IV antibiotics.
Cavernous sinus thrombosis: fever, headache, and cranial nerve palsies (III, IV, V1, V2, VI), often becoming bilateral.
Pott puffy tumor: frontal bone osteomyelitis with a doughy forehead swelling.
Intracranial extension: meningitis, epidural or brain abscess.

A diabetic (especially in DKA) or immunocompromised patient with facial pain and a black necrotic eschar on the turbinate or palate has invasive fungal sinusitis (mucormycosis) until proven otherwise: broad, non-septate hyphae with right-angle branching on biopsy. It demands emergent surgical debridement plus amphotericin B.

Epistaxis

Anterior bleeds (about 90%) come from Kiesselbach plexus (Little area) on the anterior septum. Posterior bleeds come from the sphenopalatine artery (Woodruff plexus): profuse, running down the throat, and hard to control with anterior measures; they threaten the airway through hypoxia and aspiration.

Direct pressureLean forward and pinch the soft part of the nose firmly for 10–15 minutes, plus a topical vasoconstrictor (oxymetazoline).
CauterySilver nitrate for an identified anterior source.
Anterior packingIf bleeding persists.
Posterior packing or balloon, and admitFor posterior bleeds, with monitoring for airway compromise.
Arterial ligation or embolizationFor refractory bleeding.

Epistaxis ladder: correct coagulopathy and control blood pressure throughout

Packing precautions. Nasal packing carries a risk of staphylococcal toxic shock syndrome and pressure necrosis, so packs are removed on schedule and traditionally placed with antibiotic coverage; bilateral and posterior packs especially warrant monitoring.

Recurrent unilateral epistaxis with nasal obstruction in an adolescent boy suggests juvenile nasopharyngeal angiofibroma; image it and do not biopsy, because it bleeds briskly.

Peritonsillar and deep neck infections

Deep neck space infections

Feature	Peritonsillar abscess (quinsy)	Ludwig angina	Retropharyngeal abscess
Typical patient	Adolescents and young adults, after tonsillitis	Adults with a lower molar infection	Young children
Key findings	Unilateral severe sore throat, hot-potato voice, trismus, drooling, uvula deviated to the opposite side	Rapidly spreading bilateral cellulitis of the submandibular and sublingual spaces; tongue and floor of mouth elevated	Fever, neck stiffness, dysphagia, drooling
Imaging	Usually a clinical diagnosis; CT or ultrasound if unclear	CT once the airway is safe	Widened prevertebral space on lateral neck film; CT confirms
Main danger	Airway compromise, spread to deeper spaces	Airway obstruction	Mediastinitis via the danger space
Management	Needle aspiration or incision and drainage, plus antibiotics covering strep and anaerobes	Urgent airway management, IV antibiotics, surgical drainage as needed	IV antibiotics; surgical drainage if large, threatening the airway, or not improving

Epiglottitis versus croup

Epiglottitis (Haemophilus influenzae type b; now mostly adults or unvaccinated children) brings rapid high fever, drooling, dysphagia, a muffled voice, a tripod posture, and stridor with NO cough. A lateral neck film shows the thumbprint sign.

Keep the patient calm and upright, never depress the tongue or examine the throat (it can trigger complete obstruction), and secure the airway in a controlled setting such as the operating room; then give IV ceftriaxone.

Croup versus epiglottitis

Feature	Croup (laryngotracheitis)	Epiglottitis
Cause	Parainfluenza virus	H. influenzae type b
Typical patient	Young child (about 6 months to 3 years)	Unvaccinated child or adult
Onset	Gradual, after a cold	Rapid, toxic-appearing
Cough	Barky, seal-like, with inspiratory stridor	Absent; drooling instead
Neck film	Steeple sign (AP view)	Thumbprint sign (lateral view)
Treatment	Dexamethasone; nebulized (racemic) epinephrine if stridor at rest	Secure the airway, then IV ceftriaxone