Rhinology and Sinus Surgery
Rhinology and Sinus Surgery
This domain tests acute and chronic rhinosinusitis, nasal polyposis, and red-flag recognition. Expect questions on when antibiotics are indicated, when imaging changes management, and how type 2 inflammation guides biologics.
Core rules
- Acute bacterial rhinosinusitis is likely when symptoms last beyond 10 days, worsen after 5 days, or include high fever and focal pain; amoxicillin-clavulanate is first-line in most adults.
- Chronic rhinosinusitis requires at least 12 weeks of symptoms plus objective inflammation. Saline irrigation and intranasal corticosteroids are foundation therapy.
- CRSwNP with type 2 inflammation may qualify for dupilumab, omalizumab, or mepolizumab when surgery and medical therapy fail.
- Endoscopic sinus surgery improves selected CRSwNP patients after failed medical therapy; it is not a substitute for treating acute uncomplicated disease.
- Unilateral bloody discharge, orbital swelling, vision change, or meningism demands urgent CT and specialist review.
Worked example
A 38-year-old has bilateral nasal polyps, anosmia, and 1 year of congestion despite daily intranasal corticosteroid and saline. CT shows pansinusitis. The next step is to optimize medical therapy and assess type 2 markers; if uncontrolled, biologic therapy or functional endoscopic sinus surgery is considered. Antibiotics are not indicated because there is no acute bacterial pattern. The reasoning is that chronic disease is inflammatory, not simply infectious.
Traps
Do not prescribe antibiotics for every chronic congestion. Do not miss unilateral disease or orbital signs. Do not order CT for uncomplicated acute rhinosinusitis unless complications are suspected.