Sinusitis
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Direct answer
When a common cold turns unilateral — cheek pain that deepens on bending forward, purulent discharge, and fever after initial improvement ("double worsening") — acute bacterial rhinosinusitis has set in. Amoxicillin-clavulanate is the standard first-line antibiotic, and functional endoscopic sinus surgery restores drainage when medical therapy fails. The examinable edge lies in complications — orbital cellulitis graded by Chandler classification, Pott puffy tumour and cavernous sinus thrombosis — and in the Indian context, rhino-orbital-cerebral mucormycosis in poorly controlled diabetics, classically after steroid-heavy COVID-19.
What you must remember
- The maxillary sinus is most commonly involved, partly because its ostium sits high on the medial wall so drainage works against gravity.
- Acute sinusitis lasts under four weeks, subacute up to about twelve, and chronic beyond twelve weeks; chronic disease means medical therapy with intranasal steroids and saline irrigation before surgery.
- Bacterial markers: symptoms over 10 days without improvement, deterioration after initial improvement, unilateral facial or dental pain, purulent discharge and fever; amoxicillin-clavulanate for 5–7 days in adults is the tested answer.
- Coronal-section CT of the paranasal sinuses is the imaging of choice for chronic disease and surgical planning; plain X-rays are obsolete for routine diagnosis.
- Chandler classification of orbital spread: I preseptal cellulitis, II orbital cellulitis, III subperiosteal abscess, IV orbital abscess, V cavernous sinus thrombosis.
- Cavernous sinus thrombosis signs: proptosis, chemosis, ophthalmoplegia of cranial nerves III, IV and VI with trigeminal involvement, and contralateral spread — an emergency.
- FESS works by opening the ostiomeatal complex in the middle meatus, respecting mucosa and restoring physiological drainage rather than stripping sinuses.
The Indian angle: from ordinary sinusitis to mucormycosis
Consider two patients. The first is a 24-year-old with a week of cold, then right cheek pain worse on bending forward, thick green discharge and fever. This is acute bacterial rhinosinusitis: examine the nose for pus in the middle meatus, prescribe amoxicillin-clavulanate with saline irrigations and intranasal steroid, and review. If such a patient returns with a swollen, red, proptosed eye and painful eye movements, the disease has crossed into the orbit: stage the cellulitis along Chandler, start intravenous antibiotics, obtain urgent contrast CT of orbits and sinuses, and involve ophthalmology — stages III and IV need surgical drainage, and any fall in vision is a surgical alarm.
The second patient is a 56-year-old with poorly controlled type 2 diabetes who received high-dose steroids for COVID-19 weeks earlier and now has facial pain, nasal crust and black discharge, eyelid swelling and blurred vision. During and after India's COVID-19 waves this became a recognisable emergency: rhino-orbital-cerebral mucormycosis, caused by Mucor and Rhizopus species that thrive in hyperglycaemic, steroid-immunosuppressed, acidotic tissue. The black eschar on the nasal turbinate or palate is the bedside clue; urgent confirmation is by KOH mount and biopsy, staging by contrast CT and MRI, and treatment rests on three legs: rapid glycaemic control and steroid cessation, liposomal amphotericin B, and aggressive surgical debridement, which in severe orbital disease may include exenteration. Because the fungus invades along blood vessels, it causes palatal or turbinate necrosis and ophthalmic artery involvement — the reason vision loss and cranial nerve palsies appear early. Every case is a team effort of ENT, ophthalmology, internal medicine and clinical microbiology.
How the exam frames it
Three question families recur. Duration and drug: over ten days or double worsening plus amoxicillin-clavulanate is the matched pair. Complication staging: Chandler stages and the cavernous sinus syndrome (chemosis, proptosis, ophthalmoplegia) as the terminal stage. And the diabetic-with-black-crust stem, which after 2021 answers mucormycosis with liposomal amphotericin and debridement — the single most current Indian ENT exam fact of recent years. The trap option is X-ray of the sinuses as the investigation of choice; the examinable answer for chronic disease and complications is contrast CT.
Frequently asked questions
Which sinus is most commonly involved in sinusitis?
The maxillary sinus, followed by the ethmoid; the maxillary ostium's high medial position makes dependent drainage difficult.
What criteria suggest acute bacterial rather than viral sinusitis?
Symptoms beyond 10 days without improvement, worsening after initial improvement, unilateral facial or dental pain, purulent discharge and fever.
What is the Chandler classification?
Orbital complications staged as preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess and cavernous sinus thrombosis.
What are the hallmark features of rhino-orbital mucormycosis?
Black nasal or palatal eschar, facial pain and eyelid swelling with rapidly progressive visual loss in a diabetic or immunosuppressed patient, confirmed by KOH and biopsy.
What is the principle of functional endoscopic sinus surgery?
Endoscopic opening of the ostiomeatal complex in the middle meatus to restore natural drainage and mucociliary clearance, conserving mucosa.