Rosh Emergency Medicine Practice Test

What is the most appropriate next step of management for a patient presenting with nasal congestion and purulent nasal discharge along with facial discomfort?

1. Amoxicillin-clavulanate

2. Azithromycin

3. Computed tomography scan of the sinuses

4. Supportive measures with intranasal saline and fluticasone

The correct answer is: Supportive measures with intranasal saline and fluticasone

In patients presenting with nasal congestion, purulent nasal discharge, and facial discomfort, the most appropriate initial management is often supportive measures. These can include the use of intranasal saline and a topical nasal corticosteroid like fluticasone. This approach is particularly relevant in cases of viral rhinosinusitis or mild sinus infections, which are very common and generally self-limiting. Intranasal saline helps to moisturize the nasal passages, thin mucus, and facilitate drainage, while fluticasone reduces inflammation in the nasal mucosa, relieving congestion and promoting healing. This conservative management is essential because it addresses symptoms and provides relief without the need for immediate antibiotic treatment, which is not warranted in most mild cases as they tend to resolve on their own. Other management options, such as antibiotics, might be considered if bacterial sinusitis is strongly suspected, especially if symptoms persist beyond 10 days or worsen after an initial improvement. Computed tomography scans are usually reserved for cases where there are complications or atypical presentations suggesting more serious underlying issues. Thus, starting with supportive measures is a prudent approach in this scenario, making it the correct choice.