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Abstract: Acute sinusitis refers to sinusitis with onset symptoms within 12 weeks, often secondary to upper respiratory tract infection, usually caused by direct viral or bacterial infection, mainly manifesting as nasal congestion, runny nose, headache, olfactory disturbance, and systemic symptoms may be accompanied by irritability and discomfort, depression, drowsiness, and chills and fever. The patient came to the clinic with backed-up nasal discharge with headache. After sinus CT, the patient was diagnosed with acute sinusitis and improved after applying medication.
Basic information】Male, 18 years old
Type of disease】Acute sinusitis
Hospital】Northern War Zone General Hospital
Date of consultation】March 2022
Treatment plan】Drug anti-inflammatory treatment (cefuroxime sodium for injection + ornidazole injection + budesonide nasal spray + eucalyptus pinene enteric soft capsule) + rinsing nasal cavity with nasal washer
[Treatment period] 15 days of outpatient treatment
Effectiveness】The patient’s nasal discharge and headache disappeared after medication.
I. Initial consultation
The patient’s medical history was asked in the outpatient clinic. The patient had symptoms of upper respiratory tract infection one week ago because he often stayed up late at night and had poor resistance to study, and was treated with cold and fever pellets. The patient was advised to improve the nasal coronal CT, the CT results suggest that the mucous membrane in the nasal cavity and sinuses is obviously edematous, the maxillary sinus orifice is obviously obstructed, fluid accumulation in the maxillary sinus, the rest of the sinuses are not abnormal, the sinus bone is not abnormal, the nasal septum is slightly deviated to the left, the right inferior turbinate is slightly enlarged, according to the patient’s symptoms plus the auxiliary examination, the diagnosis is now acute sinusitis, and the patient is given The patient was given conservative drug treatment.
II. Treatment history
The patient was treated with cefuroxime sodium for injection to reduce inflammation and with ornidazole injection as an antioxidant anaerobic bacteria, and the nasal cavity was rinsed locally with a nasal washer to reduce the backflow of nasal mucus. The patient and family members accept this treatment plan. If adverse drug reactions occur during the treatment period, it is necessary to stop the medication in a timely manner and seek medical consultation at the hospital in a timely manner, which the patient understands.
Third, the effect of treatment
The patient reported that after each nasal rinse, there would be a lot of yellow purulent secretion flowing out of the nasal cavity together with the rinse solution, and the symptoms of nasal reflux and headache were significantly improved compared with those before the medication. It is recommended to stop the intravenous drip, continue to apply nasal irrigation, use budesonide nasal spray, and take oral eucalyptus pinene enteric soft capsule to consolidate the treatment to avoid recurrence. After 15 days of medication, the patient said that the symptoms of nasal reflux and headache disappeared, and the odor in the nasal cavity did not recur, so the treatment effect was good and the patient was very satisfied with the treatment effect.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment. Patients need to exercise more in life to improve their immune system, avoid repeated colds to avoid triggering or aggravating sinusitis, and eat a light diet, do not eat spicy, stimulating food, avoid eating cold food, diet needs to be reasonable, eat less fish and shrimp, eat more fruits and vegetables to supplement vitamins, exercise more to promote the body’s metabolism, avoid smoking and alcohol to reduce the impact on the Avoid smoking and alcohol to reduce the stimulation of the nasal mucosa and sinus mucosa, pay attention to the quality of the air environment, ensure a good ventilation environment to avoid dust accumulation, usually you can use warm water to soak your feet to promote blood circulation and improve the nasal environment, patients can stop medication and come to the hospital in time if symptoms of discomfort occur during the use of medication.
V. Personal insight
Acute sinusitis is a very common clinical disease that requires timely treatment after diagnosis, such as poor control of inflammation, often may be combined with orbital or intracranial complications, treatment difficulties and treatment costs increase, and even life-threatening, if the inflammation does not heal, may turn into chronic sinusitis, affecting normal work life, and may even require surgery to solve. Patients usually need to exercise more to improve resistance and reduce the chances of acute sinusitis.