CCE-CBD-021

Examiner Only Information

Questions

Q1. How would you differentiate between viral and bacterial sinusitis in Daniel?

• Prompt: What clinical features suggest viral vs bacterial sinusitis?
• Prompt: When are antibiotics indicated?

Q2. What is the recommended management for Daniel’s current symptoms?

• Prompt: What symptomatic treatments should be advised?
• Prompt: How would you counsel Daniel on the limited role of antibiotics?

Q3. How would you manage Daniel’s chronic sinus symptoms and prevent recurrence?

• Prompt: What long-term management strategies are recommended for chronic sinusitis?
• Prompt: What lifestyle modifications and medical treatments can help reduce recurrence?

Q4. When would you consider further investigations or referral?

• Prompt: What features indicate the need for imaging (e.g., CT scan)?
• Prompt: When should an ENT referral be considered?

Q5. What red flags suggest complications of sinusitis requiring urgent intervention?

• Prompt: What symptoms indicate possible orbital or intracranial spread?
• Prompt: How would you escalate care if complications were suspected?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you differentiate between viral and bacterial sinusitis in Daniel?

The competent candidate should:

• Key features of viral sinusitis:
  • Symptoms lasting <10 days.
  • Clear or mildly coloured nasal discharge.
  • Symptoms gradually improving.
• Key features of bacterial sinusitis:
  • Symptoms lasting >10 days without improvement or worsening after initial improvement (double worsening).
  • Purulent nasal discharge and severe facial pain or tenderness.
  • Fever >38°C.
  • Severe symptoms lasting >3-4 days.
• Antibiotics should be considered only if bacterial sinusitis is likely.

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Q2: What is the recommended management for Daniel’s current symptoms?

The competent candidate should:

• First-line symptomatic management:
  • Intranasal corticosteroids (e.g., mometasone or fluticasone) for inflammation.
  • Saline nasal irrigation for mucus clearance.
  • Paracetamol/NSAIDs for pain relief.
  • Hydration and steam inhalation to aid sinus drainage.
• Antibiotics are NOT required unless bacterial sinusitis is strongly suspected.
• Patient education:
  • Explain the self-limiting nature of most sinus infections.
  • Set realistic expectations for symptom resolution (2-4 weeks).

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Q3: How would you manage Daniel’s chronic sinus symptoms and prevent recurrence?

The competent candidate should:

• Address underlying allergic rhinitis:
  • Regular intranasal corticosteroids (e.g., fluticasone).
  • Antihistamines (e.g., loratadine) if allergy-driven.
• Lifestyle modifications:
  • Avoid known triggers (dust, smoke, air-conditioning).
  • Improve air quality with humidifiers if needed.
• Long-term nasal hygiene:
  • Regular saline nasal irrigation.
  • Continued intranasal corticosteroids for inflammation control.

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Q4: When would you consider further investigations or referral?

The competent candidate should:

• CT sinuses if:
  • Symptoms persist >12 weeks despite optimal treatment.
  • Frequent recurrent sinus infections (≥4 per year).
  • Concern for structural abnormalities (e.g., nasal polyps, deviated septum).
• ENT referral if:
  • Symptoms persist despite medical therapy.
  • Recurrent bacterial sinusitis needing multiple antibiotic courses.

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Q5: What red flags suggest complications of sinusitis requiring urgent intervention?

The competent candidate should:

• Orbital complications:
  • Periorbital swelling, erythema, proptosis, vision changes (orbital cellulitis).
• Intracranial complications:
  • Severe headache, photophobia, neck stiffness (meningitis concern).
  • Altered mental status, focal neurological deficits (brain abscess concern).
• Systemic illness:
  • High fever, worsening pain despite treatment.

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SUMMARY OF A COMPETENT ANSWER

• Differentiates viral vs bacterial sinusitis and avoids unnecessary antibiotics.
• Provides symptomatic relief using nasal irrigation, corticosteroids, and analgesia.
• Develops a long-term plan for chronic sinusitis (allergy control, nasal hygiene).
• Recognises when imaging or ENT referral is needed.
• Identifies red flags suggesting serious complications.

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PITFALLS

• Overprescribing antibiotics for viral sinusitis.
• Failing to address underlying allergic rhinitis in chronic cases.
• Not considering CT scan or referral in persistent or recurrent sinusitis.
• Missing red flag symptoms of orbital or intracranial complications.

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REFERENCES

• RACGP Clinical Guidelines on Acute Sinusitis Management
• National Institutes of Health on Respiratory Infections
• Australian Society of Otolaryngology on Sinusitis Recommendations

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Engages the patient in a discussion about sinusitis management.

2. Clinical Information Gathering and Interpretation

2.1 Differentiates viral vs bacterial sinusitis and considers chronic factors.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies subacute sinusitis and avoids unnecessary antibiotic use.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based treatment plan including symptomatic relief.

5. Preventive and Population Health

5.2 Addresses allergic rhinitis and long-term sinus hygiene.

6. Professionalism

6.3 Provides patient-centred care while addressing concerns about antibiotics.

7. General Practice Systems and Regulatory Requirements

7.2 Follows antimicrobial stewardship principles.

9. Managing Uncertainty

9.1 Determines when imaging or specialist referral is needed.

10. Identifying and Managing the Patient with Significant Illness

10.3 Recognises red flags for sinusitis complications.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD