Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 32-year-old man is evaluated for a 3-day history of productive cough, sore throat, coryza, rhinorrhea, nasal congestion, generalized myalgia, and fatigue. His sputum is slightly yellow. His two children (ages 3 years and 1 year) had similar symptoms 1 week ago. He is a nonsmoker and has no history of asthma.

On physical examination, temperature is 37.5 °C (99.4 °F), blood pressure is 128/76 mm Hg, pulse rate is 92/min, and respiration rate is 14/min. There is bilateral conjunctival injection. The nasal mucosa is boggy, with clear drainage. The oropharynx is erythematous without tonsillar enlargement or exudates. The tympanic membranes and external auditory canals are normal. Lungs are clear to auscultation. There is no rash or lymphadenopathy.

Which of the following is the most appropriate treatment?

A: Albuterol
B: Amoxicillin
C: Chlorpheniramine
D: Codeine

MKSAP Answer and Critique

The correct answer is C: Chlorpheniramine.

Treatment with chlorpheniramine may be considered for this patient. The common cold, or rhinosinusitis, presents with acute cough, nasal congestion, rhinorrhea, and occasionally, low-grade fever. Targeted treatment is aimed at symptom relief.

Antihistamines, such as chlorpheniramine, and antihistamine-decongestant combinations have been shown to decrease congestion and rhinorrhea with variable effects on cough suppression. Second-generation nonsedating antihistamines are generally ineffective for rhinosinusitis symptoms.

Albuterol does not relieve symptoms of rhinosinusitis unless wheezing is present. The patient did not report wheezing or shortness of breath, and wheezes were not heard on examination.

Because rhinosinusitis is caused by viruses, routine antibiotic treatment in immunocompetent hosts is not recommended. Antibiotics do not improve symptoms, illness duration, or patient satisfaction with medical care. Contrary to common belief, purulent sputum does not reliably predict bacterial infection or superinfection. Therefore, sputum purulence should not be used as a criterion for antibiotic administration.

Evidence-based guidelines from the Infectious Diseases Society of America suggest that if bacterial rhinosinusitis is highly suspected, based on the presence of persistent symptoms or signs lasting more than 10 days without evidence of clinical improvement, onset with severe symptoms (fever >39.0 °C [102.2 °F]), or onset with worsening symptoms or signs (new fever, headache, or upper respiratory tract infection symptoms that were initially improving), the antibiotic of choice is amoxicillin-clavulanate.

Multiple studies have found little if any improvement in acute cough associated with acute upper respiratory tract infections by using codeine, dextromethorphan, or moguisteine antitussive therapy. The American College of Chest Physicians does not recommend treatment with these medications. Codeine may be effective in patients with chronic cough; however, it is not indicated in this patient with acute rhinosinusitis.

Other treatments that may relieve symptoms of rhinosinusitis include intranasal ipratropium (rhinorrhea and sneezing), intranasal cromolyn (rhinorrhea, cough, throat pain), and short-term topical nasal decongestants (nasal obstruction). Consistent high-quality data on the use of zinc, echinacea, and vitamin C do not support the use of these over-the-counter products for the treatment or prevention of rhinosinusitis.

Key Point

• Antibiotics are not recommended for the treatment of acute rhinosinusitis.

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