Is dark green mucus with blood tinged normal 2 weeks after functional rhinoplasty with a swollen left ethmoid sinus?

Management of Dark Green Mucus with Blood After Functional Rhinoplasty

Dark green mucus with blood tinges and swollen left ethmoid sinus 2 weeks after functional rhinoplasty likely indicates a postoperative infection requiring antibiotic treatment.

Clinical Assessment of Post-Rhinoplasty Symptoms

The presentation of dark green mucus with blood tinges at 2 weeks post-rhinoplasty, especially with ethmoid sinus swelling, is concerning for several reasons:

• Dark green mucus typically indicates bacterial infection
• Blood tinges suggest ongoing inflammation or trauma to the mucosa
• Swelling of the ethmoid sinus indicates localized inflammation that may impair sinus drainage

Treatment Recommendation

Based on the guidelines for management of postoperative sinus complications, the following approach is recommended:

1. Start antibiotic therapy immediately:

   • First-line: Amoxicillin/clavulanic acid 1g three times daily for 7-10 days 1
   • Alternative: Levofloxacin 400mg twice daily if penicillin allergic 1
   • Consider adding metronidazole 500mg three times daily for broader anaerobic coverage 1

2. Adjunctive measures:

   • Saline nasal irrigation to facilitate mucus clearance
   • Avoid forceful nose blowing to prevent further trauma
   • Monitor for worsening symptoms including fever, increasing pain, or purulent discharge

Rationale for Antibiotic Treatment

Early intervention is critical as:

• Retained secretions in the ethmoid sinus can become colonized with pathogens and elicit local inflammation 1
• Swelling of the ethmoid sinus may indicate impaired drainage, which can lead to persistent infection
• Residual disease in the ethmoid sinuses can occur due to incomplete healing or development of new inflammatory disease 1
• Postoperative sinus infections have been reported to occur within the first 2 weeks after surgery 1

Warning Signs Requiring Urgent Follow-up

Patients should seek immediate medical attention if they experience:

• Symptoms persisting beyond 3 weeks despite antibiotic therapy
• Development of severe pain, nasal obstruction, or purulent discharge
• Fever or systemic symptoms

Follow-up Recommendations

• Schedule follow-up with the surgeon within 1 week
• Consider nasal endoscopy to evaluate the surgical site and sinus drainage
• If symptoms persist beyond 3 weeks despite appropriate antibiotic therapy, CT imaging or sinus endoscopy should be performed to evaluate the maxillary sinuses 1

Common Pitfalls to Avoid

• Delayed treatment: Waiting too long to treat can lead to persistent inflammation and potential scarring of the sinus drainage pathways 1
• Inadequate antibiotic coverage: Using antibiotics without appropriate spectrum against common sinus pathogens
• Overlooking anatomic factors: Residual disease in the ethmoid sinuses may be caused by anatomic factors that impair drainage 1
• Dismissing symptoms: Patient complaints should not be dismissed even with normal-appearing tissue, as disease may still be present in one of the ethmoid cells 1

Early intervention with appropriate antibiotics is crucial to prevent complications and ensure optimal healing after functional rhinoplasty.