What is the most appropriate next step for a pediatric patient presenting with fever, headache, severe periorbital pain and swelling, and purulent nasal discharge after a recent episode of clear runny nose and low-grade fever?

Management of Pediatric Periorbital Complications from Acute Bacterial Sinusitis

This child requires immediate hospitalization with CT scan with contrast and initiation of intravenous antibiotics—this is a complicated acute bacterial sinusitis with orbital involvement that can lead to permanent blindness or death if not treated promptly.

Clinical Recognition of Complicated Sinusitis

This presentation represents periorbital/preseptal cellulitis complicating acute bacterial sinusitis, most commonly secondary to acute ethmoiditis in young children. 1 The clinical progression from viral upper respiratory infection (clear rhinorrhea, low-grade fever) to bacterial sinusitis (purulent discharge) with subsequent orbital involvement follows a classic pattern requiring urgent intervention.

Key Distinguishing Features to Assess Immediately:

• Eyelid closure percentage: If <50% closed, this may represent mild preseptal cellulitis 1
• Presence of proptosis: Indicates postseptal (intraorbital) involvement requiring immediate hospitalization 1
• Visual acuity: Any impairment mandates immediate hospitalization and imaging 1
• Extraocular movements: Impaired or painful movements indicate orbital involvement requiring hospitalization 1

Immediate Management Algorithm

If Eyelid <50% Closed AND No Warning Signs:

• Outpatient management with high-dose amoxicillin-clavulanate (80-90 mg/kg/day of amoxicillin component divided into 2-3 doses, maximum 4 g/day) 1
• Mandatory daily follow-up until definite improvement noted 1
• Hospitalize immediately if no improvement within 24-48 hours or if infection progresses 1

If ANY of the Following Present (As in This Case with "Severe" Periorbital Swelling):

• Eyelid ≥50% closed
• Proptosis
• Impaired visual acuity
• Impaired/painful extraocular mobility
• Severe headache
• Altered mental status

Then proceed with:

1. Immediate hospitalization 1
2. Contrast-enhanced CT scan (preferably coronal thin cut) of head, orbits, and sinuses to confirm intraorbital or intracranial suppurative complications 1
3. Start intravenous antibiotics immediately—do not wait for imaging results 1
4. Urgent consultation with otolaryngology, ophthalmology, and infectious disease specialists for guidance on surgical intervention and antimicrobial selection 1

Antibiotic Selection for Complicated Sinusitis

Intravenous vancomycin should be included to cover possible methicillin-resistant Streptococcus pneumoniae, combined with a third-generation cephalosporin (ceftriaxone or cefotaxime) for comprehensive coverage. 1 Therapy should be tailored once culture and sensitivity results become available. 1

Critical Pitfalls to Avoid

• Do not attempt outpatient management when severe periorbital pain and swelling are present—the description of "severe" indicates this exceeds the <50% eyelid closure threshold for outpatient therapy 1
• Do not delay imaging for specialist consultation—CT should be obtained emergently 1
• Do not use oral antibiotics alone for complicated sinusitis with orbital involvement—IV therapy is mandatory 1
• Do not refer to outpatient ENT clinic—this requires immediate inpatient ENT consultation, not scheduled outpatient follow-up 1

Why This Cannot Wait

Orbital and intracranial complications of acute bacterial sinusitis can result in permanent blindness, neurologic sequelae, or death if not treated promptly and appropriately. 1 The progression from preseptal to postseptal involvement can occur rapidly, and the presence of severe periorbital pain with fever and headache suggests extension beyond simple preseptal cellulitis. 1

Answer: C) CT scan with contrast (with simultaneous hospitalization and IV antibiotic initiation, not as an isolated intervention)