What's the next step for a patient with a 12-day persistent upper respiratory tract infection (URTI) now presenting with tenderness in the frontal bone?

Management of 12-Day URTI with Frontal Bone Tenderness

Start oral antibiotics immediately—this patient meets diagnostic criteria for acute bacterial rhinosinusitis (ABRS) based on symptom duration beyond 10 days with localized frontal sinus tenderness, and imaging is not necessary for diagnosis or treatment initiation. 1

Diagnostic Rationale

This clinical presentation is classic for bacterial superinfection of an initially viral upper respiratory infection:

• Symptom duration of 12 days exceeds the critical 10-day threshold that distinguishes uncomplicated viral URTI from ABRS, which is the primary diagnostic criterion across all major guidelines 1
• Frontal bone tenderness indicates frontal sinusitis, and the combination of persistent symptoms beyond 10 days plus facial pain/pressure (especially when localized to a particular sinus region) strongly supports the diagnosis of ABRS 1
• The diagnosis of ABRS is made clinically based on symptom duration and character—imaging is explicitly not recommended for uncomplicated ABRS 1

Why Imaging is Not Indicated

Plain X-rays and CT scans are unnecessary for diagnosing or managing uncomplicated ABRS:

• Guidelines from the American Academy of Otolaryngology clearly state that imaging is not necessary for cases of ABRS 1
• Physical examination and imaging provide limited diagnostic value in straightforward ABRS cases 1
• CT imaging should be reserved for patients with suspected complications (such as orbital involvement, severe headache with mental status changes, or treatment failure after appropriate antibiotic therapy) 1, 2

Recommended Antibiotic Treatment

First-line therapy: Amoxicillin-clavulanate (if no recent antibiotic exposure in past 4-6 weeks):

• This patient falls into the category of mild-to-moderate disease without recent antibiotic exposure 1
• Amoxicillin-clavulanate provides coverage against the most common pathogens: Streptococcus pneumoniae, Haemophilus influenzae (including β-lactamase producers at ~30% prevalence), and Moraxella catarrhalis 1
• Standard dosing: 875/125 mg twice daily orally 3

Alternative regimens (for penicillin allergy):

• Respiratory fluoroquinolones (levofloxacin or moxifloxacin) provide appropriate coverage 1
• Avoid first-generation cephalosporins or macrolides as monotherapy due to inadequate coverage 3

Critical Red Flags Requiring Immediate Escalation

Watch for complications that would necessitate hospitalization and IV antibiotics:

• Periorbital swelling, proptosis, impaired visual acuity, or painful extraocular movements (indicating orbital involvement) 2
• Severe headache with mental status changes, fever, or signs of meningeal irritation 1
• Facial swelling suggesting abscess formation 3

These complications would require immediate contrast-enhanced CT imaging, hospitalization, and IV antibiotic therapy with broader coverage 3, 2

Common Pitfalls to Avoid

• Do not delay antibiotic treatment waiting for imaging—the 12-day duration with localized tenderness is sufficient for diagnosis 1
• Do not assume this is still a simple viral URTI—bacterial superinfection is highly likely after 10 days, especially with focal sinus tenderness 1
• Do not order sinus X-rays or CT for uncomplicated cases—this adds unnecessary cost, radiation exposure, and potential for misleading incidental findings without changing management 1