What is the appropriate management for a 17-year-old female (YOF) presenting with throbbing pain under her left eyebrow, accompanied by a history of cough, sore throat, fever, nausea, vomiting, and diarrhea?

Management of Throbbing Pain Under Left Eyebrow in a 17-Year-Old with Recent Upper Respiratory Illness

This patient most likely has acute bacterial sinusitis (specifically frontal sinusitis) given the throbbing pain localized under the eyebrow, recent upper respiratory infection with fever, and associated systemic symptoms—immediate evaluation for sinusitis is warranted, with antibiotic therapy reserved only if she meets specific criteria for bacterial infection.

Critical Initial Assessment

The location of pain directly under the eyebrow strongly suggests frontal sinus involvement, which requires careful evaluation to rule out serious complications 1. Given her week-long illness with fever, cough, and sore throat followed by gastrointestinal symptoms, this presentation warrants assessment for:

• Duration and progression of symptoms: Has pain been present >10 days, or did symptoms worsen after initial improvement ("double sickening")? 1
• Severity indicators: High fever (>39°C), severe facial pain, or purulent nasal discharge for ≥3 consecutive days 1
• Red flag symptoms: Visual changes, severe headache, periorbital swelling, or signs of orbital involvement that could indicate complications 1

Determining Need for Antibiotics

Most cases of acute rhinosinusitis are viral and self-limited, even when bacterial—antibiotics should be reserved for specific clinical criteria 1:

Indications for Antibiotic Therapy:

• Persistent symptoms >10 days without improvement 1
• Severe symptoms: fever >39°C with purulent nasal discharge or facial pain for ≥3 consecutive days 1
• Worsening symptoms after initial improvement (double sickening pattern) 1

If Antibiotics NOT Indicated:

Her presentation with only one week of symptoms does not yet meet criteria for antibiotic therapy unless she has severe symptoms 1. The number needed to treat is 18 for one patient to benefit, while the number needed to harm from adverse effects is only 8 1.

Immediate Management Strategy

Symptomatic Treatment (First-Line):

• Analgesics for pain: Ibuprofen 400 mg every 4-6 hours as needed (maximum 3200 mg/day) 2
• Antipyretics for fever: Same ibuprofen dosing addresses both pain and fever 2
• Nasal saline irrigation: Helps clear secretions and reduce inflammation 1
• Systemic or topical decongestants: May provide symptomatic relief 1
• Intranasal corticosteroids: Can reduce inflammation 1

Important Considerations:

The gastrointestinal symptoms (nausea, vomiting, diarrhea) may limit oral medication tolerance 2. NSAIDs should be taken with food to minimize GI upset 2. Given her recent GI symptoms, ensure adequate hydration before starting NSAIDs 2.

When to Escalate Care

Immediate Ophthalmology Referral Required If:

• Periorbital swelling or erythema suggesting orbital involvement 3
• Visual changes or eye movement abnormalities 3
• Severe, unrelenting pain despite treatment 1
• Signs of systemic illness or sepsis 3

Consider Eyelid Pathology:

While less likely given the acute presentation with systemic illness, localized eyebrow pain could represent:

• Hordeolum (stye): Would present with localized eyelid swelling and tenderness 4, 3
• Blepharitis: Typically chronic with eyelid margin inflammation 5

If examination reveals eyelid involvement rather than sinus tenderness, initiate warm compresses 5-10 minutes, 3-4 times daily, with eyelid cleansing 4, 3, 5.

Follow-Up Plan

Reevaluate in 24-48 hours if symptoms worsen or fail to improve 1:

• If symptoms persist beyond 10 days total, reconsider antibiotic therapy 1
• If "double sickening" pattern emerges (improvement followed by worsening), initiate antibiotics 1
• If severe symptoms develop (high fever >39°C with purulent discharge for ≥3 days), start antibiotics 1

Common Pitfalls to Avoid

• Premature antibiotic prescription: Most acute rhinosinusitis is viral; antibiotics at day 7 are not yet indicated unless severe symptoms present 1
• Overlooking orbital complications: Frontal sinusitis can lead to serious complications—maintain high index of suspicion for periorbital involvement 1
• Ignoring medication timing: The patient took medication at 0400—clarify what was taken and ensure appropriate dosing intervals 2
• Missing alternative diagnoses: While sinusitis is most likely, consider dental causes, temporomandibular disorders, or rarely, malignancy in atypical presentations 1