What is the most appropriate initial step for a patient with nasal purulent discharge, eye pain, periorbital swelling, severe headache, frontal bone tenderness, and restricted Extraocular Movement (EOM)?

Immediate Contrast-Enhanced CT Scan is Required

This patient requires immediate hospitalization and urgent contrast-enhanced CT imaging—oral antibiotics and reassurance are contraindicated, and ENT referral should occur after imaging confirms the diagnosis and guides surgical planning. 1

Clinical Presentation Indicates Complicated Sinusitis with Orbital Involvement

This constellation of symptoms represents orbital cellulitis with frontal bone involvement, a medical emergency requiring immediate action:

• Nasal purulent discharge indicates acute bacterial rhinosinusitis 2
• Eye pain, periorbital swelling, and restricted extraocular movements indicate postseptal orbital involvement, distinguishing this from simple preseptal cellulitis 1, 3
• Severe headache with frontal bone tenderness raises concern for Pott's puffy tumor (frontal bone osteomyelitis) or intracranial extension 1
• The combination of these findings mandates urgent imaging due to risk of permanent blindness, intracranial abscess, meningitis, cavernous sinus thrombosis, and death 1

Why Contrast-Enhanced CT is the Correct Answer

The American College of Radiology recommends contrast-enhanced CT of the paranasal sinuses, orbits, and head as the initial imaging modality in the emergent setting to evaluate for:

• Subperiosteal abscess 1, 2
• Orbital abscess 1, 2
• Frontal bone osteomyelitis 1
• Intracranial extension 1, 2
• Bone erosion and sinus involvement 1

CT with IV contrast is superior to non-contrast CT because it effectively delineates extra-sinus extension and abscess formation, which are critical for surgical planning 2, 1.

Why the Other Options are Incorrect

Option A: Oral Amoxicillin is Dangerous

• Oral antibiotics alone are contraindicated when proptosis, impaired extraocular movements, or severe periorbital pain and swelling are present 1
• This patient requires immediate IV vancomycin combined with a third-generation cephalosporin (ceftriaxone or cefotaxime) to cover methicillin-resistant Staphylococcus aureus and typical pathogens 1
• Outpatient management with oral antibiotics would be appropriate only for uncomplicated acute bacterial rhinosinusitis without orbital involvement 4, which this patient clearly does not have

Option C: Reassurance is Negligent

• The American Academy of Otolaryngology explicitly identifies periorbital swelling, proptosis, and impaired extraocular movements as critical red flags requiring hospitalization and IV antibiotics 4
• Reassurance would be appropriate only for viral rhinosinusitis lasting less than 10 days without complications 2
• This patient has complicated sinusitis with orbital and possible intracranial involvement—reassurance risks catastrophic outcomes including blindness and death 1

Option D: ENT Referral Comes After Imaging

• While ENT consultation is absolutely necessary, imaging must be obtained first to guide surgical decision-making 1
• The American Academy of Pediatrics recommends obtaining ophthalmology consultation immediately to assess visual acuity and monitor for vision-threatening complications, otolaryngology for surgical guidance, infectious disease for antimicrobial management, and neurosurgery urgently given the frontal bone involvement 1
• However, contrast-enhanced CT must be performed before surgical consultation to determine the extent of disease and need for drainage 1, 2

Critical Management Algorithm After CT

Once imaging is obtained:

• Immediate hospitalization is mandatory 1
• IV vancomycin plus third-generation cephalosporin should be started immediately 1
• Ophthalmology consultation to assess visual acuity and extraocular movements 1
• Otolaryngology consultation for surgical planning—drainage is indicated if subperiosteal or orbital abscess is identified, or if the patient fails to improve within 24-48 hours on IV antibiotics 1
• Neurosurgical consultation given frontal bone tenderness suggesting possible Pott's puffy tumor 1
• MRI with contrast should be considered if CT suggests intracranial complications, as MRI provides superior soft-tissue resolution for detecting epidural abscess, subdural abscess, brain abscess, venous thrombosis, or meningitis 1, 3

Common Pitfalls to Avoid

• Never delay imaging while waiting for specialist consultation when intracranial complications are suspected 1
• Do not obtain plain radiographs—they are insufficient to detect orbital pathology and have been supplanted by CT 1, 2
• Do not use oral antibiotics alone for complicated sinusitis with orbital involvement—IV therapy is mandatory 1
• Monitor for signs of intracranial extension including altered mental status, severe headache, or neurologic deficits, and assess response to therapy within 24-48 hours 1