What is the next best management for a patient with symptoms of sinusitis, including frontal headache, fever, and nasal congestion, with a history of runny nose and sore throat, and tenderness over the left cheek?

Management of Acute Bacterial Sinusitis

This patient meets criteria for acute bacterial sinusitis and should be started on amoxicillin-clavulanate 875 mg/125 mg twice daily for 10 days. 1, 2

Clinical Reasoning

This patient presents with the classic triad indicating bacterial sinusitis requiring antibiotic therapy:

• Fever with purulent nasal discharge (progressed from initial runny nose) 1
• Facial pain/tenderness (left cheek tenderness on examination) 1
• Frontal headache suggesting sinus involvement 1

The 2-day progression from viral upper respiratory symptoms (runny nose, sore throat) to severe symptoms with fever and facial tenderness represents the "severe onset" pattern that warrants immediate antibiotic therapy rather than watchful waiting. 1, 2

Why Antibiotics Are Indicated Now

The American Academy of Allergy, Asthma, and Immunology explicitly states that appropriate criteria for antibiotic use include "severe symptoms of acute sinus infection, including fever with purulent nasal discharge, facial pain or tenderness." 1 This patient meets all three criteria, making antibiotics the correct next step rather than reassurance alone.

Why Amoxicillin-Clavulanate Over Plain Amoxicillin

While amoxicillin is often first-line for uncomplicated cases, amoxicillin-clavulanate is preferred when patients present with severe symptoms (fever, facial tenderness) because it provides coverage against β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis, which have become increasingly prevalent. 2, 3

The clavulanate component prevents these resistant organisms from "shielding" penicillin-susceptible pathogens, addressing both direct and indirect bacterial pathogenicity. 3

Why Not Imaging First

Radiographic imaging (orofacial X-ray) is not necessary for diagnosis in straightforward cases of acute sinusitis. 1 The diagnosis is made clinically based on history and physical examination findings. 1 Imaging should be reserved for:

• Suspected complications (orbital involvement, intracranial extension) 1
• Treatment failures after 21-28 days 1
• Recurrent sinusitis requiring evaluation of anatomic abnormalities 1

This patient has clear clinical signs without red flags requiring urgent imaging (no orbital swelling, diplopia, or neurologic signs). 1

Treatment Duration and Follow-up

Treatment should continue for 10-14 days, with reassessment at 3-5 days if no improvement occurs. 1, 2 Patients should be instructed to contact their provider if symptoms worsen (especially with increased headache or high fever) or fail to improve within 3-5 days. 1

Adjunctive Measures

While antibiotics are the cornerstone, recommend:

• Adequate hydration and rest 1
• Analgesics for pain (acetaminophen or NSAIDs) 2
• Warm facial packs and steamy showers 1
• Sleeping with head elevated 1
• Consider intranasal corticosteroids as adjunctive therapy to reduce inflammation 1, 2

Critical Pitfall to Avoid

Do not delay antibiotic therapy in patients with severe symptoms. The presence of fever, purulent discharge, and facial tenderness distinguishes this from viral rhinosinusitis that might resolve spontaneously. 1 Delaying treatment in bacterial sinusitis risks progression to complications including orbital or intracranial infection. 4

Alternative for Penicillin Allergy

If this patient had documented penicillin allergy, second-generation cephalosporins (cefuroxime) or third-generation cephalosporins (cefpodoxime, cefdinir) would be appropriate alternatives, as the cross-reactivity risk is negligible. 2

Answer: C - Amoxicillin-clavulanate for 10 days