What is the best initial approach for a pediatric patient with a runny nose and Upper Respiratory Tract Infection (URTI) symptoms who develops frontal tenderness 3 days later?

Start Amoxicillin Immediately

For a pediatric patient with URTI symptoms who develops frontal tenderness 3 days later, you should start amoxicillin immediately without obtaining a CT scan. This presentation meets criteria for acute bacterial sinusitis with a "worsening course," which mandates antibiotic therapy. 1

Why This is Acute Bacterial Sinusitis

The development of new symptoms (frontal tenderness) after initial URTI symptoms defines a worsening course presentation of acute bacterial sinusitis, which is one of three diagnostic criteria established by the American Academy of Pediatrics. 2, 1

• Worsening course means new onset or worsening of symptoms (like frontal tenderness) after initial improvement or during the course of a typical viral URI 2
• This pattern distinguishes bacterial sinusitis from uncomplicated viral URI, where symptoms should peak by days 3-6 and then improve 2
• The 3-day timeline with new frontal symptoms is classic for bacterial superinfection 1

Why Frontal Sinusitis Specifically Requires Antibiotics

Frontal sinusitis demands definitive antibiotic treatment due to high complication risk. 1

• Frontal sinusitis in pediatric patients carries significant risk for intracranial complications including meningitis, epidural abscess, subdural abscess, and osteomyelitis 3
• The proximity of the frontal sinus to the dura and frontal bone marrow, plus rich communicating venous systems, facilitates intracranial extension 3
• French guidelines explicitly state that frontal, ethmoidal, or sphenoidal sinusitis definitively indicates antibiotic therapy 1
• Male adolescents appear particularly susceptible to complicated frontal sinusitis 4, 3

Why NOT to Order a CT Scan

Do not obtain imaging for diagnosis in uncomplicated cases. 1

• The American Academy of Pediatrics explicitly states that imaging studies of any kind should not be obtained for diagnosis of uncomplicated acute bacterial sinusitis 1
• CT scanning is reserved exclusively for suspected complications such as: 1
  • Periorbital or orbital swelling with proptosis
  • Impaired extraocular muscle function or visual changes
  • Severe headache with altered mental status
  • Signs of intracranial involvement
• Clinical criteria alone are sufficient for diagnosis in children presenting with worsening course 2, 1

Antibiotic Regimen

Start amoxicillin or amoxicillin-clavulanate immediately. 1

Standard dosing options: 1

• Standard-dose amoxicillin: 45 mg/kg/day divided every 8-12 hours
• High-dose amoxicillin-clavulanate: 90 mg/kg/day divided every 12 hours

When to use high-dose amoxicillin-clavulanate: 1

• Age younger than 2 years
• Daycare attendance
• Recent antibiotic exposure (within past 30 days)
• Geographic areas with high prevalence of resistant Streptococcus pneumoniae
• Severe symptoms at presentation
• Frontal sinusitis specifically (provides broader coverage) 1

Treatment duration: 1

• Treat for 10-14 days total
• Minimum of 10 days required
• Duration individualized based on clinical response

Why NOT Reassurance Alone

Reassurance alone (Option C) is inappropriate because:

• This patient has progressed beyond uncomplicated viral URI by developing new symptoms at day 3 2, 1
• The American Academy of Pediatrics explicitly recommends prescribing antibiotic therapy for children with worsening course presentation 1
• Frontal sinusitis carries high complication risk that cannot be managed conservatively 1, 3
• Untreated frontal sinusitis can lead to life-threatening intracranial complications 3

Why NOT Just Ibuprofen

Ibuprofen alone (Option D) is inadequate because:

• While symptomatic relief is reasonable, it does not address the bacterial infection 1
• Frontal sinusitis requires definitive antibiotic treatment, not just symptom management 1
• Delaying antibiotics in worsening course presentation increases complication risk 1, 3

Mandatory Reassessment

Reassess within 72 hours of starting antibiotics. 1

• If worsening symptoms or failure to improve, consider: 1
  • Changing to broader-spectrum antibiotic
  • Evaluating for complications requiring imaging
  • Possible intracranial extension requiring urgent CT scan

Critical Red Flags Requiring Immediate CT and Possible Hospitalization

Watch for these complications that mandate immediate imaging: 1, 3

• Periorbital edema or erythema
• Proptosis or displaced globe
• Impaired extraocular movements
• Reduced visual acuity
• Severe headache with altered mental status
• Neurologic changes
• Signs suggesting osteomyelitis or intracranial abscess