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

Immediate Contrast-Enhanced CT Scan is Required

This patient requires an urgent contrast-enhanced CT scan of the maxillofacial region/orbits before any other intervention, as the clinical presentation strongly suggests complicated acute bacterial rhinosinusitis with orbital and potentially intracranial extension. 1, 2

Clinical Reasoning

This patient presents with the classic triad indicating complicated sinusitis:

• Orbital involvement: Eye pain, periorbital swelling, and restricted extraocular movements indicate postseptal (orbital) cellulitis or subperiosteal abscess 3, 1, 2
• Severe frontal involvement: Frontal bone tenderness with severe headache suggests frontal sinusitis with potential intracranial extension 3, 1
• Purulent nasal discharge: Confirms active bacterial infection 3

The presence of restricted extraocular movements is particularly concerning, as this indicates true orbital cellulitis rather than simple preseptal cellulitis and carries risk of vision-threatening complications including blindness, cavernous sinus thrombosis, meningitis, or brain abscess if not treated promptly. 3, 2

Why CT with Contrast is the Priority

Imaging Protocol

• CT maxillofacial with IV contrast is the first-line imaging examination recommended by the American College of Radiology for suspected intraorbital and intracranial complications 3, 1
• This modality provides excellent visualization of both bony sinus anatomy and soft tissue complications, with 87% diagnostic accuracy for detecting intracranial complications 1
• The contrast enhancement is essential to identify abscess formation, superior ophthalmic vein thrombosis, cavernous sinus thrombosis, or subdural empyema 2

Why Not the Other Options

Oral amoxicillin (Option A) is inappropriate because:

• This patient has signs of complicated sinusitis requiring IV antibiotics, not oral therapy 3, 1
• Treatment should only begin AFTER imaging confirms the extent of disease 1
• Orbital complications require hospitalization with broad-spectrum IV antibiotics 3, 2

Reassurance (Option C) is dangerous because:

• Restricted extraocular movements indicate serious orbital involvement that can progress to permanent blindness or death 3, 2
• Failure to recognize intracranial extension can result in cavernous sinus thrombosis, meningitis, or brain abscess 2

ENT referral (Option D) should occur simultaneously with imaging, not instead of it because:

• Imaging must be obtained urgently to guide surgical decision-making 1
• The American College of Radiology guidelines emphasize simultaneous consultation with otolaryngology and ophthalmology while awaiting imaging 1
• Delaying CT when proptosis, visual changes, or ophthalmoplegia are present is a critical pitfall 2

Immediate Management Algorithm

1. Order urgent CT maxillofacial with IV contrast immediately 1, 2
2. Simultaneously consult otolaryngology and ophthalmology while awaiting imaging 1
3. After imaging, initiate broad-spectrum IV antibiotics (such as amoxicillin-clavulanate 1.5-3.0g IV every 6 hours or vancomycin plus clindamycin for MRSA coverage) 1, 2
4. Admit to hospital for close monitoring of visual function and extraocular movements 3, 2

Critical Pitfalls to Avoid

• Never delay imaging when restricted extraocular movements are present - this is a red flag for orbital cellulitis requiring urgent evaluation 2, 4
• Do not start antibiotics before imaging in stable patients - imaging should guide the treatment approach and surgical planning 1
• Do not assume this is simple sinusitis - frontal bone tenderness with severe headache suggests potential intracranial complications requiring immediate assessment 3, 1