What is the best course of action for a patient with a sinus infection, currently being treated with Levaquin (levofloxacin), who is now experiencing facial numbness and jaw swelling?

Discontinue Levaquin Immediately and Evaluate for Serious Complications

This patient requires immediate discontinuation of levofloxacin and urgent evaluation for complicated sinusitis with potential orbital or intracranial extension, as facial numbness and jaw swelling are red flags for serious complications that can lead to permanent neurological damage or life-threatening infection spread. 1

Immediate Actions Required

1. Stop Levofloxacin Now

• The FDA explicitly warns that levofloxacin must be discontinued immediately if peripheral neuropathy symptoms develop, including numbness, pain, burning, tingling, or weakness, as nerve damage may be permanent. 2
• Facial numbness represents peripheral neuropathy affecting cranial nerves, which is a serious adverse effect requiring immediate drug cessation 2
• The FDA states that peripheral neuropathy symptoms may occur soon after initiation and can be irreversible 2

2. Urgent Clinical Evaluation for Complicated Sinusitis

• Facial swelling in the context of sinusitis is a complication warning sign that requires urgent evaluation for orbital cellulitis, cavernous sinus thrombosis, or intracranial extension. 1
• The American Academy of Allergy, Asthma, and Immunology explicitly states that patients with facial swelling-erythema over an involved sinus, visual changes, abnormal extraocular movements, proptosis, periorbital inflammation-edema-erythema, or any suggestion of intracranial or central nervous system involvement require immediate assessment 1
• Facial numbness suggests potential cranial nerve involvement (trigeminal nerve V2/V3 distribution), which can occur with sphenoid or ethmoid sinusitis extending to the cavernous sinus or orbital apex 1

Diagnostic Workup Needed

Imaging Studies

• Obtain urgent CT scan of the sinuses with contrast to evaluate for complicated sinusitis, orbital involvement, or intracranial extension. 1
• The American Academy of Otolaryngology-Head and Neck Surgery recommends imaging when complications are suspected, including severe headache, proptosis, cranial nerve palsies, or facial swelling 1
• MRI with contrast may be needed if intracranial extension or cavernous sinus thrombosis is suspected 1

Physical Examination Focus

• Assess extraocular movements for cranial nerve VI palsy (suggests cavernous sinus involvement) 1
• Check for proptosis, periorbital edema, or visual changes (orbital cellulitis/abscess) 1
• Evaluate for meningeal signs (nuchal rigidity, photophobia) suggesting intracranial extension 1
• Document the exact distribution of facial numbness (V2 maxillary vs V3 mandibular nerve territories) 1

Alternative Antibiotic Management

If Complicated Sinusitis is Confirmed

• Switch to high-dose amoxicillin-clavulanate 875 mg/125 mg twice daily or 2 g IV every 6-8 hours for complicated infections requiring broader coverage including anaerobes. 3
• For severe complications with orbital or intracranial involvement, consider IV therapy with ampicillin-sulbactam or piperacillin-tazobactam plus vancomycin (for MRSA coverage) 3
• Duration should be extended to 14-21 days for complicated sinusitis 1

If Uncomplicated Sinusitis with Drug Reaction Only

• Switch to a second-generation cephalosporin (cefuroxime-axetil) or third-generation cephalosporin (cefpodoxime-proxetil or cefdinir) to complete the antibiotic course. 4
• Avoid all fluoroquinolones in this patient given the serious adverse reaction 2

Critical Pitfalls to Avoid

• Never continue levofloxacin once peripheral neuropathy symptoms develop—the FDA is explicit that nerve damage may be permanent and irreversible. 2
• Do not assume this is simple sinusitis—facial swelling and numbness are complication warning signs requiring imaging and possible hospitalization. 1
• Do not switch to another fluoroquinolone (moxifloxacin, ciprofloxacin)—the entire class carries the same peripheral neuropathy risk. 2
• Do not delay imaging if any "red flag" features are present—complications like cavernous sinus thrombosis or orbital abscess require immediate intervention to prevent permanent vision loss or death. 1

Monitoring and Follow-up

• Reassess within 24-48 hours after antibiotic switch to ensure clinical improvement 4
• If facial numbness persists or worsens despite stopping levofloxacin, consider neurology consultation for formal cranial nerve assessment 2
• If imaging reveals complications, immediate ENT or neurosurgery consultation is required for possible surgical drainage 1