What is the diagnosis and recommended treatment for a patient with a 3-day history of right-side sinus congestion, runny nose, nasal drainage, and right eye redness with sensitivity to light, who recently traveled and has not improved with over-the-counter (OTC) medications, presenting with greenish and white mucus discharge, erythematous oropharynx, and right eye erythema?

Diagnosis and Management

This patient has acute bacterial rhinosinusitis (ABRS) and should be started on amoxicillin 500mg three times daily for 10-14 days, as the combination of purulent nasal discharge, photophobia with conjunctival injection, and symptoms persisting for 3 days meets criteria for bacterial superinfection. 1, 2

Clinical Diagnosis

The presentation strongly suggests ABRS based on several key features:

• Purulent nasal discharge (greenish mucus in one nare) combined with unilateral symptoms (right-sided congestion) and conjunctival erythema with photophobia indicates bacterial infection rather than simple viral URI 3, 2
• The failure to improve with OTC medications after 3 days of symptoms, while brief, combined with purulent features suggests progression from viral to bacterial infection 3, 1
• Erythematous oropharynx with cobblestoning indicates postnasal drainage from infected sinuses 3
• The right eye findings (erythema, photophobia without discharge) likely represent reactive conjunctivitis from adjacent sinus inflammation rather than primary conjunctivitis, given the unilateral nature matching the affected sinus side 3

Why Antibiotics Are Indicated Now

While guidelines typically recommend waiting 10 days for persistent symptoms, this patient meets alternative criteria for immediate antibiotic therapy:

• Purulent nasal discharge with localized symptoms (unilateral sinus congestion, ipsilateral eye involvement) suggests bacterial rather than viral etiology 3
• The combination of purulent rhinorrhea and facial/periorbital symptoms are key indicators that correlate with bacterial disease 2
• Failure of symptomatic treatment after 3 days with purulent features warrants antibiotic consideration rather than continued observation 3, 1

First-Line Treatment

Amoxicillin is the appropriate first-line antibiotic:

• Dosing: 500mg three times daily (or high-dose 875mg twice daily) for 10-14 days 1, 2, 4
• Rationale: Amoxicillin is effective against the most common pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), is inexpensive, and well-tolerated 1, 5, 6
• Expected response: Patient should improve within 3-5 days 1, 2

Adjunctive Symptomatic Management

In addition to antibiotics, provide symptomatic relief:

• Intranasal corticosteroids (e.g., fluticasone, mometasone) to reduce mucosal inflammation and promote drainage 3, 2
• Saline nasal irrigation to help clear secretions 2, 4
• Analgesics (acetaminophen or ibuprofen) for pain management 1, 4
• Oral decongestants (pseudoephedrine) may provide additional symptomatic benefit, though evidence is limited 3, 2

Follow-Up and Treatment Failure

Reassess in 3-5 days:

• If no improvement or worsening, switch to amoxicillin-clavulanate 875mg/125mg twice daily or high-dose formulation (2000mg/125mg twice daily) to cover beta-lactamase producing organisms 1, 2, 5
• Alternative second-line agents include cefuroxime, cefpodoxime, or respiratory fluoroquinolones (levofloxacin, moxifloxacin) 3, 5, 6
• For penicillin allergy: Use respiratory fluoroquinolones or azithromycin, though macrolide resistance is increasing 1, 5, 6

Critical Red Flags to Monitor

Instruct the patient to return immediately if any of these develop:

• Orbital complications: Worsening eye pain, diplopia, vision changes, proptosis, or periorbital swelling 3
• Intracranial extension: Severe headache, altered mental status, focal neurologic signs, or high fever 3, 4
• Frontal bone swelling (Pott's puffy tumor) 3

These complications, while uncommon, can cause significant morbidity and mortality and require urgent imaging (CT) and possible hospitalization 3, 4

Imaging Not Indicated

Do not obtain imaging (plain films or CT) at this time:

• Imaging is not recommended for uncomplicated acute sinusitis as it does not change management and has high false-positive rates 3, 2, 4
• Up to 87% of healthy individuals recovering from viral URIs show sinus abnormalities on imaging 3
• Reserve CT for suspected complications, treatment failure after 21-28 days, or recurrent/chronic sinusitis requiring anatomic evaluation 1, 4

Patient Education

• Complete the full antibiotic course even if symptoms improve earlier 1, 2
• Expect improvement within 3-5 days; if not improving or worsening, return for reassessment 1, 2
• Return immediately for any warning signs of complications (vision changes, severe headache, eye swelling, mental status changes) 3