What is the possible diagnosis and next steps for a 10-year-old male patient with a 1-week history of progressive respiratory symptoms, including dry cough, thick green nasal discharge, and productive cough, who has not responded to Ascoff Lagundi (with Lagundi, a herbal extract), and has a physical examination showing a swollen right nostril, fissures along the rim of the nostrils, and swollen tonsils?

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Acute Bacterial Rhinosinusitis

This 10-year-old boy meets diagnostic criteria for acute bacterial sinusitis and should be started on amoxicillin 45 mg/kg/day for 10 days, with reassessment in 72 hours if symptoms worsen or fail to improve. 1, 2

Diagnostic Reasoning

This patient fulfills the persistent illness criterion for acute bacterial sinusitis: 1, 2

  • Nasal discharge (thick green) and cough lasting >10 days (1 week total duration) without improvement
  • The progression from dry cough to thick green nasal discharge to productive cough over 7 days indicates bacterial superinfection rather than simple viral URI 1

The American Academy of Pediatrics defines three diagnostic patterns for bacterial sinusitis in children: 1

  • Persistent symptoms: nasal discharge or daytime cough >10 days without improvement (this patient)
  • Severe onset: fever ≥39°C for ≥3 consecutive days with purulent discharge (not present here)
  • Worsening course: initial improvement followed by new fever or increased symptoms (not present here)

The physical examination findings support upper airway inflammation: 1, 2

  • Swollen right nostril with 25% obstruction
  • Nasal fissures (indicating chronic irritation/discharge)
  • Swollen tonsils (consistent with postnasal drainage)

Treatment Plan

Immediate Management

Start amoxicillin at 45 mg/kg/day divided twice daily for 10 days. 1, 2 This provides optimal coverage for Streptococcus pneumoniae, the most common bacterial pathogen. 2, 3

Do NOT prescribe: 2

  • Intranasal steroids (no benefit in acute bacterial sinusitis)
  • Systemic steroids
  • Antihistamines (ineffective for bacterial sinusitis)
  • Decongestants

Supportive care: 2

  • High-volume saline nasal irrigation for mucociliary clearance
  • Analgesics (acetaminophen or ibuprofen) for discomfort

When to Use High-Dose Amoxicillin-Clavulanate

Consider amoxicillin-clavulanate 90 mg/kg/day (of amoxicillin component) if: 2

  • Recent antibiotic use within past 30 days
  • Daycare attendance
  • Age <2 years
  • Geographic area with high antibiotic resistance

This patient has no documented risk factors, so standard amoxicillin is appropriate first-line. 2

Reassessment Strategy

Reassess at 72 hours for: 1

  • Worsening symptoms (increased fever, discharge, or cough)
  • Failure to improve

If no improvement or worsening at 72 hours: 1

  • Switch to high-dose amoxicillin-clavulanate
  • Consider imaging only if complications suspected (orbital symptoms, severe headache, neurologic signs)

What NOT to Do

Do not obtain imaging studies (X-ray or CT) for uncomplicated acute bacterial sinusitis. 1 Imaging does not distinguish viral from bacterial infection and increases costs 4-fold without improving outcomes. 1

Do not diagnose bacterial sinusitis during the first week of URI symptoms unless severe criteria are met (high fever ≥39°C for ≥3 days with purulent discharge). 1 This patient is at day 7, meeting the >10 day threshold for persistent symptoms. 1

Alternative Consideration: Observation Option

The AAP guidelines allow for observation for 3 additional days before starting antibiotics in children with persistent symptoms (not severe or worsening). 1, 2 However, given this patient already has 7 days of symptoms with thick green discharge and productive cough, immediate antibiotic therapy is more appropriate than further observation. 1, 2

Red Flags Requiring Urgent Referral

Refer immediately to ENT or emergency department if: 4

  • Periorbital edema or erythema
  • Visual changes or proptosis
  • Severe headache or altered mental status
  • Focal neurologic signs
  • These indicate potential orbital or intracranial complications requiring imaging and possible surgical intervention 4

Follow-Up

If symptoms persist beyond 4 weeks despite appropriate antibiotic therapy, consider: 4

  • ENT referral for nasal endoscopy
  • Evaluation for chronic rhinosinusitis
  • Assessment for underlying conditions (immunodeficiency, anatomic abnormalities, cystic fibrosis if nasal polyps present) 1, 4

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Management of Orange/Yellow Nasal Discharge in Children

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Upper respiratory tract infections.

Indian journal of pediatrics, 2001

Guideline

Chronic Rhinosinusitis with Bacterial Superinfection

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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