What are the possible diagnoses and next steps for a 23-year-old female patient with a 6-day history of dry cough, feeling of phlegm stuck in the back of the throat, glabellar area headache, thick green nasal discharge, undocumented fever, and hoarseness of voice, who was previously prescribed medication 5 days prior with no improvement, and now presents with itchiness in the throat and swollen non-erythematous nostrils obstructing 75% of the nasal passage?

Diagnosis and Management

This patient most likely has acute bacterial rhinosinusitis (ABRS) complicating an initial viral upper respiratory infection, and requires antibiotic therapy given the persistent purulent symptoms beyond 10 days without improvement. 1, 2

Primary Diagnosis: Acute Bacterial Rhinosinusitis

The clinical presentation strongly suggests ABRS based on the following criteria:

• Duration >10 days without improvement - The patient has had symptoms for 11 days total (6 days of current symptoms plus 5 days prior) with no resolution, meeting the key diagnostic threshold for bacterial superinfection 1, 2, 3

• Purulent nasal discharge - Thick green nasal discharge and ability to expectorate thick green phlegm indicate purulent secretions, a cardinal feature of bacterial sinusitis 1

• Facial pain/pressure - Glabellar area headache localizes to the frontal/ethmoid sinuses, consistent with sinusitis 1

• Postnasal drainage - The sensation of phlegm stuck in the back of the throat represents postnasal drip, a common manifestation of sinusitis 1

• Nasal obstruction - Physical examination showing 75% obstruction of nasal passages from swollen turbinates confirms significant sinus ostia compromise 1

The most common bacterial pathogens in this age group are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1

Secondary Diagnosis: Acute Laryngitis

• Hoarseness of voice - New-onset hoarseness indicates laryngeal involvement, likely viral laryngitis complicating the upper respiratory infection 2

• Throat itchiness and cough - These symptoms suggest laryngeal irritation from postnasal drainage and direct viral inflammation 2, 3

Differential Considerations (Less Likely)

Allergic rhinitis is less likely because:

• The acute onset following viral URI symptoms suggests infectious rather than allergic etiology 1
• Purulent discharge and fever are uncommon in allergic rhinitis 1
• Non-erythematous swollen turbinates could suggest allergy, but the overall clinical picture favors infection 1

Chronic rhinosinusitis is excluded by the short symptom duration (<8 weeks required for chronic diagnosis) 1

Immediate Next Steps

1. Initiate Antibiotic Therapy

Prescribe amoxicillin 500mg three times daily OR amoxicillin-clavulanate 875mg twice daily for 10 days 1, 4, 5

• Amoxicillin is first-line due to effectiveness against common pathogens, narrow spectrum, and cost-effectiveness 4, 5
• Consider amoxicillin-clavulanate if the patient has received antibiotics in the past 30 days or has risk factors for resistant organisms 1
• For penicillin allergy, use a respiratory fluoroquinolone (levofloxacin) or doxycycline 1

2. Symptomatic Management

Prescribe first-generation antihistamine/decongestant combination OR naproxen 220-440mg twice daily 3

• These provide symptomatic relief for nasal congestion and postnasal drainage 3
• Avoid newer non-sedating antihistamines as they are ineffective for URI-related cough 3
• Intranasal saline irrigation can help clear purulent secretions 1

3. No Imaging Required

Do not order CT or plain radiographs 1, 2

• Imaging is not recommended for uncomplicated acute bacterial sinusitis as it does not change management 1
• Up to 90% of viral URIs show CT evidence of sinus involvement that resolves without antibiotics 2, 3
• Reserve imaging for suspected complications (orbital or intracranial extension) or failure of appropriate antibiotic therapy 1

4. No Throat Culture or Rapid Strep Test Needed

Do not perform streptococcal testing 4, 6, 5

• The patient lacks features of streptococcal pharyngitis (no tonsillar exudate, no anterior cervical adenopathy documented) 4, 5
• Prominent nasal symptoms, cough, and hoarseness suggest viral laryngitis rather than bacterial pharyngitis 4, 6, 5

Red Flags Requiring Urgent Evaluation

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

• Severe unilateral facial pain with facial swelling - suggests complicated sinusitis with potential abscess formation 1, 3
• Visual changes, periorbital edema, or ophthalmoplegia - suggests orbital complications 1
• Severe headache, altered mental status, or neck stiffness - suggests intracranial complications (meningitis, epidural/subdural empyema, brain abscess) 1
• High fever >39°C persisting beyond 3 days of antibiotic therapy - suggests treatment failure or complications 2, 3

Follow-Up Plan

• Reassess in 3-5 days if symptoms worsen or fail to improve 2, 3
• Most patients show improvement within 48-72 hours of appropriate antibiotic therapy 1
• If no improvement after 72 hours, consider treatment failure and switch to broader-spectrum antibiotic (amoxicillin-clavulanate or respiratory fluoroquinolone) 1
• Complete the full 10-day antibiotic course even if symptoms resolve earlier 4, 5

Common Pitfalls to Avoid

• Do not dismiss purulent discharge as purely viral - while purulent secretions can occur with viral infections, persistence beyond 10 days without improvement indicates bacterial superinfection 2, 3
• Do not use azithromycin as first-line therapy - increasing resistance among S. pneumoniae makes macrolides suboptimal choices 1, 4
• Do not prescribe antibiotics for shorter than 10 days - inadequate duration increases treatment failure risk 4, 5