What is the most appropriate next step for a pediatric boy with fever, headache, severe periorbital (around the eye) pain and swelling, and purulent (containing pus) nasal discharge, who had a recent history of a clear runny nose and low-grade fever that resolved?

Immediate Hospitalization with CT Imaging and IV Antibiotics

This child requires immediate hospitalization for contrast-enhanced CT scan of the head, orbits, and sinuses, followed by urgent initiation of broad-spectrum IV antibiotics including vancomycin—this is a medical emergency with potential for permanent blindness or death if not treated promptly. 1, 2

Why This is a Complication, Not Simple Sinusitis

This clinical presentation represents complicated acute bacterial sinusitis with orbital involvement, not uncomplicated sinusitis:

• Severe periorbital pain and swelling in the context of purulent nasal discharge indicates progression beyond simple sinusitis to orbital complications 1
• The biphasic illness pattern (initial viral URI that resolved, followed by worsening with fever and purulent discharge) meets criteria for acute bacterial sinusitis, but the severe periorbital findings indicate complication 1
• Fever with severe periorbital symptoms raises immediate concern for preseptal or postseptal (orbital) cellulitis, which can rapidly progress to vision-threatening complications 1, 2

Critical Red Flags Present in This Case

The American Academy of Pediatrics explicitly states that complications should be suspected when a child develops signs of orbital involvement, and that these complications can result in permanent blindness, neurologic sequelae, or death if not treated promptly 1:

• Severe periorbital pain and swelling = potential orbital cellulitis (preseptal vs. postseptal must be determined) 1, 2
• High fever = systemic involvement suggesting complicated infection 1
• Purulent nasal discharge = bacterial sinusitis, likely ethmoiditis given the orbital symptoms 1

Immediate Management Algorithm

Step 1: Hospitalize Immediately

• Do not attempt outpatient management with oral antibiotics—this is inadequate for this severity of infection 2, 3
• The child must be admitted for IV antibiotics and imaging 1, 2

Step 2: Obtain Contrast-Enhanced CT Scan

• CT with contrast of the head, orbits, and sinuses is essential to confirm intracranial or intraorbital suppurative complications 1, 2
• Alternatively, MRI may be performed to evaluate for cavernous sinus thrombosis, venous thrombosis, brain abscess, or meningitis 1, 2
• Imaging is mandatory before any surgical intervention but should not delay initiation of IV antibiotics 2

Step 3: Start IV Antibiotics Immediately

• Vancomycin must be included for MRSA coverage, particularly for intraorbital complications 1, 2
• Add a third-generation cephalosporin (ceftriaxone or cefotaxime) for comprehensive coverage of S. pneumoniae, H. influenzae, and M. catarrhalis 2
• Do not wait for imaging or culture results to start antibiotics 2

Step 4: Urgent Multidisciplinary Consultation

Immediate consultation is required with 1, 2:

• Otolaryngology for assessment and potential surgical drainage
• Ophthalmology for evaluation of visual acuity, extraocular movements, and proptosis
• Infectious disease for antibiotic selection and duration
• Neurosurgery if intracranial complications are confirmed on imaging

Why Each Answer Choice is Wrong or Right

A) Start Antibiotics - INCORRECT

• Oral antibiotics alone are inadequate for complicated sinusitis with orbital involvement 2, 3
• This child needs IV vancomycin, not oral amoxicillin-clavulanate 1, 2
• Starting oral antibiotics without imaging and hospitalization risks progression to blindness or intracranial complications 1, 2

B) Refer to ENT Outpatient Clinic - INCORRECT

• Outpatient referral is dangerous and delays life-saving treatment 1, 2
• This is a medical emergency requiring immediate hospitalization 1, 2
• Orbital and intracranial complications can progress rapidly within hours 1

C) CT Scan with Contrast - CORRECT

• This is the correct first step after immediate hospitalization 1, 2
• The American Academy of Pediatrics explicitly recommends contrast-enhanced CT when proptosis, impaired visual acuity, or impaired/painful extraocular mobility is present 1
• However, IV antibiotics should be started immediately upon hospital admission, even before imaging is obtained 2

Common Pitfalls to Avoid

• Do not treat this as uncomplicated sinusitis with oral antibiotics—the severe periorbital findings indicate complication 1, 2, 3
• Do not delay hospitalization for outpatient imaging or ENT referral 1, 2
• Do not wait for imaging results to start IV antibiotics—start vancomycin and ceftriaxone immediately upon admission 2
• Do not assume preseptal cellulitis is safe to treat outpatient when there is severe pain, high fever, or any concern for orbital involvement 2, 3

Assessment for Orbital vs. Intracranial Extension

Once hospitalized, the clinical team must assess for 1, 2:

• Proptosis (eye bulging forward)
• Impaired or painful extraocular movements
• Decreased visual acuity
• Ophthalmoplegia (paralysis of eye muscles)
• Altered mental status, severe headache, or neck rigidity (suggests intracranial extension)

Any of these findings confirms postseptal (orbital) or intracranial involvement and may require urgent surgical drainage in addition to IV antibiotics 1, 2.