What is the most appropriate next step in management for a patient with worsening symptoms of foul-smelling breath, nasal congestion, and facial tenderness after 14 days, despite multiple courses of antibiotics?

Nasal Endoscopy in Clinic

For a patient with worsening sinusitis symptoms after 14 days despite multiple courses of antibiotics, nasal endoscopy in clinic is the most appropriate next step in management. 1, 2

Rationale for Nasal Endoscopy

This patient has failed multiple antibiotic courses, which indicates treatment-refractory disease requiring direct visualization rather than additional empiric therapy. The IDSA guidelines explicitly state that patients who continue to deteriorate clinically despite extended courses of antimicrobial therapy should be referred to a specialist for consultation, and nasal endoscopy is the most appropriate diagnostic tool in this setting. 1, 2

Nasal endoscopy provides critical diagnostic information that cannot be obtained through imaging or additional antibiotics:

• Direct visualization of the middle meatus identifies purulent drainage, anatomic obstruction, nasal polyps, or fungal debris that explain antibiotic failure 2
• Allows endoscopically-guided cultures from the middle meatus to identify resistant organisms (Pseudomonas, MRSA, anaerobes) or unusual pathogens (fungi) causing treatment failure 1, 2
• Detects complications such as orbital cellulitis or intracranial extension that would require urgent intervention 2
• Identifies non-infectious causes including chronic rhinosinusitis with nasal polyps (CRSwNP), fungal sinusitis, or anatomic variants that require different management strategies 2, 3

Why Not Antibiotics?

Additional empiric antibiotic therapy is inappropriate at this stage. 2, 3 The patient has already failed multiple courses of antibiotics, and prescribing more antibiotics without objective evidence of the underlying pathology contributes to antimicrobial resistance and delays appropriate diagnosis. 3 The IDSA guidelines recommend obtaining cultures by direct sinus aspiration or endoscopically-guided sampling in patients who have failed empiric therapy, not continuing blind antibiotic treatment. 1

Why Not Sinus Radiography?

Plain sinus radiographs are explicitly not recommended in this clinical scenario. 2, 3 The American Academy of Otolaryngology-Head and Neck Surgery guidelines state that plain sinus radiographs provide inadequate diagnostic information and have been supplanted by CT and endoscopy. 2 Plain radiographs have significant false-positive and false-negative results and are not necessary for diagnosing acute sinusitis. 3, 4 If imaging is ultimately needed after endoscopy, CT scanning is the imaging modality of choice, not plain X-rays. 1, 3

Clinical Significance of Foul-Smelling Breath

The presence of foul-smelling breath in this patient suggests anaerobic infection or a dental source, which may require culture-directed antibiotics targeting anaerobes or dental evaluation. 3 This further supports the need for endoscopy with culture rather than empiric therapy.

Next Steps After Endoscopy

If purulent drainage is visualized:

• Obtain endoscopically-guided culture and adjust antibiotics based on sensitivities 2
• Target resistant organisms identified on culture 2

If anatomic obstruction is identified:

• Refer for functional endoscopic sinus surgery (FESS) 2

If fungal infection is suspected:

• Obtain CT imaging and consider antifungal therapy or surgical debridement 2

If chronic rhinosinusitis is confirmed:

• Initiate high-dose intranasal corticosteroids and daily saline irrigation rather than prolonged antibiotics 2

Critical Pitfalls to Avoid

• Do not continue empiric antibiotics in patients who have failed multiple courses without investigating the underlying cause 2, 3
• Do not rely on symptom duration alone - treatment failures require direct visualization 3
• Nasopharyngeal cultures are unreliable and do not correlate with actual sinus pathogens; they should not be used for microbiologic diagnosis 1, 2