A patient with nasal purulent discharge, eye pain, periorbital swelling, severe headache, frontal bone tenderness, and restricted extraocular movement (EOM), what is the most appropriate initial step?

Immediate Contrast-Enhanced CT Scan is Required

This patient requires an urgent contrast-enhanced CT scan of the orbits, paranasal sinuses, and brain before any other intervention, as the combination of restricted extraocular movements, severe headache, periorbital swelling, and frontal bone tenderness indicates complicated acute bacterial sinusitis with likely orbital and potential intracranial extension—life-threatening complications that mandate immediate imaging to guide surgical and medical management. 1, 2

Clinical Reasoning: Why This is a Surgical Emergency

Red Flags Present Indicating Complicated Sinusitis

This patient demonstrates multiple alarm features that distinguish complicated from uncomplicated acute rhinosinusitis:

• Restricted extraocular movements (ophthalmoplegia) is a cardinal sign of orbital cellulitis or orbital apex syndrome, indicating postseptal involvement with risk of permanent vision loss 1, 2
• Severe headache with frontal bone tenderness suggests frontal sinusitis with possible intracranial extension, the most common source of life-threatening complications including epidural abscess, subdural empyema, or meningitis 1
• Periorbital swelling with eye pain in the context of sinusitis indicates orbital involvement, which carries mortality risk if cavernous sinus thrombosis develops 1

Why Imaging Must Precede Treatment

Contrast-enhanced CT is the definitive initial imaging modality because it:

• Differentiates preseptal from postseptal (orbital) cellulitis with 97% accuracy for detecting complications 2, 3
• Identifies subperiosteal or orbital abscesses requiring urgent surgical drainage 1, 2
• Detects intracranial complications including epidural abscess, subdural empyema, cavernous sinus thrombosis, and brain abscess 1, 2
• Guides the decision between medical management alone versus combined medical-surgical intervention 1, 2, 4

Why the Other Options Are Incorrect

Oral Amoxicillin (Option A) is Dangerous

Starting oral antibiotics without imaging in this scenario is contraindicated because:

• Oral antibiotics are only appropriate for uncomplicated acute bacterial sinusitis or mild preseptal cellulitis with eyelid <50% closed and NO proptosis, NO restricted eye movements, and NO severe headache 1, 3, 5
• This patient has complicated sinusitis requiring immediate IV antibiotics, not oral therapy 1, 3
• Delaying imaging to trial oral antibiotics can allow progression to irreversible blindness, cavernous sinus thrombosis, or death 1, 2

Reassurance (Option C) is Negligent

Reassurance would be catastrophically inappropriate as:

• Restricted extraocular movements indicate established orbital involvement, not simple viral rhinosinusitis 1, 2
• Intracranial complications from frontal sinusitis have mortality rates of 5-10% even with treatment, and approach 100% without intervention 1

ENT Referral (Option D) is Premature

While ENT consultation will be necessary, referring without imaging first is incorrect because:

• The ENT surgeon requires CT imaging to plan surgical approach and determine urgency 1, 2, 4
• Imaging must be obtained emergently—waiting for ENT availability delays critical diagnostic information 2, 3
• The correct sequence is: CT scan → simultaneous ENT/ophthalmology/infectious disease consultation → IV antibiotics → surgical intervention if abscess present 1, 2, 3

Immediate Management Algorithm After CT

Once CT is obtained:

1. Start IV broad-spectrum antibiotics immediately covering Streptococcus pneumoniae, Staphylococcus aureus (including MRSA if risk factors present), Haemophilus influenzae, and anaerobes—typically vancomycin plus either high-dose ampicillin-sulbactam or ceftriaxone plus metronidazole 1, 3

2. Obtain urgent multidisciplinary consultation with ophthalmology, ENT, and infectious disease 1, 2, 3

3. Proceed to surgical drainage within 24 hours if CT demonstrates subperiosteal abscess, orbital abscess, or intracranial collection 1, 2, 4

4. Monitor visual acuity and extraocular movements every 4-6 hours as clinical deterioration despite antibiotics mandates surgical intervention even if initial CT showed only cellulitis without abscess 1, 4

Critical Pitfalls to Avoid

• Never delay CT imaging when restricted eye movements are present—this single finding indicates postseptal disease requiring immediate imaging 2, 3
• Do not assume improvement on antibiotics means surgery is unnecessary—37% of stage II (subperiosteal abscess) patients and 50% of stage III (orbital cellulitis) patients ultimately require surgery despite initial antibiotic therapy 4
• Consider invasive fungal sinusitis if the patient is immunocompromised (diabetes, chemotherapy, steroids)—this has 50-80% mortality and requires urgent surgical debridement plus antifungal therapy, not just antibiotics 1

Answer: B. Contrast enhanced CT scan