What is the appropriate treatment for a patient presenting with frontal sinus tenderness, yellow nasal discharge, and inflamed tonsils?

Treatment for Frontal Sinusitis with Purulent Discharge and Tonsillar Inflammation

For a patient presenting with frontal sinus tenderness, yellow nasal discharge, and inflamed tonsils, start a respiratory fluoroquinolone (levofloxacin 500-750 mg daily or moxifloxacin 400 mg daily) for 7-10 days, as frontal sinusitis requires aggressive initial treatment due to high risk of life-threatening intracranial complications. 1

Why Frontal Sinusitis Demands Aggressive Treatment

Frontal sinusitis is fundamentally different from maxillary sinusitis and requires immediate escalation to fluoroquinolones rather than standard first-line agents. 1 The frontal sinus location creates risk for serious complications including meningitis, subdural empyema, brain abscess, and frontal bone osteomyelitis. 1 Respiratory fluoroquinolones provide superior penetration into sinus tissues and adequate coverage against Streptococcus pneumoniae, the primary pathogen. 1

Specific Antibiotic Recommendations

• Levofloxacin 500-750 mg once daily for 7-10 days is the preferred first-line option 1
• Moxifloxacin 400 mg once daily for 7-10 days provides equivalent coverage 1
• Standard first-line agents like amoxicillin-clavulanate are explicitly not recommended for frontal sinusitis due to inadequate tissue penetration and the severity of potential complications 2, 1

Essential Adjunctive Therapies

Add intranasal corticosteroids immediately (mometasone, fluticasone, or budesonide twice daily) to reduce mucosal inflammation and improve drainage. 2, 3 This is supported by strong evidence from multiple randomized controlled trials showing improved symptom resolution. 3

Short-course oral corticosteroids may be beneficial for acute hyperalgic frontal sinusitis (severe pain), typically 4 mg dexamethasone for 5 days when combined with appropriate antibiotic therapy. 2, 3

Supportive measures include:

• Analgesics (acetaminophen or ibuprofen) for pain and fever 2, 1
• Warm facial packs applied to the forehead 2, 1
• Adequate hydration to thin secretions 2, 1
• Sleeping with head elevated to promote drainage 2, 1
• Saline nasal irrigation for symptomatic relief 2, 4

Addressing the Tonsillar Inflammation

The inflamed tonsils suggest concurrent pharyngitis, which may be viral (associated with the sinusitis) or bacterial (streptococcal). 2 However, do not delay sinusitis treatment to address the tonsils separately—the fluoroquinolone will provide adequate coverage for both conditions if bacterial pharyngitis is present. 2 If streptococcal pharyngitis is strongly suspected based on Centor criteria, consider adding a throat culture, but proceed with fluoroquinolone therapy regardless. 2

Critical Reassessment Timeline

Reassess at 3-5 days: If no clinical improvement (reduction in fever, facial pain, purulent discharge), obtain CT imaging of sinuses and consider ENT referral immediately. 1 Frontal sinusitis that fails to respond warrants urgent specialist evaluation. 1

At 7 days: If symptoms persist despite initial improvement, continue antibiotics to complete the full 10-day course, as frontal sinusitis may require longer treatment than maxillary sinusitis. 2, 1

Red Flags Requiring Immediate Hospitalization

Seek immediate hospitalization and neurosurgery/ENT consultation if any of the following develop:

• Neurological signs (altered mental status, focal deficits) 1
• Visual disturbances or eye movement abnormalities 2, 1
• Signs of meningeal irritation (severe headache, neck stiffness, photophobia) 2, 1
• Palpebral edema or exophthalmos 2
• Severe unrelenting headache preventing sleep 2

These indicate potential intracranial extension requiring IV antibiotics and possible surgical drainage. 1

Common Pitfalls to Avoid

Do not use amoxicillin or amoxicillin-clavulanate as first-line therapy for frontal sinusitis—these are appropriate only for maxillary sinusitis. 2, 1 Frontal sinusitis requires fluoroquinolones from the outset due to complication risk. 1

Do not use topical decongestants beyond 3 days to prevent rhinitis medicamentosa (rebound congestion). 4, 5

Do not prescribe NSAIDs at anti-inflammatory doses as adjunctive therapy—their efficacy has not been demonstrated in sinusitis. 2

Ensure the full 7-10 day antibiotic course is completed even after symptoms improve, as inadequate treatment duration can lead to relapse or progression to chronic sinusitis. 2, 1