A 7-year-old child with 12 days of purulent nasal discharge, low-grade fever, daytime cough, frontal sinus tenderness, and no orbital signs—what is the appropriate next step in management?

Oral Amoxicillin is the Appropriate Next Step

This 7-year-old child meets clinical criteria for acute bacterial sinusitis and should be treated with oral amoxicillin as first-line antibiotic therapy. 1

Clinical Diagnosis of Acute Bacterial Sinusitis

This child fulfills the American Academy of Pediatrics criteria for persistent acute bacterial sinusitis, characterized by:

• Purulent nasal discharge persisting for 12 days (>10 days without improvement) 1
• Daytime cough accompanying the nasal discharge 1
• Low-grade fever 1

The diagnosis of acute bacterial sinusitis is entirely clinical and does not require imaging studies. 1 The presence of purulent nasal discharge for >10 days distinguishes bacterial sinusitis from uncomplicated viral URI, where symptoms typically peak at days 3-6 and resolve by day 7-10. 1, 2

Why Imaging is NOT Indicated

Sinus X-rays (Option D) are explicitly not recommended for uncomplicated acute bacterial sinusitis in children. 1 The ACR Appropriateness Criteria state that imaging does not change management and should be avoided because:

• Over 50% of children with viral URIs show abnormal sinus radiographs 1
• 42% of healthy children demonstrate sinus abnormalities on imaging 1
• Imaging is reserved only for suspected orbital or intracranial complications 1

This child has no periorbital swelling and normal eye examination, ruling out orbital complications that would warrant imaging. 1

Frontal Sinus Tenderness: A Clinical Caveat

The frontal sinus tenderness noted in this case is anatomically unusual for a 7-year-old, as frontal sinuses are typically not fully pneumatized until age 8-10 years. 3 However, this does not change the management approach, as the clinical diagnosis remains persistent acute bacterial sinusitis based on the symptom duration and character. 1

Why Antibiotic Therapy is Indicated

The American Academy of Pediatrics guidelines support either antibiotic therapy OR additional observation for 3 days in persistent acute bacterial sinusitis without complications. 1 However, antibiotic therapy is strongly favored in this case because:

• The child has already had symptoms for 12 days (well beyond the 10-day threshold) 1
• Low-grade fever is present, suggesting ongoing bacterial infection 1
• The number needed to treat with antibiotics is only 3-5 for clinical cure 1

First-Line Antibiotic Selection

Oral amoxicillin at 45 mg/kg/day (or high-dose 80-90 mg/kg/day) is the first-line antibiotic for uncomplicated acute bacterial sinusitis in children. 1, 4, 3, 5

The major bacterial pathogens are:

• Streptococcus pneumoniae (~30%) 1, 5
• Non-typeable Haemophilus influenzae (~30%) 1, 5
• Moraxella catarrhalis (~10%) 1, 5

Treatment duration should be 10-14 days, or at least 7 days beyond substantial symptom improvement. 4, 3

Why Supportive Care Alone is Insufficient

Supportive and symptomatic management (Option A) is NOT appropriate at this stage because:

• Symptoms have persisted for 12 days, meeting criteria for bacterial rather than viral infection 1
• Antibiotic therapy has demonstrated higher cure rates compared to placebo in persistent acute bacterial sinusitis 1, 6
• Supportive care alone is reserved for uncomplicated viral URIs lasting <10 days 2

Role of Nasal Corticosteroids

Nasal corticosteroids (Option C) are adjunctive therapy only, not primary treatment for acute bacterial sinusitis. 7 They may help reduce symptom severity but do not address the underlying bacterial infection requiring antibiotic therapy. 7

Critical Monitoring Points

After initiating amoxicillin, reassess at 72 hours for:

• Worsening symptoms (new fever, increased discharge, severe headache) suggesting treatment failure 1, 8
• Lack of improvement warranting switch to high-dose amoxicillin-clavulanate 1, 8, 5
• Orbital complications (periorbital swelling, proptosis, ophthalmoplegia) requiring immediate imaging and possible hospitalization 1, 8, 6
• Intracranial complications (altered mental status, severe headache, focal neurologic signs) requiring emergent CT and specialist consultation 1, 8

Answer: B - Oral Amoxicillin