A 23‑year‑old male with >2 weeks rhinorrhea and nasal congestion, treated with Sinupret (herbal) three times daily for 5 days and amoxicillin/clavulanate 625 mg three times daily for 7 days, now has loss of smell and taste, left frontal throbbing headache worsened by movement and coughing, left periorbital pain and photophobia. What is the diagnosis and appropriate management?

Diagnosis: Acute Bacterial Rhinosinusitis with Suspected Frontal Sinusitis Complication

This 23-year-old male has developed concerning signs of frontal sinusitis with possible intracranial or orbital extension requiring urgent imaging and immediate escalation of antibiotic therapy. The new-onset anosmia, severe frontal/periorbital pain worsened by coughing and movement, photophobia, and unilateral eye pain after 2 days of treatment strongly suggest bacterial sinusitis with complications rather than simple treatment failure. 1, 2

Critical Red Flags Present

The constellation of left frontal throbbing headache aggravated by movement/coughing, left eye pain, and photophobia are classic warning signs of frontal sinusitis complications including orbital cellulitis, meningitis, or intracranial extension. 1, 2, 3 These symptoms developed acutely after only 2 days of antibiotic therapy, indicating either:

• Rapid progression of untreated bacterial infection (coamoxiclav takes 3-5 days to show improvement) 4
• Inadequate initial antibiotic coverage for resistant organisms 1, 4
• Development of a suppurative complication requiring surgical intervention 2, 3

Frontal sinusitis carries the highest risk of intracranial complications due to direct venous drainage to the dura and rich communicating venous channels. 2, 5 The frontal sinus location allows easy spread to orbital and intracranial structures through bone erosion or valveless venous channels. 1, 2

Immediate Diagnostic Workup Required

Urgent CT Imaging with IV Contrast

Obtain CT maxillofacial with IV contrast immediately—do NOT wait for clinical deterioration. 1 The presence of severe headache, photophobia, and periorbital pain in frontal sinusitis mandates imaging to exclude:

• Orbital complications: Subperiosteal abscess, orbital cellulitis, orbital abscess (suggested by eye pain and photophobia) 1
• Intracranial complications: Epidural abscess, subdural empyema, meningitis, cerebritis (suggested by severe headache worsened by coughing/movement) 1, 2
• Osteomyelitis of frontal bone (Pott's puffy tumor) 2, 3

CT maxillofacial with IV contrast is the first-line study because it captures both sinus disease and adjacent orbital/intracranial complications in a single examination. 1 Contrast enhancement identifies abscess formation, cellulitis, and vascular complications. 1

Consider MRI Brain with Contrast if CT Shows Complications

If CT demonstrates intracranial extension, add MRI brain without and with IV contrast for superior soft-tissue detail. 1 MRI has 97% accuracy for detecting intracranial complications versus 87% for CT, and is superior for identifying early cerebritis, meningitis, and cavernous sinus thrombosis. 1

Clinical Examination Priorities

• Visual acuity testing and extraocular movements: Decreased vision, proptosis, or ophthalmoplegia indicate orbital involvement requiring emergency ophthalmology consultation 1
• Neurologic examination: Altered mental status, focal deficits, or meningismus suggest intracranial spread 1, 2
• Fundoscopic examination: Papilledema indicates elevated intracranial pressure 2

Immediate Management

Escalate to High-Dose IV Antibiotics NOW

Switch immediately to high-dose IV amoxicillin-clavulanate 2g/200mg every 8 hours (or equivalent) PLUS consider adding IV metronidazole 500mg every 8 hours for anaerobic coverage if intracranial complication suspected. 1, 4, 2 The current oral coamoxiclav 625mg TID is inadequate for complicated sinusitis with suspected extension. 1, 4

Rationale for IV therapy:

• Oral antibiotics achieve insufficient CNS penetration for intracranial complications 2, 3
• IV route ensures therapeutic drug levels immediately 4
• High-dose regimen covers drug-resistant S. pneumoniae (most common pathogen in frontal sinusitis complications) 1, 4, 2

If penicillin allergy exists, use IV levofloxacin 500mg daily or moxifloxacin 400mg daily PLUS IV metronidazole. 4 Fluoroquinolones provide excellent CNS penetration and cover resistant organisms. 4

Urgent ENT and Neurosurgery Consultation

Consult ENT immediately—do not wait for imaging results. 1, 2, 3 Frontal sinusitis with these red-flag symptoms requires specialist evaluation within hours, not days. 2, 3

If CT/MRI confirms intracranial extension, add emergency neurosurgery consultation. 1, 2, 3 Combined surgical drainage (endoscopic sinus surgery + craniotomy if needed) plus IV antibiotics is the standard of care for suppurative complications. 2, 3

Supportive Care

• Admit to hospital for IV antibiotics and close monitoring 2, 3
• Analgesics: IV acetaminophen 1g every 6 hours or IV ketorolac 30mg every 6 hours for severe pain 4
• Avoid intranasal corticosteroids until complications excluded—steroids may mask progression 4
• Continue high-volume saline irrigation if patient tolerates 4, 6

Why Initial Treatment Failed

The combination of Sinupret (herbal) and standard-dose coamoxiclav 625mg TID was inadequate for several reasons:

1. Sinupret has no proven efficacy for bacterial sinusitis—it is a phytotherapeutic agent without antibiotic properties 4
2. Coamoxiclav 625mg TID provides only 1.875g amoxicillin daily, insufficient for resistant organisms or complicated disease 1, 4
3. Treatment was started too late—symptoms >2 weeks suggest established bacterial infection requiring aggressive therapy 4, 6
4. No adjunctive intranasal corticosteroids were prescribed, which significantly improve outcomes 4, 6

Expected Timeline and Monitoring

With appropriate IV antibiotics and surgical drainage (if needed), expect:

• Improvement in headache/eye pain within 24-48 hours if no abscess present 4, 2
• Persistent or worsening symptoms after 48 hours of IV therapy mandate repeat imaging and surgical intervention 2, 3
• Total antibiotic duration: 4-6 weeks for uncomplicated frontal sinusitis, 6-8 weeks if osteomyelitis present, 4-6 weeks minimum if intracranial complication 2, 3

Reassess daily for:

• Worsening headache, visual changes, or neurologic deficits (immediate neurosurgery) 1, 2
• Fever persistence >48 hours on IV antibiotics (suggests abscess requiring drainage) 2, 3
• Lack of clinical improvement by day 3-5 (repeat imaging, consider surgical drainage) 4, 2

Critical Pitfalls to Avoid

• Do NOT continue oral antibiotics and observe—this patient needs IV therapy and imaging NOW 1, 2
• Do NOT assume "treatment failure" means switching to oral fluoroquinolone—complicated sinusitis requires IV therapy 4, 2
• Do NOT delay imaging because "it's only been 2 days"—frontal sinusitis complications can progress rapidly 2, 3, 5
• Do NOT discharge home on oral antibiotics—admit for IV therapy and monitoring 2, 3

Long-Term Considerations

After acute management, evaluate for predisposing factors:

• Anatomic abnormalities (deviated septum, frontal recess obstruction) requiring surgical correction 6, 2
• Immunodeficiency if recurrent episodes develop 4, 6
• Allergic rhinitis contributing to chronic inflammation 7, 6

This patient requires close follow-up with ENT even if complications are excluded, as frontal sinusitis has high recurrence risk without addressing underlying anatomic or inflammatory factors. 6, 2