A 42-year-old man from Delhi presents with a 3-week history of purulent nasal discharge, facial pain over the cheeks, and fever (38.5°C). Examination reveals tenderness over the maxillary sinuses bilaterally and purulent secretions in the middle meatus. Nasal endoscopy shows edematous mucosa and pus draining from the ostiomeatal complex. CT paranasal sinuses shows opacification of bilateral maxillary sinuses with air-fluid levels. He has no prior sinus surgery and denies immunosuppression. What is the most likely diagnosis?

Explanation

## Diagnosis: Acute Maxillary Sinusitis ### Clinical Presentation This patient presents with the classic triad of acute sinusitis: 1. **Purulent nasal discharge** — indicates bacterial infection 2. **Facial pain and tenderness** — localized to maxillary region 3. **Fever** — systemic inflammatory response ### Key Diagnostic Features **Key Point:** Acute sinusitis is defined by symptom duration of <4 weeks with acute onset, whereas chronic sinusitis requires symptoms persisting >12 weeks. This patient has a **3-week history** — clearly within the acute window. ### Endoscopic & Imaging Findings | Feature | Acute Sinusitis | Chronic Sinusitis | |---------|-----------------|-------------------| | Mucosal appearance | Edematous, hyperemic | Pale, fibrotic, polypoidal | | Discharge | Purulent, copious | Scanty, mucoid or purulent | | CT changes | Air-fluid levels, opacification | Mucosal thickening, sclerotic bone | | Symptom duration | <4 weeks | >12 weeks | **High-Yield:** Air-fluid levels on CT are pathognomonic for acute sinusitis with retained secretions. ### Pathophysiology Acute maxillary sinusitis typically follows: 1. Upper respiratory tract infection (viral) 2. Obstruction of ostiomeatal complex → impaired mucociliary clearance 3. Secondary bacterial invasion (S. pneumoniae, H. influenzae, M. catarrhalis) 4. Purulent accumulation → facial pain and fever **Clinical Pearl:** Purulent drainage from the middle meatus on endoscopy confirms sinus origin and helps localize the affected sinus. ### Why This Is NOT Chronic Sinusitis Chronic sinusitis requires >12 weeks of symptoms; this patient is at 3 weeks. Additionally, chronic sinusitis typically presents with milder symptoms, no fever, and pale, fibrotic mucosa on endoscopy — not the acute edema and purulence seen here. ### Management Approach ```mermaid flowchart TD A[Acute Sinusitis Diagnosed]:::outcome --> B{Severity?}:::decision B -->|Mild-moderate| C[Nasal saline irrigation + Topical decongestants]:::action B -->|Moderate-severe| D[Add oral antibiotics]:::action D --> E[Amoxicillin-clavulanate or Fluoroquinolone]:::action C --> F{Improvement in 7-10 days?}:::decision F -->|Yes| G[Continue conservative care]:::action F -->|No| H[Add antibiotics or imaging]:::action E --> I[Reassess at 2-3 weeks]:::decision I -->|Persistent| J[Consider CT + ENT referral]:::action ``` [cite:Dhingra 7e Ch 11]