A 38-year-old woman from Delhi presents with a 3-week history of nasal obstruction, purulent nasal discharge, and facial pain over the maxillary region. She reports that symptoms began after an upper respiratory tract infection 4 weeks ago. On examination, she is afebrile, and nasal endoscopy reveals purulent discharge in the middle meatus with edematous mucosa. CT paranasal sinuses shows opacification of the maxillary sinuses with air-fluid levels bilaterally. She has no systemic symptoms or fever. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis This patient has **acute bacterial sinusitis** (maxillary) with classic features: purulent nasal discharge, facial pain, recent URTI, and CT evidence of sinus opacification with air-fluid levels. ## Management Approach for Acute Sinusitis **Key Point:** Acute sinusitis is self-limited in most cases (80–90%) and resolves with conservative management within 2–4 weeks. ### First-Line Management 1. **Nasal saline irrigation** — mechanical clearance of secretions and biofilm 2. **Topical nasal decongestants** (xylometazoline, oxymetazoline) — reduce mucosal edema and improve drainage 3. **Oral antibiotics** — indicated when symptoms persist >7 days or are severe - First-line: Amoxicillin-clavulanate or cephalosporin - Duration: 10–14 days (some guidelines suggest 7 days) 4. **Topical nasal steroids** (mometasone, fluticasone) — reduce inflammation 5. **Analgesics** — for pain relief 6. **Clinical review at 2 weeks** — assess response; if no improvement, consider imaging or specialist referral **High-Yield:** The majority of acute sinusitis cases resolve without surgery. Surgery is reserved for complications (orbital cellulitis, intracranial extension) or chronic disease unresponsive to medical therapy. ## Why Surgery Is NOT Indicated Here - No systemic toxicity or fever - No orbital or intracranial signs - First presentation of acute sinusitis - No immunocompromise - Uncomplicated maxillary involvement **Clinical Pearl:** FESS is indicated in acute sinusitis only when there is acute ethmoid or sphenoid sinusitis with orbital/intracranial complications, or when the patient is critically ill and requires urgent drainage. ## Why Other Options Are Wrong - **Immediate FESS:** Premature; acute sinusitis is self-limited and responds to medical therapy in >80% of cases. - **Long-term corticosteroids:** Not standard for acute sinusitis; topical steroids are sufficient. - **Repeat CT in 2 weeks:** Unnecessary; clinical assessment is the guide. Imaging is reserved for recurrent or chronic disease or suspected complications. [cite:Scott-Brown's Otorhinolaryngology Ch 4, Harrison 21e Ch 146]