A 28-year-old woman presents to the ENT clinic with a 10-day history of severe facial pain, fever (38.5°C), purulent nasal discharge, and swelling over the right cheek. Examination shows edema and erythema over the right maxilla, and nasal endoscopy reveals pus draining from the right middle meatus. CT paranasal sinuses shows opacification of the right maxillary sinus with periosteal thickening and early subperiosteal abscess formation. Which of the following is the most appropriate management?

Explanation

## Diagnosis: Acute Sinusitis with Subperiosteal Abscess (Surgical Emergency) **Key Point:** This patient has **acute bacterial sinusitis with a complication**—subperiosteal abscess formation. The presence of fever, systemic toxicity, and imaging evidence of abscess converts this from a medical problem to a **surgical emergency**. **High-Yield:** Complications of acute sinusitis include orbital cellulitis, orbital abscess, meningitis, and subperiosteal abscess. Subperiosteal abscess (pus between periosteum and bone) requires **urgent drainage** to prevent further spread (orbital involvement, intracranial extension). ### Acute Sinusitis: Medical vs. Surgical Decision Tree ```mermaid flowchart TD A[Acute Sinusitis]:::outcome --> B{Complications present?}:::decision B -->|No| C[Uncomplicated]:::outcome C --> D[Medical: IV/oral antibiotics + saline]:::action B -->|Yes| E[Complicated]:::urgent E --> F{Type of complication?}:::decision F -->|Orbital cellulitis| G[FESS + drainage]:::urgent F -->|Subperiosteal abscess| H[FESS + abscess drainage]:::urgent F -->|Meningitis/intracranial| I[FESS + neurosurgical consult]:::urgent D --> J{Response at 48-72 hrs?}:::decision J -->|Yes| K[Continue antibiotics]:::action J -->|No| L[Consider FESS]:::action ``` **Clinical Pearl:** Subperiosteal abscess is a **red flag**. The pus is under pressure and can track into the orbit or intracranial space. Delayed drainage increases morbidity and mortality. This patient needs: 1. **IV broad-spectrum antibiotics** (covering Streptococcus, Staphylococcus, anaerobes) 2. **Urgent FESS** to drain the abscess and clear the infected sinus 3. **Imaging follow-up** to ensure resolution **Mnemonic: FUSS** — **F**ESS for **U**rgent **S**inusitis **S**urgery (when complicated). ### Antibiotic Regimen for Acute Sinusitis with Complications - **First-line:** Ceftriaxone 1–2 g IV 8-hourly + Metronidazole 500 mg IV 8-hourly - **Alternative:** Piperacillin-tazobactam 4.5 g IV 6-hourly - **Duration:** 2–3 weeks IV, then switch to oral for total 3–4 weeks **Tip:** Do NOT delay surgery hoping antibiotics alone will resolve a subperiosteal abscess. Pus requires drainage; antibiotics alone will fail. [cite:Scott-Brown's Otorhinolaryngology 8e Ch 5; Harrison 21e Ch 429]