Question

A two year old child with a long history of purulent nasal discharge and fever now presents with conjunctival congestion and edema. His fever is 102 to 103 F and WBC count is 12,000. The culture of eye discharge was negative. X-rays show opacification of the ethmoid sinus. Which of the following should be the next step in evaluating this patient?

• A. CT scan
• B. Urine culture
• C. Blood culture
• D. Repeat culture of eye discharge

Hint:

Sinusitis with a swollen eye needs CT to tell preseptal from orbital spread and find an abscess.

Answer 1

The Correct Option is A

Step 1: Recognise the clinical picture. A young child with chronic purulent nasal discharge, fever, and opacified ethmoid sinus who now develops periorbital and conjunctival swelling has ethmoiditis complicated by orbital involvement. The combination of proptosis or eyelid and conjunctival oedema with sinusitis raises strong concern for orbital cellulitis or a subperiosteal/orbital abscess spreading from the ethmoid sinus.

Step 2: Decide what changes management. The crucial question is whether the infection is preseptal (anterior to the orbital septum) or has crossed into the orbit (postseptal), and whether an abscess has formed. That distinction drives the need for surgical drainage and aggressive intravenous therapy.

Step 3: Select the investigation. A contrast enhanced CT scan of the orbit and paranasal sinuses is the imaging of choice. It defines the extent of sinus disease, detects subperiosteal or orbital abscess, and guides surgical decision making. This is the appropriate next step.

Step 4: Why the others are wrong.
Urine culture has no role; this is not a urinary source.
Blood culture may be drawn as part of the workup, but it is frequently negative in localized orbital infection and does not define the anatomy or the need for surgery, so it is not the key next step.
Repeating the eye discharge culture adds little when the first was negative and the problem is deep orbital extension, not a superficial conjunctival infection.

Step 5: Imaging to assess orbital spread is the priority.

The correct answer is option A, CT scan.