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Case of the Month 12/11

This 21 yo male presented to the ED (fast track) c/o one week of unilateral right sided green rhinorrhea, one day of severe right sided facial pain and tenderness. His exam was notable for some swelling around the right eye.

Question 1: What’s wrong with these pictures?

radiology image

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Answer 1:

He has such severe sinusitis that it has caused bony dehiscence with air present just adjacent to the superior superior rectus muscle (see circles below.)

Question 2: What would you do next?

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Answer 2:

The patient was started on IV antibiotics and ophtho and ENT were consulted. He was admitted to ENT and went emergently to the OR the following morning after his infection became so severe that he developed proptosis and decreased range of right eye movement. He was discharged on postoperative day 12 with a PICC line so that he could complete 2 weeks of vancomycin and meropenem (blood and wound cultures had grown multiple different organisms).