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Clinical Challenge
April 18, 2019

Facial Cellulitis and Sinonasal Necrotizing Infection in a Middle-aged Woman

Author Affiliations
  • 1Bobby R. Alford Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
JAMA Otolaryngol Head Neck Surg. Published online April 18, 2019. doi:10.1001/jamaoto.2019.0333

A 36-year-old otherwise healthy white woman with a history of chronic sinusitis presented with progressive left facial pain and swelling of 5 months’ duration. Associated symptoms included epistaxis and left-sided epiphora. Prior to presentation, she had been treated as an outpatient with multiple rounds of oral antibiotics and steroids for presumed sinusitis without improvement. Social history included routine cocaine use 10 years ago. Physical examination demonstrated substantial erythema and edema of the left infraorbital region and left nasal sidewall and purulent nasal secretions (Figure 1A). Endoscopic nasal examination revealed substantial swelling of the left nasal vestibule completely obstructing the left naris, swelling of the left nasolacrimal duct orifice, nearly total septal perforation with areas of necrotic bone, and no identifiable intranasal landmarks except for a remnant of the left middle turbinate (Figure 1B). There was no cervical lymphadenopathy. Laboratory evaluation revealed a white blood cell count of 12 300/μL with normal neutrophil count; erythrocyte sedimentation rate of 83 mm/h; and a C-reactive protein level of 134 mg/L. (To convert white blood cells to ×109/L, multiply by 0.001; C-reactive protein to nanomoles per liter, multiply by 9.524.) A maxillofacial computed tomographic (CT) scan demonstrated cartilaginous and anterior osseous nasal septal perforation and left nasal and preseptal soft-tissue thickening with associated periosteal reaction of the nasal process of the maxilla.