when cough, halitosis, low-grade fever, and purulent rhinorrhea are present Symptoms such as headache and facial pain may be present, but are variable, particularly in younger patients Bacterial infection is also more likely to be present when the nasal discharge lasts more than 10 days and if the color of the discharge is thick yellow or green Sinus imaging in uncomplicated ABR is not recommended, given the potential for false-positive studies and risk of radiation exposure Complications of ABR are estimated to occur in approximately 5% of hospitalized patients, and are a result of extension of the infection into either the orbital or intracranial space Clinical Considerations Clinical recognition There is considerable overlap between the clinical manifestations of ABR and viral upper respiratory infections Children will often present with cough, nasal symptoms, fever, and headache in both viral upper respiratory infections as well as ABR The AAP recommends a presumptive diagnosis of ABR in patients with acute upper respiratory infections with any one of the following: Persistent illness, such as nasal discharge or daytime cough lasting more than 10 days without improvement Worsening course, such as worsening or new nasal discharge, daytime cough, or fever after an initial period of improvement Severe onset, such as fever ≥39°C and purulent nasal discharge for at least consecutive days Triage considerations Children should be evaluated for complications of ABR such as orbital cellulitis or intracranial abscess Children who present with altered mental status, vomiting associated with headache, eye swelling or pain, seizures, or focal neurologic deficits should be evaluated promptly Initial Assessment Presentation of ABR may differ widely according to age Patients who are verbal may complain of headache, facial pain/pressure, and tenderness, while nonverbal patients may simply present with fussiness in addition to symptoms often found in viral upper respiratory infections In younger verbal children, where deeper sinuses are affected, headache may be the only presenting symptom When obtaining the history, the provider should attempt to differentiate ABR from a viral URI, as well as screen for complications of ABR For example,