It is estimated that 5% of episodes of acute sinusitis progress beyond the paranasal sinuses to involve neighboring or distant structures. In these cases, timely diagnosis and delivery of competent treatment - often including challenging and urgent surgery - are essential. When such complicated infections present in children, where small size and acute inflammation can limit visualization and access, surgical intervention can be particularly challenging. While pediatric otolaryngologists are competent in managing sinonasal disease in children, experience and confidence in these challenging cases may be lacking. Indeed, the acute and rapidly progressive nature of these infections may necessitate management by surgeons without regular exposure to these surgeries. This presentation aims to provide the audience with key insights into the following topics: indications for medical versus surgical management of pediatric complicated acute sinusitis, tips on performing endoscopic sinus surgery in an acutely infected nose, detailed discussion of endoscopic and open approaches to orbital abscess decompression, appropriate use of image guidance, and the influence that intracranial complications have on management. The panel will be comprised of two pediatric otolaryngologists, an oculoplastic surgeon and a neurosurgeon, all of whom have extensive experience in managing this problem. Presenters will focus on collaborative decision making for this problem.