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Acute sinusitis management and symptoms

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acute rhinosinusitis

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CDC sinus infection acute sinusitis symptoms when antibiotics are needed

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https://www.cdc.gov/antibiotic-use/hcp/clinical-care/adult-o…

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Acute sinusitis symptoms

Acute sinusitis, also called acute rhinosinusitis, is inflammation of the nasal passages and sinuses, most often caused by a viral cold.
Typical symptoms include:
  • Blocked or stuffy nose
  • Nasal discharge or postnasal drip, sometimes thick or discolored
  • Facial pressure or pain, often over the cheeks, forehead, or around the eyes
  • Reduced sense of smell or taste
  • Headache
  • Cough, especially at night
  • Ear pressure, bad breath, tooth discomfort, fatigue, or fever
A clinical definition requires nasal blockage or drainage plus facial pain/pressure or reduced smell. Goldman-Cecil Medicine, p. 4166.

Viral versus likely bacterial

Most cases are viral and improve without antibiotics. Bacterial acute rhinosinusitis is more likely when any of these occur:
  1. Symptoms persist for more than 10 days without improvement.
  2. Severe onset: fever at least 39°C (102°F) plus purulent nasal discharge or significant facial pain for 3-4 days.
  3. "Double worsening": symptoms improve after a cold, then worsen again with new fever, discharge, or facial pain.
This approach is consistent with CDC adult outpatient guidance. About 90-98% of acute rhinosinusitis cases are viral.

Management

For uncomplicated, likely viral sinusitis

  • Rest and fluids
  • Saline nasal spray or irrigation: use sterile, distilled, or previously boiled and cooled water for nasal rinsing.
  • Pain or fever relief: paracetamol/acetaminophen or ibuprofen if safe for you.
  • Intranasal corticosteroid spray: for example, fluticasone or mometasone, particularly if allergic rhinitis is also present. It may reduce congestion and inflammation.
  • Short-term decongestant: a topical spray can help temporarily, but do not use it for more than 3 days because rebound congestion may occur. Oral decongestants are not appropriate for everyone, including many people with high blood pressure, heart disease, glaucoma, or urinary retention.
  • Avoid smoking and irritants.
Antibiotics do not treat viral sinusitis and can cause side effects and antibiotic resistance. Imaging is generally unnecessary in uncomplicated acute cases. Textbook of Family Medicine 9e, p. 421.

If bacterial sinusitis is suspected

A clinician may use watchful waiting for mild uncomplicated illness when follow-up is reliable. If antibiotics are needed, amoxicillin or amoxicillin-clavulanate is commonly first-line in adults. Antibiotic choice, dose, and duration should be individualized, especially for children, pregnancy, medication allergy, recent antibiotic use, kidney disease, or severe illness. CDC advises against routine azithromycin because of substantial pneumococcal resistance. See the CDC sinus infection overview.

Seek urgent medical care now if there is

  • Swelling, redness, pain, or impaired movement around an eye
  • Vision change, double vision, or a bulging eye
  • Severe frontal headache, confusion, stiff neck, vomiting, seizure, or neurological symptoms
  • High fever with severe illness
  • Facial swelling, rapidly worsening pain, or severe one-sided symptoms
  • Immunosuppression, uncontrolled diabetes, or suspected fungal sinus disease
See a clinician if symptoms last over 10 days without improving, worsen after initially improving, recur frequently, or persist for 12 weeks or more.
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