Rhinosinusitis

Inflammation of the nasal cavity and paranasal sinuses ("sinus infection"). Acute cases last <4 weeks (often viral URIs), whereas chronic cases last >12 weeks with ongoing inflammation. Acute bacterial rhinosinusitis is diagnosed when symptoms persist ≥10 days or recur/worsen after initial improvement (the "double-worsening" pattern).

• Rhinosinusitis is extremely common (~30 million U.S. cases/year) and a top cause of outpatient antibiotic use. However, 90–98% of sinusitis is viral, so distinguishing viral vs bacterial is crucial to avoid unnecessary antibiotics. Proper management can relieve symptoms and prevent rare but serious complications (orbital or intracranial infections).

• Often follows a common cold with nasal congestion, mucopurulent nasal discharge, and facial pain/pressure (especially when bending forward). May also cause reduced smell (hyposmia) and cough from post-nasal drip.
• Acute rhinosinusitis usually lasts a few days to <2 weeks and is viral in most cases (symptoms peak at 3–6 days and then improve). Only ~0.5–2% of cases become bacterial (acute bacterial rhinosinusitis, ABRS).
• Suspect ABRS if symptoms persist >10 days without improvement, or if a biphasic course occurs ("double-sickening" – gets better, then worse with new fever, discharge). Also, very severe symptoms (high fever ≥39 °C and intense facial pain + purulent discharge for ≥3–4 days) suggest bacterial cause.
• Chronic rhinosinusitis (>12 weeks) causes more subtle, ongoing symptoms: nasal obstruction, chronic congestion, post-nasal drip, diminished smell, and often nasal polyps (especially if allergic). Chronic cases usually lack high fever and are often associated with allergies or other inflammatory conditions rather than acute infection.

1. Confirm viral vs bacterial: Viral sinusitis typically improves by ~1 week; persistent ≥10 days or a "double worsening" pattern should raise suspicion for bacterial infection.
2. Initial management for presumed viral sinusitis is supportive care: nasal saline irrigation, decongestants (short-term), warm compresses, NSAIDs/acetaminophen for pain, and intranasal corticosteroids (especially if an allergic component). Antibiotics are not needed for mild cases that are likely viral.
3. If acute bacterial rhinosinusitis is likely or symptoms are severe, consider either watchful waiting for 2–3 more days with close follow-up or start appropriate antibiotics. Amoxicillin ± clavulanate is first-line in most adults. Avoid macrolides (high pneumococcal resistance); use doxycycline or a respiratory fluoroquinolone if penicillin-allergic.
4. For chronic or recurrent sinusitis, evaluate for underlying factors: e.g. allergies (might need allergy testing), nasal polyps, deviated septum, immunodeficiency or ciliary dyskinesia. Obtain a sinus CT scan and/or endoscopic exam to confirm chronic changes and guide treatment.
5. In chronic rhinosinusitis, emphasize long-term therapy: intranasal corticosteroids (8–12 week trials) and regular saline irrigations to reduce inflammation. A prolonged course of antibiotics (2–3 weeks) may be used if a bacterial infection is documented, but routine antibiotic use in chronic sinusitis is controversial. Refer to an otolaryngologist for patients not improving; endoscopic sinus surgery can be performed to drain sinuses and remove obstruction (e.g. polyps) if medical therapy fails.

1. For viral sinusitis (the majority of cases): focus on symptomatic relief. Advise nasal saline irrigation, steam inhalation, and consider intranasal glucocorticoid sprays to reduce inflammation. Short-term oral or topical decongestants can help congestion (avoid prolonged use of nasal decongestant sprays to prevent rebound). Analgesics (NSAIDs, acetaminophen) help headaches and facial pain.
2. For acute bacterial rhinosinusitis: first-line antibiotic is amoxicillin (high-dose if risk factors) or amoxicillin-clavulanate for 5–10 days. If penicillin-allergic, use doxycycline; if severe allergy or second-line needed, a respiratory fluoroquinolone (e.g. levofloxacin) is an option. In uncomplicated cases, guidelines often recommend a period of watchful waiting with close follow-up; start antibiotics if no improvement after 7 days or if symptoms worsen.
3. Adjunct therapies: intranasal corticosteroids can be helpful, especially if there's an allergic component or significant inflammation. They are recommended in both viral and bacterial sinusitis to reduce swelling. Antihistamines are not routinely recommended for acute sinusitis unless allergies are present (they can thicken mucus).
4. Avoid inappropriate medications: Macrolide antibiotics (like azithromycin) are not recommended for sinusitis due to high resistance rates. Also avoid systemic steroids in acute uncomplicated sinusitis (risks outweigh benefits, unless severe inflammation in chronic cases or polyps).
5. For chronic rhinosinusitis, treatment is more prolonged: daily intranasal steroids and saline irrigation for at least 3 months to improve symptoms. If a bacterial infection is confirmed in chronic sinusitis, a longer course of antibiotics (often 3-4 weeks, culture-guided if possible) may be used. Refractory cases should be referred for functional endoscopic sinus surgery (FESS) to restore sinus drainage.

• Use the "10-day rule": if a sinusitis hasn't improved in ~10 days, think about bacterial infection needing antibiotics.
• Green or yellow snot ≠ always bacterial – viral infections can also cause purulent mucus, so color alone isn't a reliable indicator.
• Sinus pressure pain often worsens when bending forward or lying down due to shifts in sinus fluid pressure.
• Chronic sinusitis + nasal polyps + asthma + NSAID sensitivity = think Samter's triad (aspirin-exacerbated respiratory disease).

• Orbital signs: Periorbital edema, erythema, or eye pain with movement and double vision indicate possible spread to the orbit (orbital cellulitis or abscess). This is an emergency that can threaten vision—requires prompt imaging and IV antibiotics.
• Intracranial signs: Severe headache, high fever, neck stiffness, vomiting, altered mental status, or focal neurologic deficits (e.g. diplopia from cranial nerve VI palsy) raise concern for spread to the CNS, like cavernous sinus thrombosis or meningitis. These complications are rare but life-threatening—urgent evaluation (CT/MRI) and intervention are needed.
• Frontal bone swelling ("Pott's puffy tumor") in a teenager with frontal sinusitis indicates osteomyelitis of the frontal bone with a subperiosteal abscess – a rare but serious complication requiring surgical drainage.

1. Patient with congestion, nasal discharge, facial pressure → suspect acute rhinosinusitis (usually following a viral URI).
2. If symptoms <10 days and not severe → manage conservatively (likely viral). No immediate antibiotics; advise saline nasal irrigation, decongestants, and observe.
3. If symptoms ≥10 days with no improvement, or if they improve then worsen, or any severe features (high fever, intense pain) → suspect bacterial sinusitis. Consider starting antibiotics (first-line amoxicillin-clavulanate) or ensure close follow-up if deferring antibiotics initially.
4. If red flag signs (eye swelling, severe headache, neurologic changes) → obtain prompt imaging (CT scan) and involve specialists (ENT, ophthalmology or neurosurgery) as needed for potential complications.
5. For chronic sinusitis (>12 weeks or frequent recurrences): get sinus CT and refer to ENT. Implement long-term topical therapy (steroids, saline washes), address underlying causes (allergies, polyps), and consider surgical intervention if medical management fails.

• Cold that "won't go away": Adult with >10 days of nasal congestion, thick purulent discharge, facial pain (especially bending forward) and maxillary toothache → acute bacterial sinusitis (needs appropriate antibiotics).
• Child with a recent sinus infection now has eyelid swelling, redness, and pain with eye movement → orbital cellulitis (sinusitis complication spreading to the orbit).
• Middle-aged asthmatic with chronic sinus congestion and nasal polyps who develops bronchospasm after aspirin → aspirin-exacerbated respiratory disease (Samter's triad linking nasal polyposis, asthma, and aspirin sensitivity).