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Diseases

Acute rhinosinusitis

OVERVIEW

  • Highlights & Basics
  • Images

DIAGNOSIS

  • Diagnostic Approach
  • Risk Factors
  • History & Exam
  • Tests
  • Differential Diagnosis

TREATMENT

  • Tx Approach
  • Tx Options
  • Emerging Tx
  • Prevention

FOLLOW-UP

  • Overview
  • Complications

REFERENCES

  • Citations
  • Guidelines
  • Credits

PATIENT RESOURCES

  • Patient Instructions

Highlights & Basics

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Key Highlights

  • Acute rhinosinusitis can be caused by either viral or bacterial infection. Majority of cases in adults and children are of viral etiology.

  • Viral rhinosinusitis typically improves within 3-5 days and resolves within 10 days, whereas symptoms persisting for more than 10 days without improvement are more suggestive of acute bacterial rhinosinusitis.

  • Imaging is not required for diagnosis unless complications are suspected.

  • Condition is usually self-limiting; however, symptomatic therapy should be considered.

  • Watchful waiting is a reasonable initial management strategy for otherwise healthy patients with uncomplicated acute bacterial rhinosinusitis whose symptoms persist but do not worsen. Antibiotics are only recommended in select patient groups (e.g., severe disease, persistent or worsening symptoms, or immunocompromised patients).

  • Complications are uncommon and their risk alone should not result in antimicrobial prescribing.

Nasal endoscopy of the left nasal cavity showing a small polyp and pus in the middle meatus
Nasal endoscopy of the left nasal cavity showing a small polyp and pus in the middle meatus
From the collection of Joseph K. Han

Quick Reference

  • History & Exam

    • Key Factors

      • symptoms <10 days (acute viral rhinosinusitis)

      • symptoms >10 days but <4 weeks (acute bacterial rhinosinusitis)

      • symptoms that worsen after an initial improvement (acute bacterial rhinosinusitis)

      • purulent nasal drainage

      • nasal obstruction

      • facial pain/pressure

      • severe symptoms at onset (acute bacterial rhinosinusitis)

      • dental pain

    • Other Factors

      • cough

      • sore throat

      • fatigue

      • hyposmia

      • anosmia

      • ear fullness or pressure

      • edematous turbinate

      • fever

    More information...

  • Diagnostics Tests

    • 1st Tests to Order

      • clinical diagnosis

    • Other Tests to consider

      • nasal endoscopy

      • sinus culture

      • CT sinuses

      • MRI

      • lateral neck x-ray

      • allergy testing

    More information...

  • Treatment Options

    • acute

      • suspected acute viral rhinosinusitis

        • supportive therapy

        • analgesic/antipyretic

        • intranasal corticosteroid

        • intranasal anticholinergic

        • intranasal saline

        • antihistamine

        • antitussive

    More information...

Definition

Acute rhinosinusitis (commonly known as acute sinusitis) is a symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal sinuses, presenting with purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both for 4 weeks or less.[1]​ "Rhinosinusitis" is the preferred term as sinusitis is usually accompanied by nasal airway inflammation and is preceded by rhinitis in most cases.[1] [2]​ Rhinosinusitis is generally classified according to the duration of symptoms as follows: acute (up to 4 weeks), subacute (4-12 weeks), chronic (12 weeks or longer), and recurrent acute (four or more episodes annually).[1] Acute rhinosinusitis may be further categorized as viral or bacterial based on its underlying cause, clinical features, and symptom course. Distinguishing between these etiologies is important, as antibiotic therapy is not indicated for viral rhinosinusitis.[1]

Classifications

Acute rhinosinusitis can be categorized according to its etiology, clinical features, and symptom duration as follows:

  • Viral rhinosinusitis: a form of acute rhinosinusitis caused, or presumed to be caused, by a viral infection.[1]​ The disease course is usually less than 10 days, but symptoms tend to improve after approximately 3-5 days.[3]​ The condition is typically self-limiting, and management is mainly directed toward symptomatic relief.[1]

  • Bacterial rhinosinusitis: a form of acute rhinosinusitis caused, or presumed to be caused, by a bacterial infection.[1] Symptoms present for more than 10 days without improvement may indicate a bacterial infection. Management may include symptomatic treatment alone or in combination with antibiotic therapy, depending on the clinical scenario.[1]

Vignette

Common Vignette 1

A 19-year-old woman presents with a 12-day history of purulent nasal drainage and nasal congestion, and reports a history of fever, myalgia, and facial pressure. She is otherwise healthy and works as a teacher. After 5 days of illness, the patient's symptoms started to improve; however, they have worsened in the last few days, despite the use of analgesia. Physical exam shows swollen inferior turbinates and thick, yellowish mucus in the nasal cavity. Nasal endoscopy demonstrates purulent drainage and a small polyp in the ostiomeatal complex. The adenoids are small and erythematous. 

Common Vignette 2

A 33-year-old man with a medical history of pediatric-onset asthma, atopic dermatitis, and allergic rhinitis presents with a 7-day history of facial pressure, dental pain, nasal blockage, and hyposmia. The patient developed these symptoms after recently mowing his lawn. The symptoms have not improved despite use of an intranasal corticosteroid, an antihistamine, and intranasal saline washes. Physical exam shows a septum deviated to the left side, and a large concha bullosa on the right side. There are no polyps, but there are swollen turbinates and thin, cloudy mucus present.

Other Presentations

Other symptoms may include sore throat or clear nasal discharge.[4]​ Patients, particularly children with a viral upper respiratory tract infection, may also present with a cough due to either postnasal drainage or an acute asthma exacerbation. Some patients may experience reduced sense of smell (hyposmia), lack of the sense of smell (anosmia), or ear fullness or pressure.[1]

Epidemiology

More than 20 million cases of acute rhinosinusitis of viral or bacterial etiology are diagnosed in the US each year across all age groups, affecting an estimated 16% of the adult population and resulting in almost 12 million office visits per year.[5] [6] [7]
It is estimated that adults will experience 1 to 3 episodes of viral acute rhinosinusitis annually. Acute rhinosinusitis accounts for 2% to 10% of primary care and otolaryngology visits.[2]
Prevalence is slightly higher in females compared with males, and there is no clear ethnic predominance.[8] [9]

Etiology

The most common cause of acute rhinosinusitis is a viral infection.[10] It is considered uncommon for viral rhinosinusitis to progress to acute bacterial rhinosinusitis, but the exact prevalence of acute bacterial rhinosinusitis is unknown.[11] In one systematic review, about half of patients with suspected acute bacterial rhinosinusitis had positive cultures.[11]​​ The most common bacteria include Streptococcus pneumoniae (up to 35% of cases), Haemophilus influenzae (up to 40% of cases), Moraxella catarrhalis (up to 20% of cases), and beta-hemolytic streptococci such as S pyogenes (up to 8% of cases).[12]
Although the bacterial pathogens have not changed over time, their antibiotic-resistance patterns have altered.[13] Antibiotic resistance depends on the geographic location; therefore, an understanding of local antibiotic resistance patterns is important.[1]​[2] [13]
Although the majority of acute rhinosinusitis infections are from viral infection, antibiotics are often prescribed for suspected bacterial infection. However, this is inappropriate for viral upper respiratory infections, rhinitis, or bronchitis.[14] [15]

Pathophysiology

Acute rhinosinusitis is most likely caused by the interaction of a predisposing condition (such as environmental triggers), a viral infection, and a consequent inflammatory response within the sinonasal mucosa.[16] With increased edema and mucus production, the sinus ostium is obstructed, blocking normal ventilation and drainage of the sinus. With decreased mucociliary clearance, stasis of secretions occurs and a secondary bacterial infection can take place. From an inflammatory standpoint, high levels of tumor necrosis factor-beta and interferon-gamma are associated with release of various proinflammatory cytokines.
Authors
  • Gordon H. Sun, MD, MBA, MSc
  • Acknowledgements
Peer Reviewers
  • Michael S. Benninger, MD
  • Daniel Merenstein, MD
  • Amin R. Javer​, ​MD, FRCSC, FARS
content by BMJ Group
Last updated Tue Aug 04 2026

Images

  • Left middle meatus with severe edema and purulent secretions

    Left middle meatus with severe edema and purulent secretions

  • Left middle meatus with healthy mucosa and non-purulent secretions

    Left middle meatus with healthy mucosa and non-purulent secretions

  • Nasal endoscopy of the left nasal cavity showing a small polyp and pus in the middle meatus

    Nasal endoscopy of the left nasal cavity showing a small polyp and pus in the middle meatus

  • Computed tomography scan with right ethmoid sinus opacification and adjacent orbital abscess

    Computed tomography scan with right ethmoid sinus opacification and adjacent orbital abscess

  • Noncontrast computed tomography scan of the sinuses showing nonspecific maxillary sinus air-fluid le

    Noncontrast computed tomography scan of the sinuses showing nonspecific maxillary sinus air-fluid levels

  • Normal noncontrast computed tomography scan of the sinuses

    Normal noncontrast computed tomography scan of the sinuses

Diagnostic Approach

Diagnosis is primarily based on the history and physical exam. In most cases the diagnosis is made presumptively. There is usually no need for further investigations unless there are complications present. Radiologic imaging is not recommended for patients who meet the diagnostic criteria for acute rhinosinusitis, unless there is concern for a complication or another possible diagnosis.[1]​ Complications, although rare, are more common in children.

History

Key risk factors include allergic rhinitis or a recent history of viral upper respiratory tract infection. Asthma may be exacerbated by acute rhinosinusitis.
Important factors in differentiating viral from bacterial rhinosinusitis are the overall symptom duration and the symptom trajectory. Symptoms of viral infection tend to peak early and gradually resolve.[1] [4]​​​[17]​​​ Thus symptoms present for less than 10 days indicate a viral infection, whereas symptoms present for more than 10 days, without an improvement, suggest a bacterial infection.[1] [18]​​ Symptoms that worsen after an initial improvement (so-called "double sickening") suggest secondary bacterial infection following viral rhinosinusitis.[1]
Cardinal symptoms of acute rhinosinusitis include purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both.[1] Purulent nasal discharge is cloudy or colored and may be described by the patient or identified during physical exam. Nasal obstruction can present as congestion, blockage, stuffiness, or difficulty breathing through the nose, and may also be noted on exam. Facial pain, pressure, or fullness may affect the front of the face or the area around the eyes, and can also appear as a localized or generalized headache.[1] Cough is a common symptom in acute viral and bacterial rhinosinusitis.[4]​ Cough may occur secondary to postnasal drainage or asthma exacerbation. Other symptoms may include sore throat, hyposmia, anosmia, ear fullness or pressure, and fever.[1]

Physical exam

Exam should include a thorough head and neck exam, with particular attention paid to the presence of:

  • Facial tenderness to gentle palpation

  • Postnasal pharyngeal secretions or exudate

  • Tender maxillary dentition

  • Middle ear effusion

The nasal cavity should be examined for the presence of mucosal erythema or purulent discharge. Either an otoscope or a nasal speculum and head light may be used.
However, because nasal exam may be difficult or the signs nonspecific, nasal endoscopy is recommended in selected patients, including patients refractory to empiric antibiotic therapy or where there is concern for antibiotic resistance, or in immunocompromised patients.
Endoscopy can provide excellent visualization of the nasal cavity and sinus drainage paths. There are two types of endoscope: rigid and flexible. A rigid nasal endoscope has superior resolution and only requires the use of one hand. This easily allows cultures of the nasal cavity or sinus to be obtained if necessary. A flexible nasal endoscope is more comfortable for patients, but requires both hands to use. There are flexible nasal endoscopes that have a channel for collecting cultures, but these tend to be larger and more uncomfortable and they are also more difficult to reprocess. Generally, the flexible nasal endoscope is preferred in children as it is better tolerated; however, either type may be used in adults and children. Choice will depend on the practitioner's familiarity with the procedure, and most will be performed by an ear, nose, and throat specialist.
Periorbital or malar edema, orbital proptosis, visual disturbances, abnormal extraocular movements, or abnormal neurologic signs may indicate the presence of complications, and urgent otolaryngology consultation is required.​Images

Investigations

Laboratory testing is of limited value in the diagnosis of acute rhinosinusitis.[19] However, culture can be an important aid in antibiotic selection if:

  • The infection has been refractory to empiric antibiotic therapy

  • There is a concern for antibiotic resistance

  • The patient is immunocompromised.

The Infectious Diseases Society of America (IDSA)/American Society for Microbiology (ASM) guidelines recommend that the ideal specimens for uncomplicated acute rhinosinusitis are aspirate obtained by antral puncture or a middle meatal swab specimen obtained with endoscopic guidance.[20]​ Endoscopic sinus culture is much less painful than sinus puncture. The two culture methods correlate well, especially when there is purulence within the middle meatus (i.e., within the sinus drainage path).[21] [22]​ Cultures taken from the nasal cavity or the nasopharynx, such as with a swab and without endoscopic visualization, are discouraged because they do not correlate with the causative pathogen.[20]
For complicated rhinosinusitis, aspirate obtained by antral puncture or tissue or aspirate obtained surgically can be used for bacterial or fungal culture.[20]​​
Skin or blood allergy testing (specific IgE) may be considered to rule out allergic rhinitis, particularly if there is no response to antibiotic therapy or for recurrent episodes.[1]

Imaging

Radiographic studies are not recommended for routine evaluation of acute rhinosinusitis because they have not been shown to change clinical outcomes.[1] [23] [24]​​​ They cannot differentiate viral from bacterial rhinosinusitis.[15] [24]​​​ Imaging may expose patients to radiation and intravenous contrast unnecessarily.[23]
Imaging studies may be indicated when a complication or an alternative diagnosis is suspected.[1] Radiographic studies are recommended in certain patients, including those with complications of rhinosinusitis, such as facial cellulitis, suspected orbital infection, or intracranial infection, and those with rapidly progressing disease or suspected acute invasive fungal rhinosinusitis.[24] Radiographic studies are also recommended in the evaluation of patients with suspected recurrent acute or chronic rhinosinusitis.[24] See Chronic rhinosinusitis without nasal polyps and Nasal polyps .
Computed tomography (CT) scan

  • CT scan with contrast can be considered in patients with acute rhinosinusitis with suspected complications.[1] [24]​​ However, do not order CT scans for uncomplicated acute rhinosinusitis.[24] [25]

  • CT imaging may be considered for patients in whom there is a suspicion for odontogenic sinusitis.[1]

  • CT without contrast may be appropriate if invasive fungal rhinosinusitis is suspected or for bony evaluation and surgical planning, but it is not as useful as a contrast CT for detecting orbital and intracranial complications.[24]
    Image

Magnetic resonance imaging (MRI)

  • MRI with and without intravenous contrast may be useful if extrasinus complications are suspected.[1] [24]

  • MRI orbits, face, and neck without and with IV contrast can confirm paranasal sinus inflammation and identify orbital and adjacent intracranial complications.[24]

X-rays

  • X-rays of the sinus are not appropriate for the evaluation of rhinosinusitis with complications due to limitations in imaging of soft tissues.[1] CT is preferred if imaging is required.[24]

  • Lateral neck x-rays can be helpful in children to evaluate the patient for adenoid hypertrophy in patients with nasal obstruction.[15]​ An alternative is flexible nasal endoscopy, which can confirm adenoiditis.

View diagnostic guideline references

Risk Factors

strong Factors
Expand All

viral upper respiratory tract infection

    • Most cases of acute rhinosinusitis in adults and children are of viral etiology.[10] In some cases, inflammation triggered by a viral upper respiratory tract infection can facilitate the development of a secondary bacterial infection.[11]​[16]​

allergic rhinitis

    • Leads to mucosal inflammation, which can cause blockage of the sinus ostium, preventing normal ventilation and drainage of the sinus.[10] Treatment of allergic rhinitis may reduce this risk.

History & Exam

Key Factors

Frequency

Expand All

symptoms <10 days (acute viral rhinosinusitis)

common

  • Symptoms that are present for less than 10 days suggest acute viral rhinosinusitis. The symptoms usually peak early and gradually resolve.[1] [4] [17]​​

common

symptoms >10 days but <4 weeks (acute bacterial rhinosinusitis)

common

  • Symptoms present for more than 10 days without improvement may indicate a bacterial infection, although these patients are less likely to benefit from antibiotic therapy compared with those with severe symptoms at the onset or those with symptoms that worsen after initial improvement.[1] [18]

common

symptoms that worsen after an initial improvement (acute bacterial rhinosinusitis)

common

  • Symptoms that worsen after an initial improvement (so-called "double sickening") suggest secondary bacterial infection. The typical scenario is a patient who experiences symptoms of viral rhinosinusitis and improves after 5 days, only to worsen 2-3 days later.[1]​​[4]​​​​[17]​[18]

common

purulent nasal drainage

common

  • Refers to cloudy or discolored (brown, yellow, green) nasal mucus. May be reported by patient, or observed on physical exam (e.g., in the nasal cavity, middle meatus, or posterior pharynx).[1] A nonspecific symptom that may be present in viral or bacterial rhinosinusitis.

common

nasal obstruction

common

  • Refers to congestion, stuffiness, or blockage.[1] Swollen septal or turbinate mucosa may be seen on exam. Nonspecific symptom that may be associated with viral or bacterial rhinosinusitis as well as allergic rhinitis.

common

facial pain/pressure

common

  • Reported by the patient as headache or discomfort in the anterior face or periorbital region.[1] Nonspecific symptom that may be associated with viral or bacterial rhinosinusitis.[1]

common

severe symptoms at onset (acute bacterial rhinosinusitis)

uncommon

  • Symptoms that are severe at the onset of illness suggest bacterial infection.[17]

uncommon

dental pain

uncommon

  • May be reported by patient or observed on physical exam with percussion of the maxillary teeth. Suggests acute maxillary sinusitis.

uncommon

Other Factors

Frequency

Expand All

cough

common

  • May present secondary to postnasal drainage or exacerbation of asthma caused by rhinosinusitis; particularly common in children.

common

sore throat

common

  • May be present in both acute viral and bacterial rhinosinusitis.[1]

common

fatigue

common

  • May be present in acute viral and bacterial rhinosinusitis.[1]

common

hyposmia

common

  • A reduced sense of smell may be present in both acute viral and bacterial rhinosinusitis.[1]

common

anosmia

common

  • Lack of the sense of smell may be present in acute viral and bacterial rhinosinusitis.[1]

common

ear fullness or pressure

common

  • May be present in acute viral and bacterial rhinosinusitis.[1]

common

edematous turbinate

common

  • Associated with any inflammation of the nasal cavity lining, whether allergic, viral, or bacterial in etiology.

common

fever

uncommon

  • May occur in acute viral rhinosinusitis but is more common in children than adults. Bacterial rhinosinusitis is less common than viral rhinosinusitis, but abrupt onset of fever and worsening symptoms after an initial improvement in acute rhinosinusitis suggests bacterial rhinosinusitis.

uncommon

Tests

1st Tests to Order

Result

Expand All

clinical diagnosis

diagnosis is based on history and physical exam

  • Laboratory tests and imaging studies are not indicated for evaluation of routine, uncomplicated acute rhinosinusitis. Imaging may be warranted in the case of complications, recurrent episodes of rhinosinusitis, suspected anatomic abnormalities, rapidly progressing or suspected acute invasive fungal rhinosinusitis, or if an alternative diagnosis is suspected.[1] [24]

diagnosis is based on history and physical exam

Other Tests to consider

Result

Expand All

nasal endoscopy

mucosal erythema, purulent discharge

  • Recommended in select patients (e.g., patient refractory to empiric antibiotic therapy, concern for antibiotic resistance, patient immunocompromised) as it can provide excellent visualization of the nasal cavity and sinuses.

  • There are two types of endoscope: rigid and flexible.

  • Rigid: has superior resolution and only requires the use of one hand. This easily allows cultures of the nasal cavity or sinus to be obtained if necessary.

  • Flexible: more comfortable for patients, but requires both hands to use. It is preferred in children as it is better tolerated.

  • Either type may be used in adults and children. Choice will depend on the practitioner's familiarity with the procedure, and most will be performed by an ear, nose, and throat specialist.

  • Image

mucosal erythema, purulent discharge

sinus culture

positive for organism

  • Not required for diagnosis but can be helpful for planning the appropriate management plan for the patient, especially if the patient is refractory to empiric antibiotic therapy, if there is a concern for antibiotic resistance, or if the patient is immunocompromised.

  • Endoscopic culture taken from the sinus drainage path is well tolerated, and has a high correlation with the pathogenic bacteria, especially when there is purulence in the middle meatus; it is therefore the procedure of choice when cultures are required.[22]

  • Cultures taken directly from the sinus (e.g., sinus puncture) are accurate but can be very painful. Endoscopic cultures are preferred for uncomplicated acute rhinosinusitis. For complicated rhinosinusitis, guidelines recommend aspirate obtained by antral puncture or tissue or aspirate obtained surgically.[20]

  • Cultures taken from the nasal cavity or the nasopharynx, such as with a swab, correlate poorly with the causative pathogen.[20]

positive for organism

CT sinuses

identifies extent of sinus disease, abnormal anatomic structures

  • Ordered if complications are suspected, or if further investigation is required (e.g., with recurrent episodes, suspected anatomic abnormalities) to rule out alternative diagnoses.​​​​[1]​[24]​​ CT imaging may be considered for patients in whom there is a suspicion for odontogenic sinusitis.[1] Do not order CT scans for uncomplicated acute rhinosinusitis because this is generally diagnosed clinically and does not require confirmation with imaging.[1] [24] [25]

  • A completely normal scan excludes the diagnosis of rhinosinusitis.

  • CT without contrast may be appropriate if invasive fungal rhinosinusitis is suspected or for bony evaluation and surgical planning, but it is not as useful as a contrast CT for detecting orbital and intracranial complications.[24]

  • CT cannot differentiate acute viral from acute bacterial rhinosinusitis, so clinical diagnosis is essential.[15] [24]

  • Images

identifies extent of sinus disease, abnormal anatomic structures

MRI

may show air-fluid level or mucosal thickening of the involved sinuses, or extension of disease into adjacent structures such as the orbit or brain

  • MRI with and without intravenous contrast may be useful if extrasinus complications are suspected.​[1]​[24]​​ Not recommended for evaluation of routine, uncomplicated acute rhinosinusitis.​​[1]

  • MRI orbits, face, and neck without and with IV contrast can confirm paranasal sinus inflammation and identify orbital and adjacent intracranial complications.[24]

may show air-fluid level or mucosal thickening of the involved sinuses, or extension of disease into adjacent structures such as the orbit or brain

lateral neck x-ray

may show adenoid hypertrophy in children

  • Lateral neck x-rays can be helpful in children to evaluate the patient for adenoid hypertrophy in patients with nasal obstruction.[15]​ An alternative is flexible nasal endoscopy, which can confirm adenoiditis.

may show adenoid hypertrophy in children

allergy testing

positive

  • Skin or blood allergy testing (specific IgE) may be considered to rule out allergic rhinitis, particularly if there is no response to antibiotic therapy or for recurrent episodes.​[1]

positive

Differential Diagnosis

Disease/Condition

  • Allergic rhinitis

    Differentiating Signs/Symptoms

    • Ocular and/or nasal pruritus.

    • Sneezing.

    • Rhinorrhea.

    • Headache, purulent discharge, and facial pain/pressure are less common.

    Differentiating Tests

    • Allergen skin-prick testing: wheal and flare reaction after specific allergen is introduced into the skin is 3 mm larger than negative (saline) control.

    • In vitro-specific IgE determination: specific allergen response.[26]

  • Nonallergic rhinitis

    Differentiating Signs/Symptoms

    • Heterogeneous group of nasal diseases that has nasal obstruction or rhinorrhea as common factors.

    • History of pregnancy, barometric changes, food-associated symptoms, or hypothyroidism.

    Differentiating Tests

    • Diagnosis is clinical: there are no differentiating tests.

  • Migraine

    Differentiating Signs/Symptoms

    • Patient reports a history of "recurrent sinus infection" in which moderate-severe headache is the most prominent symptom.

    • Other symptoms include sensitivity to light or noise, aura, and nausea.

    • Symptoms decrease if sitting/lying in a quiet, dark room.

    • Purulent nasal discharge is absent.

    Differentiating Tests

    • Diagnosis is clinical; there are no differentiating tests.[27]

  • Adenoiditis

    Differentiating Signs/Symptoms

    • Difficult to differentiate in pediatric population as both conditions have similar symptoms.

    Differentiating Tests

    • Nasal flexible endoscopy can be used to determine the source of infection, either from the adenoids or from the sinuses.

Treatment Approach

The goals of treatment are to relieve symptoms, eradicate infection, and prevent complications.[30] Management varies depending on whether the etiology is viral or bacterial, and should involve shared decision-making with the patient.[1]​ Due to a paucity of high-quality evidence on the management of acute rhinosinusitis, recommended treatment strategies and duration may vary.

Acute viral rhinosinusitis: general principles of management

This is generally a self-limiting disease, and treatment is primarily symptomatic.[1] The disease course is usually less than 10 days, but symptoms tend to improve after approximately 3-5 days.[3]​ Adequate rest and hydration, warm facial packs, and nasal saline irrigation may be useful, as well as use of vitamin C, zinc, or nonprescription drugs, depending on the specific symptoms.[4] Treatments should be tried for 5-10 days before reassessing the patient. Antibiotics should not be given to patients with suspected acute viral rhinosinusitis.[1] [18]
The goals of acute viral rhinosinusitis management are to relieve symptoms, improve patient comfort, and minimize unnecessary use of drug treatments. Because many available treatments differ in their effectiveness and supporting evidence, they are organized into three categories here to guide clinical practice:

  • Recommended on the basis of evidence demonstrating clinical benefit (e.g., analgesics/antipyretics, intranasal corticosteroids, intranasal anticholinergics, intranasal saline irrigations/sprays)

  • Frequently used in practice or may be considered in selected patients, although supporting evidence remains limited or insufficient (e.g., antihistamines, antitussives)

  • Not recommended because available evidence does not support their effectiveness or indicates that their routine use is unwarranted (e.g., decongestants, mucolytics, oral corticosteroids, expectorants)

Acute viral rhinosinusitis: treatments recommended based on evidence

Analgesics/antipyretics

  • Recommended for pain and/or fever.[1]

  • Examples include acetaminophen, ibuprofen, or acetaminophen/codeine. Selection of a specific drug depends on the subjective level of pain the patient is experiencing. Codeine is contraindicated in children younger than 12 years of age, and it is not recommended in adolescents 12-18 years of age who are obese or have conditions such as obstructive sleep apnea or severe lung disease as it may increase the risk of breathing problems.[31] Codeine is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[32] [33]

Intranasal corticosteroids

  • Recommended in patients with congestion. Intranasal corticosteroids are considered beneficial and have a low incidence of systemic adverse effects.[1]​[34] [35] [36]

  • At least 1 month of therapy is usually recommended; however, this will depend on the disease course.

Intranasal anticholinergics

  • Recommended in patients with rhinorrhea.[37]

Intranasal saline irrigations/sprays

  • May also be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing use of drug treatments.

  • Saline nasal irrigations may be helpful in relieving nasal symptoms; however, they should be used cautiously as patients who have not had an endoscopic sinus surgery may develop facial pressure or discomfort when the saline irrigations get trapped in the nonoperated sinuses.[38]

  • A home-prepared saline irrigation may be helpful for patients.[39] [40]

Acute viral rhinosinusitis: treatments commonly used in practice with limited evidence

Antihistamines

  • Intranasal antihistamines have shown inconclusive benefit for symptomatic relief, but could be helpful for patients with a history of allergic rhinitis.[1] [41]

  • There is limited evidence that oral antihistamines may provide relief from nasal congestion in patients with acute rhinosinusitis and allergic rhinitis, when used as an adjunctive therapy. However, these drugs may relieve nasal obstruction in allergic rhinitis patients with acute rhinosinusitis.[42]

Antitussives

  • Antitussives (cough suppressants) are commonly prescribed for symptomatic relief, although, clinical evidence of effectiveness is scant.[1] [43]

Acute viral rhinosinusitis: treatments not recommended due to lack of evidence

Decongestants

  • May restore sinus ostial patency and provide symptomatic relief of nasal congestion.​[1] [15] However, evidence is lacking.[44]

  • Topical agents are often preferred over systemic agents because of increased potency and less risk of adverse effects.

  • Pseudoephedrine-containing products are associated with a risk of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome. These are rare conditions with potentially serious and life-threatening complications. Pseudoephedrine-containing products should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[45]

  • If used, topical agents should only be used for up to 3-5 days, to prevent the occurrence of rebound congestion.

Mucolytics

  • Mucolytics may be useful for thinning mucus and facilitating mucus clearance, although clinical evidence of effectiveness is insufficient.[1] [46] [47]

Oral corticosteroids

  • Oral corticosteroids are ineffective for adult patients with acute rhinosinusitis.[48]​ Also not recommended due to the potential for adverse events, such as nausea and vomiting.[1]

Expectorants

  • Expectorants should not be used due to a lack of evidence of efficacy.[1]

Acute bacterial rhinosinusitis

Consensus on a universal treatment protocol for acute bacterial rhinosinusitis is lacking. However, symptom-based therapy, with or without antibiotic therapy, is generally considered an acceptable approach.[1] [18] [36] [49] [50]
Watchful waiting is an appropriate initial management approach for uncomplicated acute bacterial rhinosinusitis in otherwise healthy patients who have persistent but nonworsening symptoms.[1] The duration of watchful waiting depends on how long symptoms have been present at the time of diagnosis and may be only 3-5 days in patients diagnosed around day 10 after symptom onset.
A reliable follow-up process, with mechanisms for reassessment should the illness persist or worsen, is essential for patients managed with watchful waiting.[1]
Patients with severe symptoms or worsening symptoms are more likely to have bacterial infection compared with patients with mild symptoms, particularly if the symptoms have lasted for more than 10 days.[18] Antibiotic therapy may be initiated if the patient's condition worsens or does not improve after 3-5 days of watchful waiting, or if symptoms persist or worsen beyond 14 days from onset.[1]​ There are several sets of guidelines in existence, and practices may vary.
Antibiotic therapy

  • Guidelines generally do not recommend antibiotics for immunocompetent patients with nonsevere illness. Such cases are either viral rhinosinusitis or mild bacterial rhinosinusitis, both of which resolve without treatment.[1] [18] [51]​​​​ To this end, a randomized controlled trial (RCT) compared a 10-day course of amoxicillin with placebo for adults presenting to community practices with clinically diagnosed, uncomplicated moderate to severe acute rhinosinusitis. It found no difference in terms of improvement in disease-specific quality of life after 3-4 days of treatment.[52] One meta-analysis of six RCTs found moderate-certainty evidence that antibiotic therapy reduced the risk of treatment failure compared with placebo in children, but only 41% of children treated with placebo experienced treatment failure and none developed major complications.[53] One randomized controlled trial found that antibiotic therapy in pediatric patients with acute rhinosinusitis provided minimal benefit if the patient did not have nasopharyngeal pathogens on presentation.[54]​​

  • Antibiotic therapy is recommended for complicated rhinosinusitis, immunocompromised patients, or those with coexisting bacterial illness.[1] The clinician should also consider the patient's age, general health, cardiopulmonary status, comorbid conditions and factors that may indicate a severe degree of disease when assessing suitability for watchful waiting. Indicators of severe illness include:[18] [55] [56]

    • Fever (>102.2°F [>39°C])

    • Moderate to severe facial or dental pain

    • Unilateral sinus tenderness

    • Periorbital edema

    • Worsening of symptoms after 3-5 days

    • Lack of improvement after 7-10 days of observation.

  • A risk-benefit analysis for use of antibiotics must consider the high rate of spontaneous resolution without treatment, shortened duration of symptoms with treatment, as well as cost, adverse effects of antibiotics, need for follow-up, and increased bacterial resistance.[7] [57]

  • Although guidelines vary in their recommendations, studies have not demonstrated a difference in clinical outcomes between various antibiotic regimens.[58]

  • Amoxicillin or amoxicillin/clavulanate is the treatment of choice for most patients when antibiotic therapy is indicated.[1]

  • For patients with a penicillin allergy, a reasonable alternative is therapy with clindamycin plus an oral third-generation cephalosporin (e.g., cefixime, cefpodoxime).[1] [2] [59]​​ There is a risk of cross-sensitivity with cephalosporins in these patients, although this risk is low if the allergic manifestation is simply a rash without respiratory involvement.[60]

  • Doxycycline is a suitable alternative in adults with allergies to beta-lactam antibiotics; however, it is not recommended in children due to risks of tooth discoloration and dental enamel hypoplasia.[1] [61]

  • Trimethoprim/sulfamethoxazole or a macrolide (e.g., azithromycin) have been used in patients with an allergy to penicillins, but in some areas there are now relatively high rates of resistance to these drugs that limit their usefulness.[1] [28]​​

  • Fluoroquinolones should only be used in patients with severe acute bacterial rhinosinusitis who do not have other treatment options.[62] They may be tried in adults if treatment with a penicillin or cephalosporin is not possible. Fluoroquinolones should be used with caution in children due to risk of musculoskeletal adverse effects.[63] Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to, tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[64]

    • Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).

    • Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

  • A 5-7 day treatment course for adults and 10-14 day course for children is reasonable for most antibiotics.[1] [18] [65]

  • If the patient does not respond to treatment after 3-5 days, an alternative antibiotic (such as high-dose amoxicillin/clavulanate, a fluoroquinolone, or a cephalosporin), or an alternative, noninfectious etiology, should be considered.[1] [18]

  • Intravenous antibiotics (e.g., third-generation cephalosporin, fluoroquinolone) may be required in patients with infection that requires hospitalization.

Antibiotic resistance

  • Antibiotic treatment failure in acute bacterial rhinosinusitis may be associated with resistant organisms, including beta-lactamase producing H influenzae and M catarrhalis, as well as multidrug-resistant S pneumoniae, particularly in patients with prior antibiotic exposure.

  • Antibiotic resistance depends on the geographic location. Therefore, an understanding of local antibiotic protocols is important before prescribing a specific antibiotic.

  • Inappropriate prescribing can contribute to resistance; for example, one US study found that only 50% of antibiotic prescriptions to outpatients with pharyngitis, rhinosinusitis, or acute otitis media were for first-line recommended agents (defined as amoxicillin or amoxicillin/clavulanate for rhinosinusitis).[66] One systematic review found that otolaryngologists did not adhere to rhinosinusitis guidelines as they did not distinguish presumed acute bacterial rhinosinusitis from acute rhinosinusitis caused by viral upper respiratory tract infections (URTIs) and did not follow guideline-recommended first-line therapy when treating suspected bacterial rhinosinusitis.[67]

Symptomatic therapy

  • Measures are the same as those used for acute viral rhinosinusitis.

  • Adequate rest and hydration, warm facial packs, and nasal saline irrigation may be useful, as well as use of vitamin C, zinc, or nonprescription drugs including analgesics/antipyretics, intranasal anticholinergics, antihistamines, antitussives, and intranasal saline irrigations/sprays.[38] There may be a modest clinical benefit from use of intranasal corticosteroids.​[4] [36]​​ Decongestants, mucolytics, oral corticosteroids, and expectorants are not recommended because available evidence does not support their effectiveness or indicates that their routine use is unwarranted. Nonprescription products can contain numerous different active ingredients and doses; therefore, clinicians should be cautious when recommending specific products for symptom relief.[68] Honey can reduce cough frequency and severity associated with URTI symptoms, with moderate evidence supporting its use in preference to usual care for other URTI symptoms; however, most evidence comes from studies of children.[69]

Specialist referral

Referral to an ear, nose, and throat specialist may be indicated when:[1]​[18]

  • Patient is immunocompromised

  • A complication of rhinosinusitis is suspected (facial cellulitis, orbital cellulitis or abscess, intracranial infection)

  • Cranial nerve deficits such as facial nerve paralysis or ophthalmoplegia are present, suggesting possible invasive fungal or orbital rhinosinusitis

  • Condition is refractory to antibiotic treatment

  • Condition is recurrent (i.e., four or more episodes per year) or significantly affects quality of life

  • There is a suspected allergic or immunologic basis for the condition, or there are comorbidities (e.g., asthma, nasal polyps) present that complicate management, or rhinosinusitis is associated with unusual opportunistic infections.

The specialist may be able to enhance care:

  • Through confirmation of the diagnosis or provision of an alternative diagnosis

  • By obtaining a sinus culture

  • By adjusting antibiotic therapy to cover less common pathogens, such as anaerobes, Pseudomonas aeruginosa, orStaphylococcus aureus

  • By obtaining and interpreting imaging studies

  • Through consideration of surgery.[18]

Acute invasive fungal rhinosinusitis is a rare, rapidly progressive and life-threatening infection with a high mortality rate warranting immediate emergency referral and ENT consultation. Management consists of surgical debridement, systemic antifungal therapy, and correction of predisposing conditions.[18] [70]
View treatment guideline references

Treatment Options

  • acute
    Expand All

    • suspected acute viral rhinosinusitis

        • 1st

          supportive therapy

          Comments

          • Viral rhinosinusitis is suspected when symptoms are stable and present for less than 10 days.

          • Generally a self-limiting disease, and treatment is primarily symptomatic.[1]

          • Adequate rest and hydration and warm facial packs may be useful, as well as use of vitamin C and zinc.[4]

          • Treatments should be tried for 5-10 days before reassessing the patient.

        • adjunct

          analgesic/antipyretic

          Primary Options

            • acetaminophen

              children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

            • ibuprofen

              children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

          Secondary Options

            • acetaminophen/codeine

              children ≥12 years of age: consult specialist for guidance on dose; adults: 30-60 mg orally every 4-6 hours when required

          Comments

          • Recommended for pain and/or fever.[1] Selection of a specific drug depends on the subjective level of pain the patient is experiencing. Examples include acetaminophen, ibuprofen, or acetaminophen/codeine.

          • Codeine is contraindicated in children younger than 12 years of age, and it is not recommended in adolescents 12-18 years of age who are obese or have conditions such as obstructive sleep apnea or severe lung disease as it may increase the risk of breathing problems.[31] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[32] [33]

          • Examples of suitable analgesics/antipyretics are presented here; however, other drugs may be available and you should consult your local drug information source.

        • adjunct

          intranasal corticosteroid

          Primary Options

            • fluticasone propionate nasal

              (50 micrograms/spray) children ≥4 years of age and adults: 1-2 sprays in each nostril once daily

            • mometasone nasal

              (50 micrograms/spray) children 2-11 years of age: 1 spray in each nostril once daily; children ≥12 years of age: 2 sprays in each nostril once daily; adults: 2 sprays in each nostril once or twice daily

            • ciclesonide nasal

              (50 micrograms/spray) children ≥6 years of age and adults: 2 sprays in each nostril once daily; (37 micrograms/spray) children ≥12 years of age and adults: 1 spray in each nostril once daily

          Comments

          • Recommended in patients with congestion. Considered beneficial and has a low incidence of systemic adverse effects.[1] [34] [35] [36]

          • At least 1 month of therapy is usually recommended; however, this will depend on the disease course.

          • Examples of suitable intranasal corticosteroids are presented here; however, other drugs may be available and you should consult your local drug information source.

        • adjunct

          intranasal anticholinergic

          Primary Options

            • ipratropium bromide nasal

              children ≥6 years of age and adults: (0.03%) 42 micrograms (2 sprays) in each nostril two or three times daily

          Comments

          • Topical intranasal anticholinergics (e.g., ipratropium) can be used in patients with rhinorrhea.[37]

        • adjunct

          intranasal saline

          Comments

          • Saline sprays may be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing drug use.

          • Saline nasal irrigations may be helpful in relieving nasal symptoms; however, they should be used cautiously as patients who have not had an endoscopic sinus surgery may develop facial pressure or discomfort when the saline irrigations get trapped in the nonoperated sinuses.[38]

          • A home-prepared saline irrigation may be helpful for patients.[39] [40]​

        • adjunct

          antihistamine

          Primary Options

            • azelastine nasal

              (0.1%) children ≥12 years of age and adults: 274 micrograms (2 sprays) in each nostril twice daily

            • loratadine

              children 2-5 years of age: 5 mg orally once daily when required; children ≥6 years of age and adults: 10 mg orally once daily when required

          Comments

          • Intranasal antihistamines (e.g., azelastine) have shown inconclusive benefit for symptomatic relief, but could be helpful for patients with a history of allergic rhinitis.[1] [41]

          • There is limited evidence that oral antihistamines (e.g., loratadine) may provide relief from nasal congestion in patients with acute rhinosinusitis and allergic rhinitis, when used as an adjunctive therapy. However, these drugs may relieve nasal obstruction in allergic rhinitis patients with acute rhinosinusitis.[42]

          • Examples of suitable antihistamines are presented here; however, other drugs may be available and you should consult your local drug information source.

        • adjunct

          antitussive

          Primary Options

            • dextromethorphan

              adults: 30 mg orally (immediate-release) every 6-8 hours when required, maximum 120 mg/day

          Comments

          • Antitussives/cough suppressants (e.g., dextromethorphan) are commonly prescribed for symptomatic relief, although clinical evidence of effectiveness is scant.[1] [43]​

          • Examples of suitable antitussives are presented here; however, other drugs may be available and you should consult your local drug information source. Some pediatric organizations do not recommend the use of dextromethorphan in children. Opioid cough suppressants are not recommended in children and adolescents <18 years of age.[71]​

    • suspected acute bacterial rhinosinusitis

      • immunocompromised or with severe illness

        • 1st

          antibiotic therapy

          Primary Options

            • amoxicillin/clavulanate

              children: 90 mg/kg/day orally given in 2 divided doses; adults: 2000 mg orally (extended-release) twice daily

          Secondary Options

            • clindamycin

              children: 30-40 mg/kg/day orally given in 3 divided doses; adults: 150-450 mg orally three times daily

              AND

            • cefixime

              children: 8 mg/kg/day orally given in 1-2 divided doses; adults: 400 mg orally once daily

              or

            • cefpodoxime proxetil

              children: 10 mg/kg/day orally given in 2 divided doses; adults: 200 mg orally twice daily

            • doxycycline

              adults: 100 mg orally twice daily, or 200 mg orally once daily

            • ceftriaxone

              children: 50 mg/kg/day intravenously given in divided doses every 12 hours; adults: 1-2 g intravenously every 12-24 hours

            • cefotaxime

              children: 100-200 mg/kg/day intravenously given in divided doses every 6 hours; adults: 2 g intravenously every 4-6 hours

          Tertiary Options

            • moxifloxacin

              children: consult specialist for guidance on dose; adults: 400 mg orally/intravenously once daily

            • levofloxacin

              children: consult specialist for guidance on dose; adults: 500 mg orally/intravenously once daily

          Comments

          • Antibiotic therapy is recommended for complicated rhinosinusitis, immunocompromised patients, or those with coexisting bacterial illness.[1]​ The clinician should also consider the patient's age, general health, cardiopulmonary status, comorbid conditions and factors that may indicate a severe degree of disease when assessing suitability for watchful waiting. Indicators of severe illness include fever (>102.2°F [>39°C]); moderate to severe facial or dental pain; unilateral sinus tenderness; periorbital edema; worsening of symptoms after 3-5 days; or lack of improvement after 7-10 days of observation.​[18] [55] [56]​​​

          • Although guidelines may vary in their recommendations for empiric antibiotics, studies have not demonstrated a difference in clinical outcomes between various antibiotic regimens.[58]

          • Amoxicillin or amoxicillin/clavulanate is the treatment of choice for most patients when antibiotic therapy is indicated.[1]

          • For patients with a penicillin allergy, a reasonable alternative is therapy with clindamycin plus an oral third-generation cephalosporin (e.g., cefixime, cefpodoxime).[1] [2] [59]​​ There is a risk of cross-sensitivity with cephalosporins in these patients, although this risk is low if the allergic manifestation is simply a rash without respiratory involvement.[60]

          • Doxycycline is a suitable alternative in adults with allergies to beta-lactam antibiotics; however, its use is not recommended in children due to risk of tooth discoloration and dental enamel hypoplasia.[1] [61]

          • Fluoroquinolones should only be used in patients who do not have other treatment options.[62] They may be tried in adults if treatment with a penicillin or cephalosporin is not possible. Fluoroquinolones should be used with caution in children due to risk of musculoskeletal adverse effects.[63] Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to, tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[64]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in ​situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

          • A 5-7 day treatment course for adults and 10-14 day course for children is reasonable for most antibiotics.[1] [18] [65]

          • If the patient does not respond to treatment after 3-5 days, an alternative antibiotic (such as high-dose amoxicillin/clavulanate, a fluoroquinolone, or a cephalosporin), or an alternative, noninfectious etiology, should be considered.[1] [18] Another consideration should be an ear, nose, and throat specialist consultation.

          • Intravenous antibiotics (e.g., third-generation cephalosporin, fluoroquinolone) may be required in patients with an infection that requires hospitalization.

        • plus

          ear, nose, and throat (ENT) specialist referral

          Comments

          • The specialist may adjust antibiotic therapy to cover less common causative microorganisms (e.g., add metronidazole or clindamycin to cover anaerobes), reevaluate the patient for underlying conditions or anatomic abnormalities, or consider surgery.[18]

        • plus

          supportive therapy

          Comments

          • ​Adequate rest and hydration and warm facial packs may be useful, as well as use of vitamin C and zinc.[4] Selection of therapy will depend on the specific symptoms.

        • adjunct

          analgesic/antipyretic

          Primary Options

            • acetaminophen

              children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

            • ibuprofen

              children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

          Secondary Options

            • acetaminophen/codeine

              children ≥12 years of age: consult specialist for guidance on dose; adults: 30-60 mg orally every 4-6 hours when required

          Comments

          • Recommended for pain and/or fever.[1] Selection of a specific drug depends on the subjective level of pain the patient is experiencing. Examples include acetaminophen, ibuprofen, or acetaminophen/codeine.

          • Codeine is contraindicated in children younger than 12 years of age, and it is not recommended in adolescents 12-18 years of age who are obese or have conditions such as obstructive sleep apnea or severe lung disease as it may increase the risk of breathing problems.[31] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[32] [33]

          • Examples of suitable analgesics/antipyretics are presented here; however, other drugs may be available and you should consult your local drug information source.

        • adjunct

          intranasal corticosteroid

          Primary Options

            • fluticasone propionate nasal

              (50 micrograms/spray) children ≥4 years of age and adults: 1-2 sprays in each nostril once daily

            • mometasone nasal

              (50 micrograms/spray) children 2-11 years of age: 1 spray in each nostril once daily; children ≥12 years of age: 2 sprays in each nostril once daily; adults: 2 sprays in each nostril once or twice daily

            • ciclesonide nasal

              (50 micrograms/spray) children ≥6 years of age and adults: 2 sprays in each nostril once daily; (37 micrograms/spray) children ≥12 years of age and adults: 1 spray in each nostril once daily

          Comments

          • Recommended in patients with congestion. Considered beneficial and has a low incidence of systemic adverse effects.[1]​[34] [35] [36]

          • At least 1 month of therapy is usually recommended; however, this will depend on the disease course.

          • Examples of suitable intranasal corticosteroids are presented here; however, other drugs may be available and you should consult your local drug information source.

        • adjunct

          intranasal anticholinergic

          Primary Options

            • ipratropium bromide nasal

              children ≥6 years of age and adults: (0.03%) 42 micrograms (2 sprays) in each nostril two or three times daily

          Comments

          • Topical intranasal anticholinergics (e.g., ipratropium) can be used in patients with rhinorrhea.[37]

        • adjunct

          intranasal saline

          Comments

          • Saline sprays may be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing drug use.

          • Saline nasal irrigations may be helpful in relieving nasal symptoms; however, they should be used cautiously as patients who have not had an endoscopic sinus surgery may develop facial pressure or discomfort when the saline irrigations get trapped in the nonoperated sinuses.[38]

          • A home-prepared saline irrigation may be helpful for patients.[39] [40]​

        • adjunct

          antihistamine

          Primary Options

            • azelastine nasal

              (0.1%) children ≥12 years of age and adults: 274 micrograms (2 sprays) in each nostril twice daily

            • loratadine

              children 2-5 years of age: 5 mg orally once daily when required; children ≥6 years of age and adults: 10 mg orally once daily when required

          Comments

          • Intranasal antihistamines (e.g., azelastine) have shown inconclusive benefit for symptomatic relief, but could be helpful for patients with a history of allergic rhinitis.[1] [41]

          • There is limited evidence that oral antihistamines (e.g., loratadine) may provide relief from nasal congestion in patients with acute rhinosinusitis and allergic rhinitis, when used as an adjunctive therapy. However, these drugs may relieve nasal obstruction in allergic rhinitis patients with acute rhinosinusitis.[42]

          • Examples of suitable antihistamines are presented here; however, other drugs may be available and you should consult your local drug information source.

        • adjunct

          antitussive

          Primary Options

            • dextromethorphan

              adults: 30 mg orally (immediate-release) every 6-8 hours when required, maximum 120 mg/day

          Comments

          • Antitussives/cough suppressants (e.g., dextromethorphan) are commonly prescribed for symptomatic relief, although clinical evidence of effectiveness is scant.[1] [43]

          • Examples of suitable antitussives are presented here; however, other drugs may be available and you should consult your local drug information source. Some pediatric organizations do not recommend the use of dextromethorphan in children. Opioid cough suppressants are not recommended in children and adolescents <18 years of age.[71]

      • immunocompetent nonsevere

        • 1st

          watchful waiting

          Comments

          • Watchful waiting is an appropriate initial management approach for uncomplicated acute bacterial rhinosinusitis in otherwise healthy patients who have persistent but nonworsening symptoms.[1]​ The duration of watchful waiting depends on how long symptoms have been present at the time of diagnosis and may be only 3-5 days in patients diagnosed around day 10 after symptom onset.

          • A reliable follow-up process, with mechanisms for reassessment should the illness persist or worsen, is essential for patients managed with watchful waiting.[1]

        • plus

          supportive therapy

          Comments

          • Adequate rest and hydration and warm facial packs may be useful, as well as use of vitamin C and zinc.[4]​ Selection of therapy will depend on the specific symptoms.

        • adjunct

          antibiotic therapy

          Primary Options

            • amoxicillin

              children: 45-90 mg/kg/day orally given in 2 divided doses; adults: 500-1000 mg orally three times daily, or 875 mg orally twice daily

            • amoxicillin/clavulanate

              children: 45-90 mg/kg/day orally given in 2 divided doses; adults: 500-875 mg orally twice daily, or 2000 mg orally (extended-release) twice daily

          Secondary Options

            • clindamycin

              children: 30-40 mg/kg/day orally given in 3 divided doses; adults: 150-450 mg orally three times daily

              AND

            • cefixime

              children: 8 mg/kg/day orally given in 1-2 divided doses; adults: 400 mg orally once daily

              or

            • cefpodoxime proxetil

              children: 10 mg/kg/day orally given in 2 divided doses; adults: 200 mg orally twice daily

            • doxycycline

              adults: 100 mg orally twice daily, or 200 mg orally once daily

          Comments

          • Antibiotics are not usually recommended immediately in patients who are immunocompetent and who have nonsevere illness (i.e., absence of fever, mild facial or dental pain), as the majority of cases will resolve without them.[1]​[51]

          • Antibiotic therapy may be initiated if the patient's condition worsens or does not improve after 3-5 days of watchful waiting, or if symptoms persist or worsen beyond 14 days from onset.[1]

          • Amoxicillin or amoxicillin/clavulanate is the treatment of choice for most patients when antibiotic therapy is indicated.[1]

          • For patients with a penicillin allergy, a reasonable alternative is therapy with clindamycin plus third-generation cephalosporin (e.g., cefixime, cefpodoxime).[1] [2] [59]​​ There is a risk of cross-sensitivity with cephalosporins in these patients, although this risk is low if the allergic manifestation is simply a rash without respiratory involvement.[60]

          • Doxycycline is a suitable alternative in adults with allergies to beta-lactam antibiotics; however, its use is not recommended in children due to risk of tooth discoloration and dental enamel hypoplasia.[1] [61]

          • Fluoroquinolones should not be used in nonsevere infections.[1] [63] [72]

          • The recommended treatment course is unclear.[55] A 5-7 day treatment course for adults and 10-14 day course for children is reasonable.[1] [18] [65]

          • If the patient does not respond to treatment after 3-5 days, an alternative antibiotic (such as high-dose amoxicillin/clavulanate, a fluoroquinolone, or a cephalosporin), or an alternative, noninfectious etiology, should be considered.[1] [18] Another consideration should be an ear, nose, and throat specialist consultation.

        • adjunct

          analgesic/antipyretic

          Primary Options

            • acetaminophen

              children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

            • ibuprofen

              children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

          Secondary Options

            • acetaminophen/codeine

              children ≥12 years of age: consult specialist for guidance on dose; adults: 30-60 mg orally every 4-6 hours when required

          Comments

          • Recommended for pain and/or fever.[1]​ Selection of a specific drug depends on the subjective level of pain the patient is experiencing. Examples include acetaminophen, ibuprofen, or acetaminophen/codeine.

          • Codeine is contraindicated in children younger than 12 years of age, and it is not recommended in adolescents 12-18 years of age who are obese or have conditions such as obstructive sleep apnea or severe lung disease as it may increase the risk of breathing problems.[31] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[32] [33]

          • Examples of suitable analgesics/antipyretics are presented here; however, other drugs may be available and you should consult your local drug information source.

        • adjunct

          intranasal corticosteroid

          Primary Options

            • fluticasone propionate nasal

              (50 micrograms/spray) children ≥4 years of age and adults: 1-2 sprays in each nostril once daily

            • mometasone nasal

              (50 micrograms/spray) children 2-11 years of age: 1 spray in each nostril once daily; children ≥12 years of age: 2 sprays in each nostril once daily; adults: 2 sprays in each nostril once or twice daily

            • ciclesonide nasal

              (50 micrograms/spray) children ≥6 years of age and adults: 2 sprays in each nostril once daily; (37 micrograms/spray) children ≥12 years of age and adults: 1 spray in each nostril once daily

          Comments

          • Recommended in patients with congestion. Considered beneficial and has a low incidence of systemic adverse effects.[1]​​[34] [35]​​[36]

          • At least 1 month of therapy is usually recommended; however, this will depend on the disease course.

          • Examples of suitable intranasal corticosteroids are presented here; however, other drugs may be available and you should consult your local drug information source.

        • adjunct

          intranasal anticholinergic

          Primary Options

            • ipratropium bromide nasal

              children ≥6 years of age and adults: (0.03%) 42 micrograms (2 sprays) in each nostril two or three times daily

          Comments

          • Topical intranasal anticholinergics (e.g., ipratropium) can be used in patients with rhinorrhea.[37]

        • adjunct

          intranasal saline

          Comments

          • Saline sprays may be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing drug use.

          • Saline nasal irrigations may be helpful in relieving nasal symptoms; however, they should be used cautiously as patients who have not had an endoscopic sinus surgery may develop facial pressure or discomfort when the saline irrigations get trapped in the nonoperated sinuses.[38]

          • A home-prepared saline irrigation may be helpful for patients.[39] [40]​

        • adjunct

          antihistamine

          Primary Options

            • azelastine nasal

              (0.1%) children ≥12 years of age and adults: 274 micrograms (2 sprays) in each nostril twice daily

            • loratadine

              children 2-5 years of age: 5 mg orally once daily when required; children ≥6 years of age and adults: 10 mg orally once daily when required

          Comments

          • Intranasal antihistamines (e.g., azelastine) have shown inconclusive benefit for symptomatic relief, but could be helpful for patients with a history of allergic rhinitis.[1] [41]

          • There is limited evidence that oral antihistamines (e.g., loratadine) may provide relief from nasal congestion in patients with acute rhinosinusitis and allergic rhinitis, when used as an adjunctive therapy. However, these drugs may relieve nasal obstruction in allergic rhinitis patients with acute rhinosinusitis.[42]

          • Examples of suitable antihistamines are presented here; however, other drugs may be available and you should consult your local drug information source.

        • adjunct

          antitussive

          Primary Options

            • dextromethorphan

              adults: 30 mg orally (immediate-release) every 6-8 hours when required, maximum 120 mg/day

          Comments

          • Antitussives/cough suppressants (e.g., dextromethorphan) are commonly prescribed for symptomatic relief, although clinical evidence of effectiveness is scant.[1] [43]

          • Examples of suitable antitussives are presented here; however, other drugs may be available and you should consult your local drug information source. Some pediatric organizations do not recommend the use of dextromethorphan in children. Opioid cough suppressants are not recommended in children and adolescents <18 years of age.[71]

        • adjunct

          ear, nose, and throat (ENT) specialist referral

          Comments

          • Patients should be referred to an ENT specialist when condition is refractory to usual antibiotic treatment.[1]​[18]

          • The specialist may adjust antibiotic therapy to cover less common causative microorganisms (e.g., add metronidazole or clindamycin to cover anaerobes), reevaluate the patient for underlying conditions or anatomic abnormalities, or consider surgery.[18]

    • suspected acute invasive fungal rhinosinusitis

        • 1st

          immediate ear, nose, and throat (ENT) specialist referral

          Comments

          • Acute invasive fungal rhinosinusitis is a rare, rapidly progressive and life-threatening infection with a high mortality rate warranting immediate emergency referral and ENT consultation. Management consists of surgical debridement, systemic antifungal therapy, and correction of predisposing conditions.[18] [70]

  • ongoing
    Expand All

    • recurrent episodes

        • 1st

          ear, nose, and throat (ENT) specialist referral

          Comments

          • Patients should be referred to an ENT specialist when condition is recurrent (i.e., four or more episodes per year) or significantly affects quality of life.[1]​[18]

          • The specialist may adjust antibiotic therapy to cover less common causative microorganisms (e.g., add metronidazole or clindamycin to cover anaerobes), reevaluate the patient for underlying conditions or anatomic abnormalities, or consider surgery.[18]

Emerging Tx

Intranasal sodium hyaluronate

Intranasal sodium hyaluronate may improve olfaction, nasal congestion, and rhinorrhea as adjuvant therapy in conjunction with nebulized nasal saline.[73]

Prevention

Primary Prevention

Good hand washing practices (i.e., using soap or alcohol-based rubs) are recommended, especially when in contact with people who currently have an upper respiratory tract infection. Exposure to environmental irritants, such as cigarette smoke, pollutants, and allergens, should be avoided where possible.

Secondary Prevention

Secondary prevention measures may be useful for patients who have recurrent acute rhinosinusitis.
Good hand washing practices (i.e., using soap or alcohol-based rubs) are recommended, especially when in contact with people who are ill. Exposure to environmental irritants, such as cigarette smoke, pollutants, and allergens, should be avoided where possible.
Any underlying conditions should be assessed and treated appropriately. If recurrent episodes are due to the presence of allergies, consultation and evaluation with an otolaryngologist or allergist is considered beneficial.

Follow-Up Overview

Prognosis

In general, acute rhinosinusitis is a self-limiting disease and generally resolves within 1 month. However, the use of antibiotics in appropriately selected patients may limit the length and severity of symptoms.

Recurrence

Patients with structural anatomic variants (e.g., concha bullosa, deviated septum, infraorbital ethmoid cell) are more prone to develop recurrent acute rhinosinusitis and even persistent rhinosinusitis. Recurrence is also dependent on exposure to an exacerbating condition such as a viral upper respiratory tract infection.

Complications

Complications are more commonly seen in the pediatric population, and occur due to direct extension of the infection into neighboring structures. One database review in the US estimated the incidence of hospital admissions for acute rhinosinusitis among children and adolescents (ages <20 years) was 8.92 per 10,000 in 2016.[77] Severe complications are more common among boys.[77] [78]​
Orbital spread of infection with orbital cellulitis or orbital abscess represent the most common complications. Intracranial spread of infection resulting in meningitis or abscess is much less common.​[78] [79]
Concern about reducing the risk of serious complications can drive antibiotic prescribing for common infections such as acute rhinosinusitis, and use of antibiotics is the major driver of antibiotic resistance. One study found antibiotic use was associated with a lower risk of brain abscess following acute rhinosinusitis; however, thousands of patients would need to be treated to prevent a single instance of one complication.[79]​ In a stratified analysis, antibiotic prescribing was only associated with reduced odds of orbital cellulitis following acute rhinosinusitis, in those ages ≤20 years. Cases of brain abscess following acute rhinosinusitis only occurred in those ages >20 years, and antibiotic prescription was found to significantly reduce the likelihood of this outcome in this age group. Therefore, given the current threat from antibiotic resistance, lack of symptomatic benefit from antibiotic use for these conditions, and risk of adverse effects from antibiotics, these results should not change current recommendations not to prescribe antibiotics for the majority of cases of acute rhinosinusitis.[79]

Monitoring

No specific monitoring is required. However, patients with conditions that predispose them to developing acute rhinosinusitis, such as allergic rhinitis or asthma, may require further monitoring, including skin/blood testing and pulmonary function tests.

Complications

Low Likelihood

Timeframe

Expand All

chronic rhinosinusitis

variable

  • Defined as rhinosinusitis symptoms persisting 12 weeks or longer.[1]​

  • The microbial pathogens responsible for acute rhinosinusitis and chronic rhinosinusitis are different, so the empiric antibiotics of choice should reflect the likely causative bacteria.

variable

bacterial meningitis

variable

  • Although the true rate of bacterial meningitis from acute rhinosinusitis is unknown, it is considered to be uncommon. It occurs due to direct extension of the sinus infection.

  • A common organism associated with infection is Streptococcus milleri, which is often difficult to isolate from routine culture.[80]

  • Appropriate intravenous antibiotics and surgical intervention are the mainstays of management.

variable

subdural abscess

variable

  • Occurs due to direct extension of the sinus infection into the subdural space. Most common intracranial complication of rhinosinusitis.[81]

  • Commonly caused by S milleri.[80]

  • Subdural abscess is more common in adults than in children.[81] However, 25% of brain abscesses overall occur in children.[82]

  • Appropriate intravenous antibiotics, seizure prophylaxis, and surgical intervention are the mainstays of management.

  • Cerebral abscess results from extension of epidural abscess or subdural empyema into the brain parenchyma. Headache is most common sign, though fever, altered mental status, seizure, and other neurologic deficits are also possible.[81] Appropriate intravenous antibiotics, surgical drainage, and seizure prophylaxis are usual approaches to treatment. Cerebral (brain) abscess, epidural abscess, and subdural empyema are key suppurative intracranial complications.[83] These are rare conditions with widely varying treatment protocols.

  • Epidural abscess is purulence that develops between skull and dura mater. It occurs most often due to osteomyelitis of posterior table of frontal sinus.[83] It may be the most common intracranial complication of rhinosinusitis in children.[81]

variable

periorbital or orbital cellulitis

variable

  • Periorbital (preseptal) cellulitis occurs more commonly in children under 3 years of age, and does not affect vision.

  • Orbital (postseptal) cellulitis occurs more commonly in children over 3 years of age, and may cause vision impairment.

  • Periorbital cellulitis may develop into orbital cellulitis, which is a more serious condition that warrants hospital admission, and has a higher morbidity compared with periorbital cellulitis.

  • Mainstay of treatment is broad-spectrum antibiotics. Treatment is always empiric initially, with therapy targeted according to cultures, once known.

variable

subperiosteal abscess or orbital abscess

variable

  • Although the incidence is unknown, these are common enough that physicians who manage patients with acute rhinosinusitis should be familiar with these complications.

  • Diagnosis is made based on physical exam that demonstrates exophthalmos and periorbital erythema. CT scan confirms the diagnosis.

  • Appropriate empiric intravenous antibiotics and intravenous corticosteroids (in some cases) are the mainstays of management. However, patients with an abscess >2 cm and age >9 years are more likely to require surgical intervention. A meta-analysis found that approximately half of pediatric patients (<18 years) with a subperiosteal abscess undergo surgical drainage; abscess volume appears to be the most significant predictive risk factor.[84]

variable

cavernous sinus thrombosis

variable

  • Extremely rare, but should be considered as a possible complication.

  • Culture-directed intravenous antibiotic therapy, anticoagulation, and appropriate surgical intervention are important for optimal outcome.

variable

Pott puffy tumor

variable

  • Osteomyelitis of the frontal bone with subperiosteal abscess, resulting in forehead edema, headache, fever, and rhinorrhea. Common organisms associated with infection include Streptococcus and Staphylococcus species.[85]

  • Typically managed with a combination of intravenous antibiotics and surgery.[85] [86]

variable

Citations

    Key Articles

    • Payne SC, McKenna M, Buckley J, et al. Clinical practice guideline: adult sinusitis update. Otolaryngol Head Neck Surg. 2025 Aug;173 Suppl 1:S1-56.[Abstract][Full Text]

    • Orlandi RR, Kingdom TT, Smith TL, et al. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol. 2021 Mar;11(3):213-739.[Abstract]

    • Fokkens WJ, Lund VJ, Hopkins C, et al. European position paper on rhinosinusitis and nasal polyps 2020. Rhinology. 2020 Feb 20;58(suppl s29):1-464.[Abstract][Full Text]

    • Peters AT, Spector S, Hsu J, et al. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol. 2014 Oct;113(4):347-85.[Full Text]

    Referenced Articles

    • 1. Payne SC, McKenna M, Buckley J, et al. Clinical practice guideline: adult sinusitis update. Otolaryngol Head Neck Surg. 2025 Aug;173 Suppl 1:S1-56.[Abstract][Full Text]

    • 2. Orlandi RR, Kingdom TT, Smith TL, et al. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol. 2021 Mar;11(3):213-739.[Abstract]

    • 3. Hopkins C, Surda P, Walker A, et al. EPOS 4 patients. Rhinology. 2021 Oct 29;59(30 suppl):1-57.[Abstract]

    • 4. Fokkens WJ, Lund VJ, Hopkins C, et al. European position paper on rhinosinusitis and nasal polyps 2020. Rhinology. 2020 Feb 20;58(suppl s29):1-464.[Abstract][Full Text]

    • 5. Anand VK. Epidemiology and economic impact of rhinosinusitis. Ann Otol Rhinol Laryngol Suppl. 2004 May;193:3-5.[Abstract]

    • 6. Osguthorpe JD. Adult rhinosinusitis: diagnosis and management. Am Fam Physician. 2001 Jan 1;63(1):69-77.[Abstract][Full Text]

    • 7. Piccirillo JF. Clinical practice. Acute bacterial sinusitis. N Engl J Med. 2004 Aug 26;351(9):902-10.

    • 8. Chen Y, Dales R, Lin M. The epidemiology of chronic rhinosinusitis in Canadians. Laryngoscope. 2003 Jul;113(7):1199-205.[Abstract]

    • 9. Taylor A. Sinusitis. Pediatr Rev. 2006 Oct;27(10):395-7.

    • 10. Fireman P. Diagnosis of sinusitis in children: emphasis on the history and physical examination. J Allergy Clin Immunol. 1992 Sep;90(3 Pt 2):433-6.[Abstract]

    • 11. Smith SS, Ference EH, Evans CT, et al. The prevalence of bacterial infection in acute rhinosinusitis: a systematic review and meta-analysis. Laryngoscope. 2015 Jan;125(1):57-69.[Abstract][Full Text]

    • 12. Brook I. Microbiology and antimicrobial management of sinusitis. J Laryngol Otol. 2005 Apr;119(4):251-8.[Abstract]

    • 13. Jenkins SG, Farrell DJ, Patel M, et al. Trends in anti-bacterial resistance among Streptococcus pneumoniae isolated in the USA, 2000-2003: PROTEKT US years 1-3. J Infect. 2005 Dec;51(5):355-63.[Abstract]

    • 14. Martinez KA, Rood M, Rothberg MB. Coding bias in respiratory tract infections may obscure inappropriate antibiotic use. J Gen Intern Med. 2019 Jun;34(6):806-8.[Full Text]

    • 15. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: a practice parameter update. J Allergy Clin Immunol. 2020 Oct;146(4):721-67.[Abstract][Full Text]

    • 16. Eloy P, Poirrier AL, De Dorlodot C, et al. Actual concepts in rhinosinusitis: a review of clinical presentations, inflammatory pathways, cytokine profiles, remodeling, and management. Curr Allergy Asthma Rep. 2011 Apr;11(2):146-62.[Abstract]

    • 17. Meltzer EO, Hamilos DL, Hadley JA, et al; Rhinosinusitis Initiative. Rhinosinusitis: developing guidance for clinical trials. Otolaryngol Head Neck Surg. 2006 Nov;135(5 Suppl):S31-80.[Abstract]

    • 18. Peters AT, Spector S, Hsu J, et al. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol. 2014 Oct;113(4):347-85.[Full Text]

    • 19. Ebell MH, McKay B, Guilbault R, et al. Diagnosis of acute rhinosinusitis in primary care: a systematic review of test accuracy. Br J Gen Pract. 2016 Aug 1;66(650):e612-32.[Abstract][Full Text]

    • 20. Miller JM, Binnicker MJ, Campbell S, et al. Guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2024 update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis. 2024 Mar 5:ciae104.[Abstract][Full Text]

    • 21. Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008 Mar 15;371(9616):908-14.[Abstract]

    • 22. Dubin MG, Ebert CS, Coffey CS, et al. Concordance of middle meatal swab and maxillary sinus aspirate in acute and chronic sinusitis: a meta-analysis. Am J Rhinol. 2005 Sep-Oct;19(5):462-70.[Abstract]

    • 23. Frerichs N, Brateanu A. Rhinosinusitis and the role of imaging. Cleve Clin J Med. 2020 Jul 31;87(8):485-92.[Abstract][Full Text]

    • 24. American College of Radiology. ACR appropriateness criteria: sinonasal disease. 2021 [internet publication].[Full Text]

    • 25. American Academy of Allergy, Asthma & Immunology. Ten things physicians and patients should question. Choosing Wisely, an initiative of the ABIM Foundation. 2021 [internet publication].​[Full Text]

    • 26. Gendo K. Evidence-based diagnostic strategies for evaluating suspected allergic rhinitis. Ann Intern Med. 2004 Feb 17;140(4):278-89.[Abstract]

    • 27. Benoliel R, May A. Orofacial migraine-a narrative review. J Clin Med. 2024 Sep 26;13(19):5745.[Abstract][Full Text]

    • 28. Wald ER, Applegate KE, Bordley C, et al; American Academy of Pediatrics. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013 Jul;132(1):e262-80.[Abstract][Full Text]

    • 29. Desrosiers M, Evans GA, Keith PK, et al. Canadian clinical practice guidelines for acute and chronic rhinosinusitis. Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2.[Abstract][Full Text]

    • 30. Aring AM, Chan MM. Current concepts in adult acute rhinosinusitis. Am Fam Physician. 2016 Jul 15;94(2):97-105.[Abstract][Full Text]

    • 31. US Food and Drug Administration. FDA drug safety communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. Apr 2017 [internet publication].[Full Text]

    • 32. Medicines and Healthcare products Regulatory Agency. Codeine: restricted use as analgesic in children and adolescents after European safety review. Jun 2013 [internet publication].[Full Text]

    • 33. European Medicines Agency. Restrictions on use of codeine for pain relief in children - CMDh endorses PRAC recommendation. Jun 2013 [internet publication].[Full Text]

    • 34. Meltzer EO, Bachert C, Staudinger H. Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo. J Allergy Clin Immunol. 2005 Dec;116(6):1289-95.[Abstract][Full Text]

    • 35. Hayward G, Heneghan C, Perera R, et al. Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis. Ann Fam Med. 2012 May-Jun;10(3):241-9.[Abstract][Full Text]

    • 36. Zalmanovici Trestioreanu A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2013 Dec 2;(12):CD005149.[Abstract][Full Text]

    • 37. AlBalawi ZH, Othman SS, Alfaleh K. Intranasal ipratropium bromide for the common cold. Cochrane Database Syst Rev. 2013 Jun 19;(6):CD008231.[Abstract][Full Text]

    • 38. King D, Mitchell B, Williams CP, et al. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev. 2015 Apr 20;(4):CD006821.[Abstract][Full Text]

    • 39. Papsin B, McTavish A. Saline nasal irrigation: its role as an adjunct treatment. Can Fam Physician. 2003 Feb;49:168-73.[Abstract]

    • 40. Rabago D, Zgierska A. Saline nasal irrigation for upper respiratory conditions. Am Fam Physician. 2009 Nov 15;80(10):1117-9.[Abstract]

    • 41. Butler FM, Hernandez DR. Acute rhinosinusitis: rapid evidence review. Am Fam Physician. 2025 Jan;111(1):47-53.[Abstract]

    • 42. Seresirikachorn K, Khattiyawittayakun L, Chitsuthipakorn W, et al. Antihistamines for treating rhinosinusitis: systematic review and meta-analysis of randomised controlled studies. J Laryngol Otol. 2017 Sep 13;132(2):105-10.[Abstract]

    • 43. Benninger MS, Holy CE, Trask DK. Acute rhinosinusitis: prescription patterns in a real-world setting. Otolaryngol Head Neck Surg. 2016 May;154(5):957-62.[Abstract]

    • 44. Shaikh N, Wald ER. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2014 Oct 27;(10):CD007909.[Abstract][Full Text]

    • 45. European Medicines Agency. Pseudoephedrine-containing medicinal products - referral. Mar 2024 [internet publication].​[Full Text]

    • 46. Macchi A, Terranova P, Castelnuovo P. Recurrent acute rhinosinusitis: a single blind clinical study of N-acetylcysteine vs ambroxol associated to corticosteroid therapy. Int J Immunopathol Pharmacol. 2012 Jan-Mar;25(1):207-17.[Abstract]

    • 47. Romano FR, Anselmo-Lima WT, Kosugi EM, et al. Rhinosinusitis: evidence and experience - 2024. Braz J Otorhinolaryngol. 2025 Sep-Oct;91(5):101595.[Abstract][Full Text]

    • 48. Venekamp RP, Thompson MJ, Hayward G, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev. 2014 Mar 25;2014(3):CD008115.[Abstract][Full Text]

    • 49. Lemiengre MB, van Driel ML, Merenstein D, et al. Antibiotics for acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2018 Sep 10;(9):CD006089.[Abstract][Full Text]

    • 50. Smith MJ. Evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children: a systematic review. Pediatrics. 2013 Jul;132(1):e284-96.[Abstract][Full Text]

    • 51. Guarch Ibáñez B, Buñuel Álvarez JC, López Bermejo A, et al. The role of antibiotics in acute sinusitis: a systematic review and meta-analysis [in Spanish]. An Pediatr (Barc). 2011 Mar;74(3):154-60.[Abstract]

    • 52. Garbutt JM, Banister C, Spitznagel E, et al. Amoxicillin for acute rhinosinusitis: a randomized controlled trial. JAMA. 2012 Feb 15;307(7):685-92.[Abstract]

    • 53. Conway SJ, Mueller GD, Shaikh N. Antibiotics for acute sinusitis in children: a meta-analysis. Pediatrics. 2024 May 1;153(5):e2023064244.[Abstract]

    • 54. Shaikh N, Hoberman A, Shope TR, et al. Identifying children likely to benefit from antibiotics for acute sinusitis: a randomized clinical trial. JAMA. 2023 Jul 25;330(4):349-58.[Abstract][Full Text]

    • 55. Falagas ME, Giannopoulou KP, Vardakas KZ, et al. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomized controlled trials. Lancet Infect Dis. 2008 Sep;8(9):543-52.[Abstract]

    • 56. Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the ACP and the CDC. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016 Mar 15;164(6):425-34.[Abstract][Full Text]

    • 57. Babela R, Jarcuska P, Uraz V, et al. Decision and cost analysis of empirical antibiotic therapy of acute sinusitis in the era of increasing antimicrobial resistance: do we have an additional tool for antibiotic policy decisions? Neuro Endocrinol Lett. 2017 Nov;38(suppl1):9-26.[Abstract]

    • 58. Rosenfeld RM. Clinical Practice. Acute sinusitis in adults. N Engl J Med. 2016 Sep 8;375(10):962-70.

    • 59. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012 Apr;54(8):e72-112.[Abstract][Full Text]

    • 60. Pichichero ME, Zagursky R. Penicillin and cephalosporin allergy. Ann Allergy Asthma Immunol. 2014 May;112(5):404-12.

    • 61. Gaillard T, Briolant S, Madamet M, et al. The end of a dogma: the safety of doxycycline use in young children for malaria treatment. Malar J. 2017 Apr 13;16(1):148.[Abstract][Full Text]

    • 62. US Food and Drug Administration. FDA drug safety communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. Jul 2016 [internet publication].[Full Text]

    • 63. Adefurin A, Sammons H, Jacqz-Aigrain E, et al. Ciprofloxacin safety in paediatrics: a systematic review. Arch Dis Child. 2011 Sep;96(9):874-80.[Abstract][Full Text]

    • 64. Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804.[Abstract][Full Text]

    • 65. National Institute for Health and Care Excellence. Sinusitis (acute): antimicrobial prescribing. Oct 2017 [internet publication].[Full Text]

    • 66. Palms DL, Hicks LA, Bartoces M, et al. First-line antibiotic selection in outpatient settings. Antimicrob Agents Chemother. 2019 Nov;63(11):e01060-19.[Abstract][Full Text]

    • 67. Ryan MA, Leu GR, Boss EF, et al. Adherence to American Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines: a systematic review. Otolaryngol Head Neck Surg. 2020 Oct;163(4):626-44.[Abstract]

    • 68. McCoul ED. Assessment of pharmacologic ingredients in common over-the-counter sinonasal medications. JAMA Otolaryngol Head Neck Surg. 2020 Sep 1;146(9):810-5.[Abstract][Full Text]

    • 69. Abuelgasim H, Albury C, Lee J. Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis. BMJ Evid Based Med. 2021 Apr;26(2):57-64.[Abstract]

    • 70. Ahmed Y, Delaney S, Markarian A. Successful isavuconazole therapy in a patient with acute invasive fungal rhinosinusitis and acquired immune deficiency syndrome. Am J Otolaryngol. 2015 Dec 9;37(2):152-5.[Abstract]

    • 71. Food and Drug Administration. FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older. Jan 2018 [internet publication].​[Full Text]

    • 72. Medicines and Healthcare products Regulatory Agency. Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects. Mar 2019 [internet publication].[Full Text]

    • 73. Ciofalo A, de Vincentiis M, Zambetti G, et al. Olfactory dysfunction in acute rhinosinusitis: intranasal sodium hyaluronate as adjuvant treatment. Eur Arch Otorhinolaryngol. 2016 Aug 27;274(2):803-8.[Abstract]

    • 74. Intermountain Healthcare. Care process model: diagnosis and management of sinusitis in adults and children - 2023 update. Jul 2023 [internet publication].[Full Text]

    • 75. Malaysia Health Technology Assessment Section (MaHTAS). Management of rhinosinusitis in adults and adolescents. 2016 [internet publication].[Full Text]

    • 76. Mion OG, Mello JF Jr, Dutra DL, et al. Position statement of the Brazilian Academy of Rhinology on the use of antihistamines, antileukotrienes, and oral corticosteroids in the treatment of inflammatory sinonasal diseases. Braz J Otorhinolaryngol. 2017 Jan 21;83(2):215-27.[Abstract][Full Text]

    • 77. Levy DA, Pecha PP, Nguyen SA, et al. Trends in complications of pediatric rhinosinusitis in the United States from 2006 to 2016. Int J Pediatr Otorhinolaryngol. 2020 Jan;128:109695.[Abstract]

    • 78. Hultman Dennison S, Hertting O, Bennet R, et al. A Swedish population-based study of complications due to acute rhinosinusitis in children 5-18 years old. Int J Pediatr Otorhinolaryngol. 2021 Nov;150:110866.[Abstract][Full Text]

    • 79. Cushen R, Francis NA. Antibiotic use and serious complications following acute otitis media and acute sinusitis: a retrospective cohort study. Br J Gen Pract. 2020 Apr;70(693):e255-63.[Abstract][Full Text]

    • 80. Han JK, Kerschner JE. Streptococcus milleri: an organism for head and neck infections and abscess. Arch Otolaryngol Head Neck Surg. 2001 Jun;127(6):650-4.[Abstract][Full Text]

    • 81. Carr TF. Complications of sinusitis. Am J Rhinol Allergy. 2016 Jul;30(4):241-5.[Abstract]

    • 82. Mameli C, Genoni T, Madia C, et al. Brain abscess in pediatric age: a review. Childs Nerv Syst. 2019 Jul;35(7):1117-1128.[Abstract]

    • 83. Ziegler A, Patadia M, Stankiewicz J. Neurological Complications of Acute and Chronic Sinusitis. Curr Neurol Neurosci Rep. 2018 Feb 5;18(2):5.[Abstract]

    • 84. Adil EA, Muir ME, Kawai K, et al. Pediatric subperiosteal abscess secondary to acute sinusitis: a systematic review and meta-analysis. Laryngoscope. 2020 Dec;130(12):2906-12.[Abstract]

    • 85. Rohde RL, North LM, Murray M, et al. Pott's puffy tumor: a comprehensive review of the literature. Am J Otolaryngol. 2022 Sep-Oct;43(5):103529.[Abstract][Full Text]

    • 86. Klivitsky A, Erps A, Regev A, et al. Pott's puffy tumor in pediatric patients: case series and literature review. Pediatr Infect Dis J. 2023 Oct 1;42(10):851-6.[Abstract]

Guidelines

Diagnostic

  • Clinical practice guideline: adult sinusitis update[1]​​

    Summary

    Evidence-based guidelines on the diagnosis of acute rhinosinusitis in adults.

    Published by

    American Academy of Otolaryngology-Head and Neck Surgery Foundation

    Published

    2025

  • Guide to utilization of the microbiology laboratory for diagnosis of infectious diseases[20]

    Summary

    Provides recommendations on the use of appropriate microbiology sampling and test methods for diagnosing infectious diseases, including recommendations on acute rhinosinusitis.

    Published by

    Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)

    Published

    2024

  • ACR appropriateness criteria: sinonasal disease[24]

    Summary

    Evidence-based guidelines that rate the appropriateness of imaging procedures for sinonasal disease.

    Published by

    American College of Radiology

    Published

    2021

  • Diagnosis and management of rhinosinusitis: a practice parameter update[18]

    Summary

    Evidence-based guidelines on the diagnosis of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps. Update of guidelines from 1998 and 2005.

    Published by

    American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology

    Published

    2014

  • Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years[28]

    Summary

    Guidelines that discuss the diagnosis of sinusitis in children and adolescents.

    Published by

    American Academy of Pediatrics

    Published

    2013

  • Canadian clinical practice guidelines for acute and chronic rhinosinusitis[29]

    Summary

    Evidence-based guidelines that discuss the diagnosis of acute and chronic rhinosinusitis.

    Published by

    Association of Medical Microbiology and Infectious Disease Canada; Canadian Society of Allergy and Clinical Immunology; Canadian Society of Otolaryngology - Head and Neck Surgery; Canadian Association of Emergency Physicians; Family Physicians Airways Group of Canada

    Published

    2011

  • European position paper on rhinosinusitis and nasal polyps 2020[4]

    Summary

    Evidence-based guidelines for the diagnosis of acute and chronic rhinosinusitis.

    Published by

    European Rhinologic Society; European Academy of Allergology and Clinical Immunology

    Published

    2020

Treatment

  • Clinical practice guideline: adult sinusitis update[1]​​

    Summary

    Evidence-based guidelines on the management of acute rhinosinusitis in adults.

    Published by

    American Academy of Otolaryngology-Head and Neck Surgery Foundation

    Published

    2025

  • Diagnosis and management of sinusitis in adults and children: 2023 update[74]

    Summary

    Provides best-practice recommendations for diagnosis and management of acute sinusitis in adult and pediatric patients including guidance for when and which antibiotics should be used for acute bacterial sinusitis.

    Published by

    Intermountain Healthcare

    Published

    2023

  • Appropriate antibiotic use for acute respiratory tract infection in adults[56]

    Summary

    Recommendations for the appropriate use of antibiotics for acute respiratory tract infection in adults.

    Published by

    American College of Physicians; Centers for Disease Control and Prevention

    Published

    2016

  • Diagnosis and management of rhinosinusitis: a practice parameter update[18]

    Summary

    Evidence-based guidelines on the treatment of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps. Update of guidelines from 1998 and 2005.

    Published by

    American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology

    Published

    2014

  • Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years[28]

    Summary

    Guidelines that discuss the treatment of sinusitis in children and adolescents.

    Published by

    American Academy of Pediatrics

    Published

    2013

  • Canadian clinical practice guidelines for acute and chronic rhinosinusitis[29]

    Summary

    Evidence-based guidelines that discuss the treatment of acute and chronic rhinosinusitis.

    Published by

    Association of Medical Microbiology and Infectious Disease Canada; Canadian Society of Allergy and Clinical Immunology; Canadian Society of Otolaryngology - Head and Neck Surgery; Canadian Association of Emergency Physicians; Family Physicians Airways Group of Canada

    Published

    2011

  • European position paper on rhinosinusitis and nasal polyps 2020[4]

    Summary

    Evidence-based guidelines for the management of acute and chronic rhinosinusitis.

    Published by

    European Rhinologic Society; European Academy of Allergology and Clinical Immunology

    Published

    2020

  • Management of rhinosinusitis in adolescents and adults[75]

    Summary

    Evidence-based guidelines on the management of rhinosinusitis in adolescents and adults.

    Published by

    Malaysia Health Technology Assessment Section (MaHTAS)

    Published

    2016

  • Position statement of the Brazilian Academy of Rhinology on the use of antihistamines, antileukotrienes, and oral corticosteroids in the treatment of inflammatory sinonasal diseases[76]

    Summary

    Evidence-based guidelines on the use of antihistamines, antileukotrienes, and oral corticosteroids in the treatment of inflammatory sinonasal diseases.

    Published by

    Brazilian Academy of Rhinology

    Published

    2017

  • Sinusitis (acute): antimicrobial prescribing[65]

    Summary

    This guideline sets out an antimicrobial prescribing strategy for acute sinusitis.

    Published by

    National Institute for Health and Care Excellence

    Published

    2017

Credits

Authors

Topic last updated: 2026-08-04

Gordon H. Sun, MD, MBA, MSc

Director of Specialty Care

High Desert Health Center Group

Lancaster, CA

Clinical Associate Professor of Otolaryngology-Head and Neck Surgery

Charles R. Drew University of Medicine and Science

Los Angeles, CA

[disclosures]

Acknowledgements:

Dr Gordon H. Sun would like to gratefully acknowledge Dr Melissa A. Pynnonen and Dr Joseph K. Han, previous contributors to this topic.

[disclosures]

Peer Reviewers

Michael S. Benninger, MD

Professor of Otolaryngology Head and Neck Surgery

Cleveland Clinic

Lerner College of Medicine

Cleveland

OH

[disclosures]

Daniel Merenstein, MD

Director of Research Family Medicine

Georgetown University

Washington, DC

[disclosures]

Amin R. Javer​, ​MD, FRCSC, FARS

​Clinical Professor

Division of Otolaryngology

University of British Columbia

Vancouver

Canada

[disclosures]

Patient Instructions

Patients should be instructed to notify their physician if symptoms do not improve as expected. Pain and fever should begin to improve within 2-3 days without treatment in patients with acute viral rhinosinusitis. Nasal obstruction and drainage may take a week or more to improve. Patients should be advised to avoid cigarette smoke, environmental pollutants and allergens, alcohol, air travel, and diving in deep water. Warm facial packs and nasal saline irrigation may be useful. Adequate sleep and hydration should be encouraged. If air travel is unavoidable, advise patients to avoid stress, ensure a good night's sleep before traveling, stay well hydrated, and avoid alcohol and caffeine.
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