Acute rhinosinusitis

Highlights & Basics

Key Highlights

Majority of cases of acute rhinosinusitis in adults and children are of viral etiology.
Duration of symptoms more than 10 days often indicates bacterial cause.
Imaging is not required for diagnosis unless complications are suspected.
Condition is usually self-limiting; however, symptomatic therapy should be considered.
Antibiotics are only recommended in select patient groups (e.g., severe disease, persistent or worsening symptoms, or immunocompromised patients) because symptoms often resolve without intervention and there is a risk of antimicrobial resistance.
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

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 discharge
  - nasal obstruction
  - facial pain/pressure
  - severe symptoms at onset (acute bacterial rhinosinusitis)
  - dental pain
- Other Factors
  - cough
  - sore throat
  - hyposmia
  - 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
    - decongestant
    - intranasal corticosteroid
    - ipratropium
    - intranasal saline
More information...

Definition

Acute rhinosinusitis (also 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. "Rhinosinusitis" is the preferred term as sinusitis is usually accompanied by nasal airway inflammation and is preceded by rhinitis in most cases.[1] [2] It can be caused by either a viral or a bacterial infection.[1]

Classifications

Types of rhinosinusitis

Duration of symptoms:[1]

Acute: ≤4 weeks
Subacute: 4-12 weeks
Chronic: ≥12 weeks
Recurrent acute: ≥4 episodes per year.

Severity:[3]

Characterized according to the presence of fever with purulent nasal discharge, moderate to severe facial or dental pain, or periorbital swelling lasting for at least 3-4 days.

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 over-the-counter 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.

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.

Images

Right inferior turbinate and septum are visible prior to decongestant spray
Right middle turbinate and middle meatus are visible after decongestant spray
Left middle meatus with severe edema and 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
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 levels
Normal noncontrast computed tomography scan of the sinuses

Diagnostic Approach

Diagnosis is primarily based on the history and physical exam. There is usually no need for further investigations unless there are complications present. In most cases the diagnosis is made presumptively. 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] [3] Symptoms that worsen after an initial improvement (so-called "double sickening") suggest secondary bacterial infection following viral rhinosinusitis.[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, purulent nasal discharge, and fever.

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. Optimal exam is performed after topical decongestant spray.[18] 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.[23] [24] They cannot differentiate viral from bacterial rhinosinusitis.[15] [24] Imaging may expose patients to radiation and intravenous contrast unnecessarily.[23]

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] In this setting the study may be used to confirm the diagnosis of rhinosinusitis or rule out an alternative diagnosis.[1] For further details, see Chronic rhinosinusitis without nasal polyps .

Computed tomography (CT) scan

CT scan with contrast is the imaging study of choice for acute rhinosinusitis with suspected complications.[1] [24] However, do not order CT scans for uncomplicated acute rhinosinusitis. This is generally diagnosed clinically and does not require confirmation with imaging.[24] [25]
Findings consistent with, but not diagnostic of, acute rhinosinusitis include sinus opacification, air-fluid level, or marked or severe mucosal thickening.[1] [24]
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. 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] [3]

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] [3] [4][17]

common

purulent nasal discharge

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). A nonspecific symptom that may be present in viral or bacterial rhinosinusitis.

common

nasal obstruction

common

Refers to congestion, stuffiness, or blockage. 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.

common

hyposmia

common

Loss of sense of smell may be present in both acute viral and bacterial rhinosinusitis.

common

edematous turbinate

common

Associated with any inflammation of the nasal cavity lining, whether allergic, viral, or bacterial in etiology. Decongestion of the turbinate is essential prior to inspection of the middle meatus for purulence.[18]

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.[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. 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]
CT scan with contrast is the imaging study of choice for acute rhinosinusitis with suspected complications.[1] [24] Sinus opacification, air-fluid level, or marked or severe mucosal thickening is consistent with, but not diagnostic of, acute rhinosinusitis.[1] 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.
Sensitivity to light or noise.
Aura.
Nausea.
Symptoms decrease if sitting/lying in a quiet, dark room.
Absence of purulent nasal discharge.
Differentiating Tests
Diagnosis is clinical; there are no differentiating tests.[27] Radiologic tests may exclude features of acute bacterial rhinosinusitis.
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

This is generally a self-limiting disease, and treatment is primarily symptomatic. The disease course is usually less than 10 days, but symptoms tend to improve after approximately 3-5 days.[31] Adequate rest and hydration, warm facial packs, and nasal saline irrigation may be useful, as well as use of vitamin C, zinc, or over-the-counter medications, 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] [3]

Analgesics/antipyretics

Recommended for pain and/or fever.
Examples include acetaminophen, ibuprofen, or acetaminophen/codeine. Selection of agent 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 to 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.[32] 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.[33] [34]

Decongestants

May restore sinus ostial patency and provide symptomatic relief of nasal congestion.[1] [15] However, evidence is lacking.[35]
Topical agents (e.g., oxymetazoline) are often preferred over systemic agents (e.g., pseudoephedrine) because of increased potency and less risk of adverse effects. Pseudoephedrine-containing medications 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 medications should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[36]
Topical agents should only be used for up to 3-5 days, to prevent the occurrence of rebound congestion.

Intranasal corticosteroids

Recommended in patients with congestion; considered beneficial and have a low incidence of systemic adverse effects.[1] [37] [38] [39]
May decrease allergic response in patients with allergic rhinitis, and therefore decrease swelling associated with rhinosinusitis.[1]
At least 1 month of therapy is usually recommended; however, this will depend on the disease course.

Topical anticholinergics (e.g., ipratropium)

Recommended in adults with rhinorrhea.[40]

Intranasal saline irrigations/sprays

May also be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing medication 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.[41]
The following instructions for a home-prepared saline irrigation may be helpful for patients:University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis
- Add 1 cup (240 mL) of distilled water to a clean container. If using tap water, boil it first to sterilize it, and then let it cool down.
- Add half a teaspoon (2.5 g) of salt to the water.
- Add half a teaspoon (2.5 g) of baking soda.
- This solution can be stored at room temperature for 3 days.
- To use the homemade solution, fill a large medical syringe, squeeze bottle, or nasal cleansing pot with the solution, insert the tip into the nostril, and squeeze gently.
- Aim the stream of solution toward the back of the head.
- The solution should go through the nose and out of the mouth or the other nostril.
- Gently blow the nose after using the solution, unless instructed otherwise.
- Repeat several times every day.
- Clean the syringe or bottle after each use.

Expectorants

Guaifenesin 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] [3] [39] [42] [43]

For nonsevere symptoms in immunocompetent people, some guidelines recommend watchful waiting for up to 10 days with symptomatic therapy before instituting subsequent antibiotic therapy, as the majority of nonsevere cases will resolve without them.[1] [44] However, immediate antibiotic therapy can shorten the duration of symptoms, so may be used if the benefits (i.e., eradication of infection, improvement in symptoms, reduced duration of illness) outweigh the risks (i.e., adverse effects, cost, need for follow-up, increased bacterial resistance) of therapy.[1] [3] [45]

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.[3] In this context, current guidelines recommend more broad-spectrum first-line therapy for acute bacterial rhinosinusitis (ABRS).[1] [3] 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] [3] [44] 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.[46] 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.[47] One 2023 RCT found that antibiotic therapy in pediatric patients with acute rhinosinusitis provided minimal benefit if the patient did not have nasopharyngeal pathogens on presentation.[48]
Guidelines generally recommend antibiotic therapy for immunocompromised patients or those with severe illness. Indicators of severe illness include:[1] [3] [45] [49]
- 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] [50]
Although guidelines vary in their recommendations, studies have not demonstrated a difference in clinical outcomes between various antibiotic regimens.[51]
Amoxicillin or amoxicillin/clavulanate has generally been recommended as a first-line agent for nonsevere disease in immunocompetent people, owing to its safety, efficacy, and low cost.[1] One pediatric cohort study found there was no difference in treatment failure rates between the use of amoxicillin or amoxicillin/clavulanate for acute rhinosinusitis, but amoxicillin/clavulanate was associated with a higher risk of gastrointestinal symptoms and yeast infections.[52] A pharmacokinetically enhanced extended-release formulation of amoxicillin/clavulanate can be used for the treatment of acute bacterial rhinosinusitis caused by penicillin-resistant Streptococcus pneumoniae.[53] High-dose amoxicillin/clavulanate is recommended as first-line therapy for patients who have severe disease or are immunocompromised.[1]
For penicillin-allergic patients, a reasonable alternative is therapy with clindamycin plus an oral third-generation cephalosporin (e.g., cefuroxime, cefpodoxime).[2] [54] 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.[55]
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.[56]
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.[57] 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.[58] 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.[59]
- 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 formulary for more information on suitability, contraindications, and precautions.
The recommended treatment course is unclear.[45] However, a 5-7 day course for adults and 10-14 day course for children is reasonable for most antibiotics for non-severe illness.[1] [3] [60] A 10-14 day course is reasonable for immunocompromised patients or those with severe disease.[1] [3]
If there is no symptom improvement after 3-5 days of antibiotic treatment, an alternative should be considered.[3]
Intravenous antibiotics (e.g., third-generation cephalosporin, fluoroquinolone) may be required in patients with infection that requires hospitalization.

Antibiotic resistance

The prevalence of penicillin-resistant S pneumoniae, both intermediate- and high-level resistance, may be up to 35%.[1] [13] Even so, high-dose amoxicillin remains effective against intermediate-resistant pneumococci of variable susceptibilities.[61]
The prevalence of macrolide-resistant S pneumoniae is likely to be >40%.[1] [13]
H influenzae and M catarrhalis develop penicillin resistance as a result of beta-lactamase production, with prevalence ranging from 27% to 60%, and approaching 100% in some study populations.[1] [2] [13]
Antibiotic resistance depends on the geographic location. Therefore, an understanding of local antibiotic protocols is important before prescribing a specific antibiotic. If the patient does not respond to treatment after 3-5 days, an alternative antibiotic (such as high-dose amoxicillin/clavulanate, a quinolone, or a cephalosporin), or an alternative, noninfectious etiology, should be considered.[3]
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).[62] 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.[63]

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 over-the-counter medications including analgesics/antipyretics, decongestants, and intranasal saline sprays.[41] There may be a modest clinical benefit from use of intranasal corticosteroids.[1] [4] [39] No studies conclusively support the use of the other symptomatic therapies.[35] Products available over the counter can contain numerous different active ingredients and doses; therefore, clinicians should be cautious when recommending specific products for symptom relief.[64] 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.[65]

Specialist referral

Referral to an ear, nose, and throat specialist may be indicated when:[1] [3]

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., 4 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.[3]

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.[3] [66]

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.
      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. Selection of agent 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 to 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.[32] 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.[33] [34]
    - adjunct
      decongestant
      Primary Options
      oxymetazoline nasal
      children 2-5 years of age: (0.025%) 2-3 sprays/drops into each nostril twice daily when required; children >5 years of age and adults: (0.05%) 1-2 sprays/drops into each nostril twice daily when required
      Secondary Options
      pseudoephedrine
      adults: 30-60 mg orally every 4-6 hours when required, maximum 240 mg/day
      Comments
      May provide symptomatic relief of nasal congestion.[1] [15]
      Topical agents (e.g., oxymetazoline) are often preferred over systemic agents (e.g., pseudoephedrine) because of increased potency and less risk of adverse effects.
      Pseudoephedrine-containing medications 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 medications should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[36]
      Topical agents should only be used for up to 3-5 days, to prevent the occurrence of rebound congestion.
    - 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] [37] [38] [39]
      At least 1 month of therapy is usually recommended; however, this will depend on the disease course.
    - adjunct
      ipratropium
      Primary Options
      ipratropium bromide nasal
      children ≥6 years of age: (0.03%) 42 micrograms (2 sprays) in each nostril two or three times daily; adults: (0.06%) 84 micrograms (2 sprays) in each nostril three times daily
      Comments
      Topical anticholinergics such as ipratropium can be used in patients with rhinorrhea.[40]
    - adjunct
      intranasal saline
      Primary Options
      saline nasal
      children and adults: 1-2 sprays/drops into each nostril every 2-3 hours or when required
      Comments
      Saline sprays may be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing medication 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.[41]
      A home-prepared saline irrigation may be helpful for patients.University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis
- 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
      Guidelines generally recommend antibiotic therapy for immunocompromised patients or those with severe illness. 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.[1] [3] [45] [49]
      Although guidelines may vary in their recommendations for empiric antibiotics, studies have not demonstrated a difference in clinical outcomes between various antibiotic regimens.[51]
      High-dose amoxicillin/clavulanate is recommended as a first-line agent for people who have severe disease or are immunocompromised, owing to the increased endemic rates of beta-lactamase-producing S pneumoniae.[1] High-dose amoxicillin/clavulanate is effective against pneumococci of variable susceptibilities.[61]
      For penicillin-allergic patients, a reasonable alternative is therapy with clindamycin plus an oral third-generation cephalosporin (e.g., cefixime, cefpodoxime).[2] [54] 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.[55]
      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.[56]
      Fluoroquinolones should only be used in patients with acute bacterial rhinosinusitis who do not have other treatment options.[57] 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.[58] 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.[59] 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 formulary for more information on suitability, contraindications, and precautions.
      The recommended treatment course is unclear.[45] However, 10-14 days is reasonable, particularly for immunocompromised patients or those with severe disease.[1] [3]
      If there is no improvement in symptoms after 3-5 days of antibiotic treatment, an alternative should be considered.[3] 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 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.[3]
    - 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. Selection of agent 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.[32] 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.[33] [34]
    - adjunct
      decongestant
      Primary Options
      oxymetazoline nasal
      children 2-5 years of age: (0.025%) 2-3 sprays/drops into each nostril twice daily when required; children >5 years of age and adults: (0.05%) 1-2 sprays/drops into each nostril twice daily when required
      Secondary Options
      pseudoephedrine
      adults: 30-60 mg orally every 4-6 hours when required, maximum 240 mg/day
      Comments
      May provide symptomatic relief of nasal congestion.[1]
      Topical agents (e.g., oxymetazoline) are often preferred over systemic agents (e.g., pseudoephedrine) because of increased potency and less risk of adverse effects.
      Pseudoephedrine-containing medications 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 medications should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[36]
      Topical agents should only be used for up to 3-5 days, to prevent the occurrence of rebound congestion.
    - 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] [37] [39]
      At least 1 month of therapy is usually recommended; however, this will depend on the disease course.
    - adjunct
      intranasal saline
      Primary Options
      saline nasal
      children and adults: 1-2 sprays/drops into each nostril every 2-3 hours or when required
      Comments
      Saline sprays may be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing medication 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.[41]
      A home-prepared saline irrigation may be helpful for patients.University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis
  - immunocompetent nonsevere
    - 1st
      watchful waiting for up to 10 days, or immediate commencement of antibiotics, and supportive therapy
      Comments
      Some guidelines recommend watchful waiting for up to 10 days with symptomatic therapy before instituting subsequent antibiotic therapy, as the majority of nonsevere cases will resolve without them.[1] [44] However, immediate antibiotic therapy can shorten the duration of symptoms, so may be used if the benefits (i.e., eradication of infection, improvement in symptoms, reduced duration of illness) outweigh the risks (i.e., adverse effects, cost, need for follow-up, increased bacterial resistance) of therapy.[1] [3] [45]
      For supportive therapy, 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
      cefuroxime axetil
      children: 30 mg/kg/day orally given in 2 divided doses; adults: 250-500 mg orally twice 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] [44]
      However, immediate antibiotic therapy can shorten the duration of symptoms, so may be used if the benefits (i.e., eradication of infection, improvement in symptoms, reduced duration of illness) outweigh the risks (i.e., adverse effects, cost, need for follow-up, increased bacterial resistance) of therapy.[1] [3] [45]
      Amoxicillin or amoxicillin/clavulanate has generally been recommended as a first-line agent for nonsevere disease in immunocompetent people, owing to its safety, efficacy, and low cost.[1] One pediatric cohort study found there was no difference in treatment failure rates between the use of amoxicillin or amoxicillin/clavulanate for acute rhinosinusitis, but amoxicillin/clavulanate was associated with a higher risk of gastrointestinal symptoms and yeast infections.[52]
      For penicillin-allergic patients, a reasonable alternative is therapy with clindamycin plus third-generation cephalosporin (e.g., cefuroxime, cefpodoxime).[2] [54] 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.[55]
      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.[56]
      Fluoroquinolones should not be used in nonsevere infections.[58] [67]
      The recommended treatment course is unclear.[45] However, a 5-7 day course for adults and 10-14 day course for children is reasonable.[1] [3] [60]
      If there is no improvement in symptoms after 3-5 days of treatment, an alternative antibiotic should be considered.[3] 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. Selection of agent 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.[32] 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.[33] [34]
    - adjunct
      decongestant
      Primary Options
      oxymetazoline nasal
      children 2-5 years of age: (0.025%) 2-3 sprays/drops into each nostril twice daily when required; children >5 years of age and adults: (0.05%) 1-2 sprays/drops into each nostril twice daily when required
      Secondary Options
      pseudoephedrine
      adults: 30-60 mg orally every 4-6 hours when required, maximum 240 mg/day
      Comments
      May provide symptomatic relief of nasal congestion.[1] [15]
      Topical agents (e.g., oxymetazoline) are often preferred over systemic agents (e.g., pseudoephedrine) because of increased potency and less risk of adverse effects.
      Pseudoephedrine-containing medications 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 medications should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[36]
      Topical agents should only be used for up to 3-5 days, to prevent the occurrence of rebound congestion.
    - 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] [37] [39]
      At least 1 month of therapy is usually recommended; however, this will depend on the disease course.
    - adjunct
      intranasal saline
      Primary Options
      saline nasal
      children and adults: 1-2 sprays/drops into each nostril every 2-3 hours or when required
      Comments
      Saline sprays may be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing medication 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.[41]
      A home-prepared saline irrigation may be helpful for patients.University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis
    - 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] [3]
      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.[3]
- suspected acute invasive fungal rhinosinusitis
  - - 1st
      immediate ear, nose, and throat 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.[3] [66]
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., 4 or more episodes per year) or significantly affects quality of life.[1] [3]
      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.[3]

Emerging Tx

Antihistamines

There is limited evidence that antihistamines, such as loratadine, may provide relief from nasal congestion in patients with acute rhinosinusitis and allergic rhinitis, as an adjunctive therapy. However, these may relieve nasal obstruction in allergic rhinitis patients with acute rhinosinusitis.[68]

Intranasal sodium hyaluronate

Intranasal sodium hyaluronate may improve olfaction, nasal congestion, and rhinorrhea as adjuvant therapy in conjunction with nebulized nasal saline.[69]

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.[73] Severe complications are more common among boys.[73] [74]

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.[74] [75]

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.[75] 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.[75]

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.[76]
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.[77]
Commonly caused by S milleri.[76]
Subdural abscess is more common in adults than in children.[77] However, 25% of brain abscesses overall occur in children.[78]
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.[77] 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.[79] 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.[79] It may be the most common intracranial complication of rhinosinusitis in children.[77]

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.[80]

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.[81]
Typically managed with a combination of intravenous antibiotics and surgery.[81] [82]

variable

Citations

Key Articles

Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015 Apr;152(2 Suppl):S1-39.[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]
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]
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]

Other Online Resources

University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis

Referenced Articles

1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015 Apr;152(2 Suppl):S1-39.[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. 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]
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. Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003 Sep;129(3 Suppl):S1-32.
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. Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1337-45.[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. Hopkins C, Surda P, Walker A, et al. EPOS 4 patients. Rhinology. 2021 Oct 29;59(30 suppl):1-57.[Abstract]
32. 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]
33. 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]
34. European Medicines Agency. Restrictions on use of codeine for pain relief in children - CMDh endorses PRAC recommendation. Jun 2013 [internet publication].[Full Text]
35. 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]
36. European Medicines Agency. Pseudoephedrine-containing medicinal products - referral. Mar 2024 [internet publication].[Full Text]
37. 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]
38. 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]
39. Zalmanovici Trestioreanu A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2013 Dec 2;(12):CD005149.[Abstract][Full Text]
40. 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]
41. 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]
42. 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]
43. 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]
44. 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]
45. 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]
46. 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]
47. Conway SJ, Mueller GD, Shaikh N. Antibiotics for acute sinusitis in children: a meta-analysis. Pediatrics. 2024 May 1;153(5):e2023064244.[Abstract]
48. 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]
49. 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]
50. 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]
51. Rosenfeld RM. Clinical Practice. Acute sinusitis in adults. N Engl J Med. 2016 Sep 8;375(10):962-70.
52. Savage TJ, Kronman MP, Sreedhara SK, et al. Treatment failure and adverse events after amoxicillin-clavulanate vs amoxicillin for pediatric acute sinusitis. JAMA. 2023 Sep 19;330(11):1064-73.[Abstract][Full Text]
53. Anon JB, Ferguson B, Twynholm M, et al. Pharmacokinetically enhanced amoxicillin/clavulanate (2000/125 mg) in acute bacterial rhinosinusitis caused by Streptococcus pneumoniae, including penicillin-resistant strains. Ear Nose Throat J. 2006 Aug;85(8):500, 502, 504.[Abstract]
54. 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]
55. Pichichero ME, Zagursky R. Penicillin and cephalosporin allergy. Ann Allergy Asthma Immunol. 2014 May;112(5):404-12.
56. 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]
57. 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]
58. 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]
59. 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]
60. National Institute for Health and Care Excellence. Sinusitis (acute): antimicrobial prescribing. Oct 2017 [internet publication].[Full Text]
61. Harrison CJ, Woods C, Stout G, et al. Susceptibilities of Haemophilus influenzae, Streptococcus pneumoniae, including serotype 19A, and Moraxella catarrhalis paediatric isolates from 2005 to 2007 to commonly used antibiotics. J Antimicrob Chemother. 2009 Mar;63(3):511-9.[Abstract][Full Text]
62. 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]
63. 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]
64. 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]
65. 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]
66. 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]
67. 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]
68. 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]
69. 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]
70. Intermountain Healthcare. Care process model: diagnosis and management of sinusitis in adults and children - 2023 update. Jul 2023 [internet publication].[Full Text]
71. Malaysia Health Technology Assessment Section (MaHTAS). Management of rhinosinusitis in adults and adolescents. 2016 [internet publication].[Full Text]
72. 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]
73. 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]
74. 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]
75. 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]
76. 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]
77. Carr TF. Complications of sinusitis. Am J Rhinol Allergy. 2016 Jul;30(4):241-5.[Abstract]
78. 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]
79. Ziegler A, Patadia M, Stankiewicz J. Neurological Complications of Acute and Chronic Sinusitis. Curr Neurol Neurosci Rep. 2018 Feb 5;18(2):5.[Abstract]
80. 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]
81. 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]
82. 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

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
Clinical practice guideline: adult sinusitis [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
2015
Diagnosis and management of rhinosinusitis: a practice parameter update [3]
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 on the diagnosis of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps. Update of guidelines from 2005, 2007, and 2012. It provides evidence-based recommendations and integrated care pathways in acute rhinosinusitis.
Published by
European Rhinologic Society
Published
2020

Treatment

Diagnosis and management of sinusitis in adults and children: 2023 update [70]
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 [49]
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
Clinical practice guideline: adult sinusitis [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
2015
Diagnosis and management of rhinosinusitis: a practice parameter update [3]
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
The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence-based position papers published in 2005, 2007, and 2012. It provides revised, up-to-date, and clear evidence-based recommendations and integrated care pathways in ARS and CRS. It involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis.
Published by
European Rhinologic Society
Published
2020
Management of rhinosinusitis in adolescents and adults [71]
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 [72]
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 [60]
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: 2025-05-01

Gordon H. Sun, MD, MBA, MSc

Director of Specialty Care

High Desert Regional Health Center

Lancaster

Clinical Associate Professor of Otolaryngology-Head and Neck Surgery

Charles R. Drew University of Medicine and Science

Los Angeles

[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

[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.[1] 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, avoid alcohol and caffeine, and consider using intranasal decongestant spray just before boarding the flight.

Diseases

Highlights & Basics

Quick Reference

Definition

Classifications

Vignette

Epidemiology

Etiology

Pathophysiology

Images

Diagnostic Approach

History

Physical exam

Investigations

Imaging

Risk Factors

viral upper respiratory tract infection

allergic rhinitis

History & Exam

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 discharge

nasal obstruction

facial pain/pressure

severe symptoms at onset (acute bacterial rhinosinusitis)

dental pain

cough

sore throat

hyposmia

edematous turbinate

fever

Tests

clinical diagnosis

nasal endoscopy

sinus culture

CT sinuses

MRI

lateral neck x-ray

allergy testing

Differential Diagnosis

Allergic rhinitis

Nonallergic rhinitis

Migraine

Adenoiditis

Treatment Approach

Acute viral rhinosinusitis

Acute bacterial rhinosinusitis

Specialist referral

Treatment Options

suspected acute viral rhinosinusitis

suspected acute bacterial rhinosinusitis

suspected acute invasive fungal rhinosinusitis

recurrent episodes

Emerging Tx

Antihistamines

Intranasal sodium hyaluronate

Prevention

Primary Prevention

Secondary Prevention

Follow-Up Overview

Prognosis

Monitoring

Complications

chronic rhinosinusitis

bacterial meningitis

subdural abscess

periorbital or orbital cellulitis

subperiosteal abscess or orbital abscess

cavernous sinus thrombosis

Pott puffy tumor

Citations

Key Articles

Other Online Resources

Referenced Articles

Guidelines

Diagnostic

Summary

Summary