What are the typical symptoms of sinusitis and recommended treatment options?

Sinusitis: Symptoms and Treatment

Sinusitis is diagnosed when at least two of the following symptoms persist: purulent nasal discharge (anterior or posterior), nasal obstruction/congestion, facial pain/pressure, or decreased sense of smell, with acute sinusitis lasting less than 4 weeks and chronic sinusitis persisting for 8 weeks or longer. 1

Clinical Symptoms

Acute Sinusitis (< 4 weeks)

The cardinal symptoms include:

• Purulent rhinorrhea (anterior and/or posterior, often unilateral)
• Nasal congestion/obstruction
• Facial pain or pressure (particularly over affected sinuses, worsening when bending forward)
• Headache
• Fever
• Cough
• Decreased sense of smell (anosmia)
• Postnasal drainage

1

Physical examination may reveal mucosal erythema, purulent secretions in the nasal cavity, and sinus tenderness on palpation. 1

Chronic Sinusitis (≥ 8 weeks)

Symptoms are similar but may be more subtle or vague:

• Nasal obstruction (most common: 81-95%)
• Facial congestion/pressure/fullness (70-85%)
• Discolored nasal discharge (51-83%)
• Hyposmia (61-69%)

2, 3, 4

Important caveat: Chronic sinusitis requires objective evidence on CT/MRI or endoscopy showing inflammation, not just symptoms alone. 1, 2

When to Suspect Bacterial Sinusitis

Bacterial sinusitis should be suspected when:

1. Persistent symptoms for >10 days without improvement
2. Severe symptoms (high fever >37.5°C and purulent discharge) for 3-4 consecutive days
3. Worsening symptoms after initial improvement ("double sickening")

5, 6, 7

Critical warning signs requiring immediate evaluation: facial swelling/erythema, visual changes, abnormal eye movements, proptosis, periorbital edema, altered mental status, or severe headache preventing sleep. These suggest complications requiring hospitalization. 1, 8

Treatment Approach

Acute Bacterial Sinusitis

First-line antibiotic: Amoxicillin is the drug of choice for both children and adults—it is effective, inexpensive, and well-tolerated. 1

Treatment algorithm:

1. Start amoxicillin for 3-5 days and assess response
2. If improving: Continue until patient is well for 7 days (typically 10-14 day total course)
3. If no improvement after 3-5 days: Switch to:
   • High-dose amoxicillin-clavulanate (90 mg/kg amoxicillin and 6.4 mg/kg clavulanate, not exceeding 2g every 12 hours), OR
   • Cefuroxime axetil, cefpodoxime, cefprozil, or cefdinir

1

For penicillin allergy:

• Adults: Trimethoprim-sulfamethoxazole, macrolides, or quinolones
• Consider cephalosporins if not severe allergy

1

For treatment failure (21-28 days): Use broader-spectrum agents covering resistant organisms (β-lactamase producing H. influenzae, M. catarrhalis, drug-resistant S. pneumoniae):

• High-dose amoxicillin-clavulanate
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) for severe cases or frontal/sphenoid sinusitis
• Consider adding anaerobic coverage (clindamycin or metronidazole) if needed

8, 1, 2

Adjunctive Therapies

Nasal corticosteroids may be helpful in both acute and chronic sinusitis, though efficacy is not definitively proven for acute cases. 1

Short-term oral corticosteroids are reasonable when:

• Patient fails initial treatment
• Nasal polyposis present
• Marked mucosal edema demonstrated

1

Supportive measures:

• Adequate rest and hydration
• Analgesics as needed
• Warm facial packs
• Steamy showers
• Sleep with head elevated
• Nasal saline irrigation (first-line for chronic sinusitis)

1, 3

Chronic Sinusitis

First-line treatment:

• Nasal saline irrigation
• Intranasal corticosteroid sprays

3

Antibiotics have a limited role in chronic sinusitis unless there is evidence of acute superimposed bacterial infection. Chronic hyperplastic eosinophilic sinusitis does not respond to antibiotics and may require systemic corticosteroids. 1, 3, 4

Referral indications:

• Failure of first-line medical therapy
• Recurrent sinusitis (≥3 episodes per year)
• Structural abnormalities (septal deviation, nasal polyps)
• Suspected immunodeficiency or comorbidities
• Radiographic evidence of ostiomeatal obstruction despite aggressive medical management

1, 3

Surgical intervention: Functional endoscopic sinus surgery may be effective when medical management fails, but maximize medical treatment first. Most patients benefit from continued medical therapy after surgery. 1

Important Clinical Pitfalls

• Do not routinely order imaging for uncomplicated acute sinusitis—plain radiographs have significant false-positive and false-negative results. 1
• Do not use antibiotics for viral upper respiratory infections or symptoms <10 days without severe features
• Nasal polyps in children are uncommon and should prompt evaluation for cystic fibrosis. 1
• Evaluate for underlying allergic rhinitis in recurrent or chronic cases—this requires specific treatment beyond antibiotics. 1
• Complete the antibiotic course even if symptoms improve to prevent relapse and ensure organism eradication. 1