What are the typical symptoms of sinusitis?

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Last updated: October 3, 2026 • View editorial policy

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Symptoms of Sinusitis

The cardinal symptoms of sinusitis are purulent (cloudy or colored) nasal drainage accompanied by either nasal obstruction/congestion OR facial pain-pressure-fullness—you need purulent drainage plus at least one of these other two symptoms to diagnose sinusitis. 1, 2

Primary (Cardinal) Symptoms

The three most diagnostically important symptoms are:

  • Purulent nasal discharge (anterior, posterior, or both): This is cloudy or colored drainage, NOT the clear secretions typical of viral upper respiratory infections. This can be reported by the patient or observed on examination 1

  • Nasal obstruction: Reported as congestion, blockage, or stuffiness 1, 2

  • Facial pain-pressure-fullness: May involve the anterior face, periorbital region, or present as localized or diffuse headache 1

Critical diagnostic caveat: Facial pain or nasal obstruction alone, WITHOUT purulent nasal drainage, is insufficient to diagnose sinusitis 1. Many patients with "sinus headaches" actually have migraines or other primary headache disorders if purulent drainage is absent 2.

Additional Symptoms

Secondary symptoms that may accompany the cardinal features include:

  • Cough (often worse at night) 3
  • Headache 3
  • Reduced or absent sense of smell (hyposmia/anosmia) 3
  • Fever 3
  • Maxillary dental pain 3, 1
  • Ear fullness or pressure 1, 2
  • Fatigue/malaise 3, 1
  • Sore throat 3, 2
  • Halitosis (bad breath) 3

Timing Distinguishes Viral from Bacterial Sinusitis

The duration and pattern of symptoms determines whether sinusitis is viral or bacterial:

  • Viral rhinosinusitis: Symptoms present <10 days without worsening 1, 2

  • Acute bacterial rhinosinusitis (ABRS): Either:

    • Symptoms persist ≥10 days without improvement, OR
    • Symptoms worsen within 10 days after initial improvement ("double worsening") 1, 2

Important clinical pearl: Fever alone does NOT distinguish bacterial from viral sinusitis—it has only 50% sensitivity and specificity for bacterial infection 2. Fever may occur in the first few days of viral illness but is not a reliable diagnostic criterion by itself.

Physical Examination Findings

Clinical signs that may be present include:

  • Tenderness overlying the sinuses 3
  • Dark circles beneath the eyes (periorbital edema) 3
  • Purulent drainage visible in nasal cavity or posterior pharynx (the only physical finding with proven diagnostic value) 1
  • Mucosal erythema on nasal examination 3

Chronic Sinusitis Presentation

For chronic sinusitis (symptoms ≥8-12 weeks), patients present with:

  • At least 2 of the 4 cardinal symptoms: facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal obstruction 4
  • Symptoms may be more vague or insidious compared to acute presentations 3
  • Requires objective evidence on examination or imaging 4

Pediatric Considerations

Children with acute sinusitis may additionally exhibit:

  • Increased irritability 3
  • Vomiting associated with gagging on mucus 3
  • Prolonged cough 3

Red Flag Symptoms Requiring Urgent Evaluation

Any patient with the following needs immediate assessment for complications:

  • Orbital swelling or pain
  • Swelling of the forehead
  • Diplopia (double vision)
  • Visual changes
  • Proptosis
  • Periorbital inflammation/edema/erythema
  • Neurologic signs suggesting intracranial involvement 3

References

1
Guideline

clinical practice guideline (update): adult sinusitis.

Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2015

2
Guideline

clinical practice guideline: adult sinusitis update.

Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2025

3
Guideline

the diagnosis and management of sinusitis: a practice parameter update.

Journal of Allergy and Clinical Immunology, 2005

4
Research

Chronic Rhinosinusitis.

American family physician, 2017

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.