Symptoms of Acute Sinusitis
Acute sinusitis typically presents as persistent upper respiratory tract infection symptoms lasting 10-14 days without improvement, characterized primarily by nasal congestion, purulent rhinorrhea (often unilateral), facial pain or tenderness, and postnasal drainage. 1
Key Symptoms
Major Symptoms
Nasal symptoms:
- Nasal congestion/obstruction
- Purulent rhinorrhea (anterior and/or posterior)
- Postnasal drainage
- Hyposmia (decreased sense of smell)
Pain-related symptoms:
- Facial pain or pressure (often unilateral)
- Pain that increases when bending forward
- Dental pain (particularly with maxillary sinusitis)
- Headache (location varies by sinus involvement)
Other prominent symptoms:
- Cough (often worse at night)
- Fever (more common in severe cases)
Location-Specific Symptoms 1
- Maxillary sinusitis: Unilateral or bilateral infraorbital pain that increases when bending forward; sometimes pulsatile and worse in evening/night
- Frontal sinusitis: Supraorbital headache
- Fronto-ethmoidal sinusitis: Filling of inner angle of eye, palpebral edema, retro-orbital headache
- Sphenoidal sinusitis: Permanent retro-orbital headache radiating to vertex; purulent discharge on posterior pharyngeal wall
Less Common Symptoms 1
- Nausea
- Malaise
- Irritability
- Fatigue
- Halitosis (bad breath)
- Sore throat
Special Considerations in Children
Children with acute sinusitis may present differently, with: 1
- Increased irritability
- Vomiting associated with gagging on mucus
- Prolonged cough
Warning Signs of Complications
Urgent evaluation is needed with any of these signs: 1, 2
- Orbital swelling or pain
- Swelling of the forehead
- Visual changes or diplopia (double vision)
- Proptosis (bulging eye)
- Abnormal extraocular movements
- Periorbital inflammation/edema/erythema
- Neurological symptoms
- Severe headache preventing sleep
- High fever
Diagnostic Criteria
Acute sinusitis can be diagnosed clinically based on: 2
- Persistent symptoms - URI symptoms lasting >7-10 days without improvement
- Severe symptoms - High fever with purulent nasal discharge for 3-4 consecutive days
- Worsening symptoms - Initial improvement followed by worsening ("double sickening")
Physical Examination Findings
- Tenderness over involved sinuses
- Dark circles beneath eyes
- Periorbital edema
- Mucosal erythema and purulent secretions on nasal examination
- Pharyngeal erythema
- Purulent material in posterior pharynx
- Middle ear effusions may be present
Distinguishing from Viral Upper Respiratory Infections
Viral rhinitis typically presents with diffuse, bilateral symptoms of moderate intensity with congestion and serous discharge, often in an epidemic context. Bacterial sinusitis should be suspected when symptoms persist beyond 10 days, are severe, or worsen after initial improvement. 1
Pitfalls to Avoid
- Overdiagnosis of sinusitis leading to unnecessary antibiotic use
- Failure to recognize warning signs of complications requiring urgent care
- Mistaking dental infections for sinusitis (or vice versa)
- Overlooking the possibility of underlying allergic rhinitis as a contributing factor
In summary, acute sinusitis presents with a constellation of nasal and facial symptoms that persist beyond the typical duration of a viral URI. Proper recognition of the symptoms pattern is essential for appropriate management and to avoid complications.