Symptoms of Bacterial Sinusitis
The key symptoms of bacterial sinusitis include nasal congestion, purulent rhinorrhea, facial pain/pressure (especially when unilateral), postnasal drainage, and headache, with purulent nasal discharge being the most indicative symptom. 1
Distinguishing Bacterial from Viral Sinusitis
Bacterial sinusitis is suspected when:
- Upper respiratory infection symptoms persist beyond 10-14 days without improvement 2, 1
- Symptoms worsen after initial improvement (double worsening) 1
- Unusually severe symptoms occur during the first several days 1
Key Symptoms in Adults
- Purulent rhinorrhea (yellow-green nasal discharge) - highest specificity for bacterial infection 1
- Nasal congestion/obstruction - very common but less specific when occurring alone 2, 1
- Facial pain/pressure - especially when unilateral and focused in a particular sinus region 2
- Postnasal drainage - contributes to cough and throat discomfort 2
- Headache - often worsens when bending forward 2
- Cough - particularly when persistent 2
- Hyposmia/anosmia (reduced/lost sense of smell) - more common in chronic cases 1
- Less frequent symptoms: fever, fatigue, maxillary dental pain, ear pressure/fullness, halitosis, and sore throat 2
Additional Symptoms in Children
Children with bacterial sinusitis may also experience:
- Increased irritability
- More prolonged cough
- Vomiting associated with gagging on mucus 2
Objective Signs on Physical Examination
The most reliable objective signs include:
- Purulent nasal secretions (colored, opaque discharge)
- Mucosal erythema
- Sinus tenderness on palpation
- Increased pharyngeal secretions 2, 1
Important Clinical Considerations
Diagnostic Pitfalls
Color of nasal discharge alone is not diagnostic: Mucopurulent nasal secretions may occur after a few days of viral infection due to neutrophil influx 2, 1
Facial pain alone has a broad differential diagnosis: Should not be interpreted as sinusitis without purulent nasal discharge 1
Duration is critical: Viral URIs typically improve within 7-10 days, while bacterial sinusitis persists or worsens 2
Risk Factors for Bacterial Sinusitis
- Allergic rhinitis
- Anatomic abnormalities (septal deviation, concha bullosa)
- Nasal polyps
- Immunodeficiency
- Cystic fibrosis
- Ciliary dyskinesia
- Rhinitis medicamentosa
- Cocaine abuse 2, 1
Microbiology
The most common bacterial pathogens in acute bacterial sinusitis are:
In chronic rhinosinusitis, the predominant pathogens include:
- Staphylococcus aureus (including MRSA strains)
- Anaerobic bacteria (Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species) 4, 5
When to Suspect Complications
Immediate medical attention is warranted for:
- Severe facial swelling
- Orbital involvement (periorbital edema, vision changes)
- Neurological symptoms
- Persistent high fever
- Failure to respond to appropriate antibiotic therapy 1
Remember that bacterial sinusitis is diagnosed primarily through clinical assessment. While imaging studies can confirm the diagnosis, they are not routinely required for uncomplicated cases. The presence of purulent nasal discharge along with facial pain/pressure and symptoms persisting beyond 10-14 days strongly suggests bacterial rather than viral etiology.