What are the treatment options for an adult experiencing sinus and ear pain?

Treatment of Sinus and Ear Pain in Adults

For an adult with sinus and ear pain, first distinguish between viral rhinosinusitis (symptoms <10 days) and acute bacterial rhinosinusitis (symptoms ≥10 days or worsening after initial improvement), as this determines whether antibiotics are needed; symptomatic relief with analgesics, intranasal corticosteroids, and saline irrigation should be offered regardless of etiology. 1

Initial Diagnostic Approach

The key clinical decision is determining whether the patient has viral versus bacterial rhinosinusitis, as this fundamentally changes management 1:

• Viral rhinosinusitis (VRS): Symptoms present for <10 days from onset 1
• Acute bacterial rhinosinusitis (ABRS): Either symptoms ≥10 days OR symptoms that worsen within 10 days after initial improvement (double-worsening pattern) 1

Do not obtain imaging (X-rays or CT) for patients meeting diagnostic criteria for acute rhinosinusitis unless complications or alternative diagnoses are suspected 1. The ear pain is typically secondary to nasal congestion affecting Eustachian tube function 2.

Treatment Algorithm

For Viral Rhinosinusitis (<10 days of symptoms)

Symptomatic relief only—no antibiotics 1:

• Analgesics: Acetaminophen or ibuprofen for pain and fever 1
• Intranasal corticosteroids: May reduce symptoms after 15 days of use, though benefit is modest (number needed to treat = 14) 1
• Nasal saline irrigation: Relieves symptoms and removes mucus 1
• Decongestants: May help breathing; nasal sprays limited to ≤3 days to avoid rebound congestion 1

Avoid antihistamines and oral corticosteroids routinely—they have side effects without proven benefit 1. Oral corticosteroids as monotherapy are ineffective for acute sinusitis 3.

For Acute Bacterial Rhinosinusitis (≥10 days or double-worsening)

You have two evidence-based options 1:

Option 1: Watchful Waiting

• Delay antibiotics for up to 7 days to see if symptoms resolve spontaneously 1
• Provide symptomatic relief as above 1
• Most patients improve naturally; antibiotics only modestly increase symptom relief (number needed to treat = 10-15) 1
• Appropriate for patients with mild illness (mild pain, temperature <38.3°C/101°F) and assured follow-up 1

Option 2: Immediate Antibiotic Therapy

If prescribing antibiotics, use amoxicillin with or without clavulanate as first-line therapy for 5-10 days 1:

• Standard dosing: Amoxicillin-clavulanate 875 mg/125 mg every 12 hours for respiratory tract infections 4
• Alternative: Amoxicillin-clavulanate 500 mg/125 mg every 8 hours 4
• For penicillin allergy: Respiratory fluoroquinolones (levofloxacin or moxifloxacin) or cephalosporins if not anaphylactically sensitive 5

Always assess and treat pain severity as a strong recommendation 1. Continue symptomatic measures (analgesics, intranasal steroids, saline irrigation) alongside antibiotics 1.

For Diabetic Patients with Maxillary Sinus Pain

Use amoxicillin-clavulanate as preferred first-line therapy for 10-14 days or until symptom-free for 7 days 5. Avoid short-course antibiotics like 5-day azithromycin, which are insufficient for complete eradication in diabetic patients 5.

Reassessment and Treatment Failure

If the patient worsens or fails to improve within 7 days, reassess to confirm ABRS, exclude other causes, and detect complications 1:

• Evaluate response after 3-5 days of antibiotic therapy 5
• Consider changing antibiotics if no improvement 5
• Most patients feel better within 7 days; by 15 days, approximately 90% are cured or improved 1

When to Consider Chronic Rhinosinusitis

If symptoms persist >12 weeks, the diagnosis shifts to chronic rhinosinusitis (CRS) 1:

• Assess for modifying factors: allergic rhinitis, anatomic variations, immunocompromised state 6
• CT imaging is appropriate for diagnosing or evaluating CRS 6
• Consider nasal endoscopy and testing for allergy/immune function 6

Addressing Ear Pain Specifically

The ear pain in rhinosinusitis is typically secondary otalgia from Eustachian tube dysfunction due to nasal congestion 2, 7:

• Intranasal corticosteroids help manage nasal congestion affecting the ear 2
• If ear pain persists despite treating rhinosinusitis, examine the ear for primary otalgia (otitis media, otitis externa) 7
• Topical otic analgesics (antipyrine-benzocaine) can provide symptomatic relief for ear pain and congestion 8

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for viral rhinosinusitis (<10 days without worsening)—this promotes resistance without benefit 1
• Do not obtain routine imaging for uncomplicated acute rhinosinusitis 1
• Do not use antihistamines or oral corticosteroids routinely—they lack proven benefit and have side effects 1
• Do not attribute persistent symptoms to psychogenic causes without thorough evaluation 9
• Do not miss red flags: fever with constitutional symptoms, neurological signs, ophthalmological involvement, or severe unilateral symptoms warrant immediate further evaluation 1, 9