Is a persistent cough common after bacterial sinusitis?

Persistent Cough After Bacterial Sinusitis

Yes, persistent cough after bacterial sinusitis is common and well-recognized as a manifestation of upper airway cough syndrome (UACS), which can occur both during active infection and as a postinfectious phenomenon. 1

Understanding the Mechanism

The cough associated with bacterial sinusitis occurs through two primary pathways:

• During active infection: Persistent inflammation of the nose and paranasal sinuses leads to upper airway cough syndrome (previously called postnasal drip syndrome), which directly triggers cough 1
• Postinfectious phase: Even after bacterial eradication, extensive disruption of epithelial integrity and widespread airway inflammation can persist, causing cough that may last 3-8 weeks (subacute cough) 1

Clinical Presentation Patterns

The cough from bacterial sinusitis can be either productive or nonproductive—a critical point often missed in clinical practice. 1

• Chronic sinusitis may cause productive cough with excessive sputum (>30 mL/day), though UACS is the cause only about one-third of the time in these cases 1
• More commonly, the cough is relatively or completely nonproductive, and typical acute sinusitis findings may be absent—this "clinically silent" presentation is frequently overlooked 1
• Cough is frequently worse at night, which is a cardinal symptom of sinusitis 2

Duration and Natural History

The timeline matters significantly for diagnosis and management:

• Postinfectious cough is defined as lasting >3 weeks after acute symptoms but resolving within 8 weeks (subacute cough category) 1
• The cough eventually resolves on its own in most cases, with normal chest radiograph findings ruling out pneumonia 1
• Chronic sinusitis (>90 days) is defined by persistent respiratory symptoms including cough, rhinorrhea, or nasal obstruction 1

Key Diagnostic Considerations

When evaluating persistent cough after bacterial sinusitis:

• A history of upper respiratory tract infection is the key to diagnosis 1
• The pathogenesis involves extensive inflammation and disruption of upper and/or lower airway epithelial integrity, with possible mucus hypersecretion and transient airway hyperresponsiveness 1
• Importantly, antibiotics have no role in treating postinfectious cough unless there is ongoing bacterial sinusitis 1

Treatment Approach

For postinfectious cough following bacterial sinusitis:

• First-generation antihistamine combined with a decongestant (e.g., pseudoephedrine) is the recommended treatment, similar to acute common cold management 1
• Inhaled ipratropium may be helpful for lower airway involvement 1
• If bacterial sinusitis is still active (evidenced by sinus opacification, air-fluid levels, or significant mucosal thickening), antibiotic therapy is indicated 1

Common Pitfalls to Avoid

• Don't assume all persistent cough after sinusitis requires continued antibiotics—most postinfectious cough is not due to ongoing bacterial infection 1
• Don't overlook that mucosal thickening <8 mm on imaging is associated with sterile sinus aspirates 100% of the time; antibiotic therapy was needed for cough resolution in only 29% of cases with mucosal thickening alone 1
• Consider alternative diagnoses if cough persists beyond 8 weeks, including asthma, gastroesophageal reflux (which can be triggered by vigorous coughing), or underlying conditions like allergic rhinitis 1
• In children with recurrent or chronic sinusitis and cough, always consider underlying causes such as asthma, gastroesophageal reflux, cystic fibrosis, obstructive sleep apnea, or allergic rhinitis 1