What is the best course of treatment for a 45-year-old patient with a 5-day history of worsening sore throat and sinus symptoms, including sinus pressure and congestion, who has not taken any medication for the symptoms?

Management of 5-Day Sore Throat with Sinus Symptoms

This patient requires testing for group A streptococcal pharyngitis with a rapid antigen detection test or throat culture, and should receive symptomatic treatment with analgesics while awaiting results; antibiotics should only be prescribed if streptococcal testing is positive. 1

Initial Diagnostic Approach

Assess for Bacterial vs. Viral Etiology

For the sore throat component:

• The 5-day duration of worsening symptoms warrants streptococcal testing, as this patient has persistent symptoms suggestive of possible bacterial pharyngitis 1
• Test with rapid antigen detection test and/or throat culture for group A Streptococcus before prescribing antibiotics 1
• Look specifically for: persistent fevers, anterior cervical adenitis, tonsillopharyngeal exudates, or absence of cough and coryza (which suggest viral etiology) 1

For the sinus symptoms:

• At 5 days duration, this is most likely viral acute rhinosinusitis, as fewer than 2% of viral upper respiratory infections are complicated by acute bacterial rhinosinusitis 1
• Acute bacterial rhinosinusitis should only be suspected when symptoms persist >10 days without improvement, symptoms are severe (fever >39°C, purulent nasal discharge, or facial pain for >3 consecutive days), or symptoms worsen after initial improvement ("double sickening") 1
• This patient does not meet criteria for bacterial sinusitis at 5 days 1, 2

Immediate Symptomatic Management

Analgesic Therapy (Start Now)

• Offer ibuprofen or acetaminophen for pain relief from sore throat 1
• Throat lozenges can provide additional symptomatic relief 1
• Consider nasal saline irrigation for sinus congestion 2

Supportive Care Measures

• Adequate rest and hydration 2
• Warm facial packs and steamy showers to relieve sinus congestion 2
• Reassure the patient that typical viral sore throat resolves in less than 1 week 1

Antibiotic Decision Algorithm

If Streptococcal Test is POSITIVE:

• Prescribe penicillin V (or amoxicillin for better palatability) for 10 days 1
• This shortens symptom duration by 1-2 days and prevents complications like peritonsillar abscess and acute rheumatic fever 1
• First-generation cephalosporins or erythromycin for penicillin-allergic patients 1, 3

If Streptococcal Test is NEGATIVE:

• Do NOT prescribe antibiotics for the sore throat 1
• Continue symptomatic management only 1
• The sinus symptoms at 5 days do not warrant antibiotics as they represent viral rhinosinusitis 1

When to Reassess for Bacterial Sinusitis

Instruct the patient to return or call if:

• Symptoms persist beyond 10 days without improvement 1, 2
• Development of high fever (>39°C), severe purulent nasal discharge, or severe facial pain lasting >3 consecutive days 1
• Initial improvement followed by worsening symptoms ("double sickening") 1

Only at that point would bacterial sinusitis be suspected and antibiotics considered:

• First-line: Amoxicillin 1.5-4g/day for 10-14 days 2
• If no response in 3-5 days: High-dose amoxicillin-clavulanate (2g every 12 hours) 2
• Consider adding intranasal corticosteroids for significant mucosal inflammation 2, 4

Critical Pitfalls to Avoid

• Do not prescribe antibiotics empirically for this 5-day presentation without positive streptococcal testing 1
• Most sore throats (>60%) receive unnecessary antibiotics despite being viral in origin 1
• Sinus symptoms at 5 days are almost certainly viral and do not meet the >10-day threshold for bacterial sinusitis 1
• Imaging has no role in diagnosing acute bacterial rhinosinusitis and would only increase costs 4-fold without changing management 1
• Overuse of antibiotics drives resistance and exposes patients to unnecessary adverse effects 1, 5