What are the treatment options for sinus pressure?

Treatment of Sinus Pressure

For sinus pressure, start with symptomatic relief using analgesics (acetaminophen or ibuprofen), nasal saline irrigation, and intranasal corticosteroids, while reserving antibiotics only for bacterial sinusitis confirmed by symptoms lasting ≥10 days without improvement or severe symptoms from onset. 1, 2

Distinguishing Viral from Bacterial Disease

The critical first step is determining whether you're treating viral rhinosinusitis (VRS) or acute bacterial rhinosinusitis (ABRS), as this fundamentally changes management:

• Viral rhinosinusitis accounts for the vast majority of cases and symptoms typically peak within 3 days, then gradually resolve within 10-14 days 1
• Bacterial sinusitis should be suspected when symptoms persist ≥10 days without improvement, worsen after initial improvement (double worsening), or present with severe symptoms (high fever ≥39°C, purulent nasal discharge, and facial pain) from onset 1, 2, 3
• Nasal purulence alone does NOT indicate bacterial infection—discolored discharge reflects neutrophil presence from inflammation, not bacteria 1

Symptomatic Treatment (First-Line for All Patients)

These measures provide relief regardless of whether the cause is viral or bacterial:

Analgesics and Anti-inflammatory Agents

• Acetaminophen or ibuprofen for pain and fever relief 1, 2
• These address the sinus pressure directly and are recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2

Nasal Saline Irrigation

• Provides cleansing and modest symptom relief with minimal risk of adverse effects 1, 2
• Can be used in physiologic or hypertonic concentrations 1

Intranasal Corticosteroids

• Recommended as adjunctive therapy for both acute and chronic sinusitis 1, 2
• Reduce inflammation, improve ostial patency, and relieve facial pain and nasal congestion 1
• In viral rhinosinusitis, 73% of patients improved with steroid therapy versus 66% with placebo at 14-21 days—a modest but safe benefit 1
• For bacterial sinusitis, use as adjunct to antibiotics 2

Decongestants

• Oral decongestants (pseudoephedrine) may provide symptomatic relief of sinus congestion and pressure, though evidence is limited 1, 4, 5
• Consider if no contraindications (hypertension, anxiety) exist 1
• Topical decongestants can be used but limit to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 1

Antihistamines

• No role in acute bacterial sinusitis unless underlying allergic rhinitis is present 1
• First-generation antihistamines may help with excessive secretions in viral illness, though evidence is limited 1

Antibiotic Therapy (Only for Bacterial Sinusitis)

When to Initiate Antibiotics

Antibiotics should ONLY be started when bacterial sinusitis is confirmed by:

• Symptoms persisting ≥10 days without improvement, OR 1, 2
• Worsening symptoms after initial improvement (double worsening), OR 1, 2
• Severe symptoms from onset (high fever ≥39°C, purulent discharge, facial pain for ≥3-4 consecutive days) 1, 2

First-Line Antibiotic Choice

For adults with mild disease and no recent antibiotic use (past 4-6 weeks):

• Amoxicillin 1.5-4 g/day for 10-14 days is the drug of choice 1, 2
• Alternative options: amoxicillin-clavulanate (1.75-4 g/250 mg per day), cefpodoxime proxetil, cefuroxime axetil, or cefdinir 1
• For β-lactam allergies: doxycycline, trimethoprim-sulfamethoxazole, or macrolides (though bacteriologic failure rates of 20-25% are possible) 1

For adults with moderate disease or recent antibiotic use:

• High-dose amoxicillin-clavulanate (4 g/250 mg per day) or respiratory fluoroquinolones (levofloxacin, moxifloxacin) provide 90-92% predicted clinical efficacy 1, 3
• Reserve fluoroquinolones as second-line to minimize resistance development 1, 3

Reassessment and Treatment Failure

• Reassess at 72 hours (3 days) of antibiotic therapy 1, 2
• If no improvement or worsening, switch to broader-spectrum antibiotic considering limitations of initial agent 1, 2
• Switch to high-dose amoxicillin-clavulanate or respiratory fluoroquinolone if initially on amoxicillin alone 1, 2

Adjunctive Corticosteroid Therapy

Oral corticosteroids (prednisone 24-80 mg daily) as adjunct to antibiotics show benefit:

• Increase short-term symptom resolution at days 3-7 (RR 1.4) and days 4-12 (RR 1.3) 6
• However, evidence is limited with significant risk of bias, and long-term effects are unknown 6
• Consider for severe symptoms but weigh against potential side effects 6

Red Flags Requiring Urgent Referral

Immediately refer to otolaryngology if:

• Unilateral sinus disease (suggests fungal infection or tumor) 7
• Signs of complicated sinusitis: severe headache, visual changes, periorbital edema, altered mental status, meningeal signs 1, 2
• Immunocompromised patients with sinusitis (risk of invasive fungal disease) 7
• Failure to respond to appropriate antibiotic therapy 7, 2
• CT findings suspicious for mass or fungal disease 7

Common Pitfalls to Avoid

• Don't prescribe antibiotics for viral rhinosinusitis—62-63% spontaneous resolution rate occurs without treatment, and antibiotics provide no benefit while promoting resistance 1
• Don't assume purulent discharge equals bacterial infection—it's a sign of inflammation, not necessarily bacteria 1
• Don't use topical decongestants beyond 5 days—this causes rebound congestion 1
• Don't ignore unilateral symptoms—these warrant imaging and possible biopsy to rule out serious pathology 7