What is the treatment for acute viral rhinosinusitis?

Treatment of Acute Viral Rhinosinusitis

Acute viral rhinosinusitis should be managed with symptomatic treatment only—antibiotics are not indicated and provide no benefit while exposing patients to unnecessary adverse effects and promoting antimicrobial resistance. 1, 2

Distinguishing Viral from Bacterial Disease

Before initiating treatment, confirm this is truly viral rhinosinusitis by ensuring the patient does NOT meet criteria for bacterial infection: 1, 2

• Symptoms lasting <10 days without worsening = viral 1, 2
• No severe features (fever <39°C, no severe unilateral facial pain, no purulent discharge for ≥3-4 consecutive days) = viral 1, 2
• No "double-sickening" (worsening after initial improvement at days 5-6) = viral 1, 2

Critical pitfall: Purulent or colored nasal discharge alone does NOT indicate bacterial infection—this reflects neutrophil presence from inflammation that occurs in both viral and bacterial infections. 2, 3 The yellow-green color comes from inflammatory cells and their enzymes, not bacteria. 2

First-Line Symptomatic Management

Non-Pharmacological Interventions

• Nasal saline irrigation: Relieves congestion and facilitates clearance of secretions 1, 2, 3
• Adequate hydration: Helps thin secretions 3
• Humidification: Alleviates mucosal dryness 3
• Rest: Supports recovery 3

Pharmacological Symptomatic Relief

For pain and fever: 1, 2, 3

• Acetaminophen or NSAIDs (ibuprofen) as needed

For nasal congestion: 1, 2, 3

• Intranasal corticosteroids: May provide modest symptom relief 1, 2, 3
• Oral decongestants (pseudoephedrine): Can provide relief but use cautiously in patients with hypertension or anxiety 2, 3, 4
• Topical nasal decongestants: Limit to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 2, 3

For excessive secretions/sneezing: 3

• First-generation antihistamine/decongestant combinations (sustained-release pseudoephedrine with brompheniramine) have shown efficacy 3
• Newer non-sedating antihistamines are relatively ineffective for common cold symptoms 3

Expected Clinical Course

Most viral rhinosinusitis resolves spontaneously within 7-10 days, with symptoms typically peaking at days 3-5 before gradual improvement. 2, 5 The typical viral cold lasts 5-10 days. 2

When to Reassess for Bacterial Infection

Instruct patients to return if: 1, 2, 3

• Symptoms persist ≥10 days without improvement
• Symptoms worsen after initial improvement (double-sickening)
• Severe symptoms develop (fever ≥39°C with purulent discharge and facial pain for ≥3 consecutive days)
• Warning signs appear: periorbital edema, diplopia, severe headache, altered mental status 2

Critical Pitfalls to Avoid

• Never prescribe antibiotics for viral rhinosinusitis—they are ineffective, expose patients to adverse effects (number needed to harm = 8), and contribute to resistance 1, 3, 5
• Do not use antihistamines as primary treatment unless concurrent allergic symptoms are present 2
• Avoid prolonged topical decongestants beyond 3-5 days 2, 3
• Do not obtain imaging for uncomplicated cases—abnormal findings are common in viral disease and do not change management 1, 2, 6
• Do not use colored mucus as sole criterion for bacterial infection 2, 3
• Avoid underutilizing simple measures like saline irrigation and hydration, which provide significant relief 3

Special Populations

Children <3 years: Avoid decongestants and antihistamines due to potential adverse effects 3

Patients with chronic conditions (asthma): Monitor symptom evolution closely 3