Pertinent Positives for Acute Viral Rhinosinusitis
Acute viral rhinosinusitis is characterized by symptoms lasting less than 10 days with gradual improvement, absence of high fever, and no severe or worsening pattern—this is the typical common cold affecting the sinuses. 1
Cardinal Symptoms (Need at Least 2 of 4)
The diagnosis requires at least two of the following four cardinal symptoms present for less than 4 weeks: 1
- Nasal obstruction or congestion 1
- Purulent or colored nasal discharge (anterior or posterior) 1
- Facial pain or pressure (particularly maxillary or unilateral) 1
- Loss of smell or hyposmia 1
Key Temporal Pattern (Critical for Viral Diagnosis)
Symptoms lasting fewer than 7-10 days strongly suggest viral etiology and do not warrant antibiotics. 2, 1 The typical viral cold lasts 5-10 days, with symptoms peaking at days 3-5 before gradual improvement. 1
Additional Supportive Features
- Rhinorrhea with sneezing 3
- Sore throat 3
- Cough 3
- Low-grade fever (not high fever ≥39°C) 3
- Headache and malaise 3
- Oral ulcers and/or hoarseness (strongly suggests viral etiology) 3
Critical Pitfall to Avoid
Purulent or colored nasal discharge alone does NOT distinguish viral from bacterial rhinosinusitis and should never be used as the sole criterion for prescribing antibiotics. 1 The yellow-green color comes from neutrophils and their enzymes that accumulate during both viral AND bacterial infections—it reflects inflammation, not bacterial infection. 1 Purulent discharge increases specificity for bacterial infection only when combined with other cardinal symptoms AND appropriate timing criteria (≥10 days persistent, severe onset, or double-sickening pattern). 1
What Viral Rhinosinusitis is NOT
Viral rhinosinusitis does NOT present with: 2, 1
- Persistent symptoms ≥10 days without improvement (suggests bacterial)
- Severe onset with high fever ≥39°C (102°F) plus purulent discharge and facial pain for ≥3-4 consecutive days (suggests bacterial)
- "Double-sickening" pattern: initial improvement followed by new fever or substantial worsening of symptoms after 5-6 days (suggests bacterial)
Management Implications
For viral rhinosinusitis, symptomatic treatment only—antibiotics are contraindicated. 2, 3 Approximately 40-60% of cases resolve spontaneously. 4 Recommended symptomatic measures include: 3, 5
- Acetaminophen or NSAIDs for pain and fever control 3
- Nasal saline irrigation for cleansing and symptom relief 3, 5
- Topical decongestants (oxymetazoline) for no more than 3 days to avoid rebound congestion 6, 5
- Intranasal corticosteroids may provide benefit 1
Antihistamines should not be used as primary treatment unless concurrent allergic symptoms are present in atopic patients. 1
When to Reassess
Reassess patients if: 3
- Symptoms persist ≥10 days without improvement
- High fever ≥39°C with purulent discharge or facial pain for ≥3-4 consecutive days develops
- Worsening symptoms occur after initial improvement (double-sickening pattern)
These patterns indicate possible progression to acute bacterial rhinosinusitis and warrant consideration of antibiotic therapy. 2, 1