Symptoms of Bacterial Sinusitis
Suspect acute bacterial sinusitis when upper respiratory symptoms persist beyond 10-14 days without improvement, or when symptoms worsen after initial improvement at 5-7 days, or when severe symptoms (high fever ≥39°C with purulent discharge) occur for 3-4 consecutive days. 1
Primary Diagnostic Criteria
The diagnosis requires one of three distinct clinical patterns 2, 3:
- Persistent illness: Symptoms lasting ≥10 days without improvement (most common presentation) 1, 2
- Worsening course: New symptoms or worsening after 5-7 days of initial improvement (allows earliest diagnosis) 2, 3
- Severe onset: High fever (≥39°C/102.2°F) with purulent nasal discharge for 3-4 consecutive days 2, 3
Cardinal Symptoms in Adults
The most prominent symptoms include 1:
- Purulent rhinorrhea (thick, colored nasal discharge) - most predictive when combined with facial pain 1, 4
- Nasal congestion 1
- Facial-dental pain (particularly unilateral maxillary pain) 1
- Postnasal drainage 1
- Headache 1
- Cough 1
Critical distinction: The combination of persistent purulent rhinorrhea and facial pain has the strongest correlation with bacterial disease, though these symptoms remain relatively nonspecific (sensitivity 69%, specificity 64%) 1, 4, 3
Additional Supporting Symptoms
Less frequent but supportive symptoms include 1:
- Fever (though typically resolves within 24-48 hours in viral infections) 3
- Malaise and fatigue 1
- Halitosis 1
- Sore throat 1
- Hyposmia/anosmia (reduced/absent sense of smell) 3
- Ear pressure or fullness 3
Physical Examination Findings
Clinical signs on examination include 1:
- Sinus tenderness on palpation 1
- Mucosal erythema 1
- Purulent nasal secretions visible on examination 1
- Increased pharyngeal secretions 1
- Periorbital edema 1
Pediatric Presentation Differences
In children, symptoms are similar but often include 1:
Critical Pitfalls to Avoid
Do not diagnose bacterial sinusitis based on colored nasal discharge alone - mucopurulent secretions occur normally after a few days of viral infection and are not specific for bacterial disease 5, 3. Approximately 40% of uncomplicated viral URIs have symptoms persisting beyond 10 days 3.
Do not obtain imaging studies for uncomplicated cases - radiographic abnormalities appear in 87% of viral URIs, yet 79% show marked improvement after 2 weeks without antibiotics 3. Imaging should be reserved for treatment failures, confusing presentations, or surgical planning 1, 6.
Recognize the 10-day rule - most viral URIs last 5-7 days with symptoms peaking at days 3-6, so the critical threshold is persistence beyond 10-14 days without improvement 1, 2, 3.
Chronic Sinusitis Distinction
Chronic sinusitis symptoms are more subtle than acute 1:
- Pain is much less prominent in chronic disease 1
- Patients may only perceive mild increases in baseline congestion and fatigue 1
- May present as decreased effectiveness of usual rhinitis medications 1
- Headache attributed to chronic sinusitis may actually be migraine equivalent 1
Differential Diagnosis Considerations
Always consider alternative diagnoses 1: