What is the best approach for treating sinusitis with symptoms of headaches, stuffy nose, and cough, while avoiding antibiotics?

Managing Sinusitis Without Antibiotics

For this patient with headaches, stuffy nose, and cough without severe symptoms or prolonged duration, antibiotics are not indicated—symptomatic treatment with nasal saline irrigation, intranasal corticosteroids, and analgesics is the appropriate evidence-based approach. 1

Determining If Antibiotics Are Needed

The critical first step is establishing whether this patient meets criteria for acute bacterial rhinosinusitis (ABRS), which requires one of three specific patterns 1:

• Persistent symptoms ≥10 days without improvement
• Severe symptoms including fever >39°C (102.2°F) with purulent nasal discharge AND facial pain for ≥3 consecutive days
• "Double sickening" pattern: initial improvement followed by worsening of symptoms within 10 days

If none of these criteria are met, this is viral rhinosinusitis and antibiotics provide no benefit. 1, 2 In fact, antibiotics cause more harm than good in viral cases, with a number needed to harm of 8 versus a number needed to treat of 18 for bacterial cases. 1

Evidence-Based Symptomatic Treatment

First-Line Therapies

Nasal saline irrigation is the cornerstone of symptomatic relief, providing low-risk congestion relief and facilitating mucus clearance—can be used multiple times daily. 3, 4

Intranasal corticosteroids (such as fluticasone or mometasone) provide modest symptom relief after 15 days of use, with a number needed to treat of 14. 3, 4

Analgesics including acetaminophen or ibuprofen for headache and facial discomfort. 3, 4

Additional Symptomatic Options

Oral decongestants (pseudoephedrine) may provide additional relief but use with caution in patients with hypertension or anxiety. 3, 4

Topical nasal decongestants (oxymetazoline) can be used for severe congestion but limit to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa). 3, 4

First-generation antihistamine/decongestant combinations may help through a drying effect, though evidence is limited for viral rhinosinusitis specifically. 1, 3

Critical Pitfalls to Avoid

Do not prescribe antibiotics based on colored nasal discharge alone. The yellow-green color reflects neutrophil presence from inflammation, not bacterial infection—this occurs in both viral and bacterial cases. 2

Do not use imaging routinely. Sinus radiographs or CT scans cannot differentiate viral from bacterial causes and increase costs 4-fold without improving outcomes. 1

Avoid prolonged topical decongestants beyond 3-5 days, as this leads to rebound congestion that can be worse than the original symptoms. 3, 4

When to Reassess

Instruct the patient to return or call if 3, 4:

• Symptoms persist beyond 10 days without improvement
• Symptoms worsen after initial improvement (double sickening)
• High fever (>39°C) develops with purulent discharge and facial pain for ≥3 consecutive days
• Severe headache, facial swelling, visual changes, or periorbital edema occur (warning signs of complications)

Patient Education for the Medical Certificate

Explain that 1:

• Viral rhinosinusitis typically peaks within 3 days and resolves within 10-14 days
• Adequate rest, hydration, and the symptomatic measures above will facilitate recovery
• Antibiotics would not speed recovery and expose them to unnecessary side effects (diarrhea, rash, yeast infections)
• Most cases resolve without antibiotics, even when bacterial

This approach aligns with high-value care principles from the American College of Physicians and CDC, prioritizing patient safety while avoiding unnecessary antibiotic exposure and resistance. 1