What are the typical presentations of sinus infections?

How Sinus Infections Present

Suspect acute bacterial sinusitis when upper respiratory symptoms persist beyond 10-14 days without improvement, or when symptoms initially improve but then worsen within 10 days (the "double worsening" pattern). 1, 2

Cardinal Symptoms

The most prominent symptoms that should raise suspicion for bacterial sinusitis include:

• Purulent rhinorrhea (thick, yellow-green, or gray nasal discharge) combined with facial pain has the strongest correlation with bacterial disease 1, 2
• Nasal congestion is a hallmark feature 1, 3
• Postnasal drainage with purulent secretions 1, 2
• Facial or dental pain that may worsen with movement or percussion 1, 3
• Headache (though this is nonspecific) 1, 2
• Cough, particularly worse at night 2, 3

Critical Timing Distinction

Do not diagnose bacterial sinusitis before 10 days of symptoms. 2 Most viral upper respiratory infections resolve within 5-7 days and rarely last beyond 10 days. 1, 2 The key differentiator is persistence of purulent symptoms beyond this timeframe or the double worsening pattern. 1

Physical Examination Findings

When examining patients with suspected sinusitis, look for:

• Red, swollen nasal mucosa (infectious rhinitis/sinusitis) versus pale, boggy turbinates (allergic rhinitis) 1, 2
• Purulent secretions in the middle meatus (yellow-green, green, or gray) are highly predictive of bacterial sinusitis, though may require nasal decongestant to visualize 1, 2
• Sinus tenderness on palpation over maxillary and frontal sinuses 1, 2
• Periorbital edema or dark infraorbital circles 1, 2
• Posterior pharyngeal mucopurulent secretions 1

Pediatric Presentation Differences

Children with sinusitis often present differently than adults:

• Cough is the most common symptom (80% of cases) 3
• Increased irritability 1
• Vomiting associated with gagging on mucus 1
• Malodorous breath (approximately 50% of preschoolers) 3
• Nasal polyps in children should prompt evaluation for cystic fibrosis 1, 2

Common Diagnostic Pitfalls to Avoid

Colored nasal discharge alone does not confirm bacterial sinusitis. 2 Viral infections can also produce purulent-appearing secretions in the first few days. The critical factor is persistence beyond 10-14 days. 1, 2

Do not rely on imaging for routine diagnosis. 2 Plain radiographs have significant false-positive and false-negative results. 2 Up to 40% of asymptomatic adults have abnormalities on sinus CT scans, and over 80% with minor upper respiratory infections show imaging changes. 1 Reserve CT imaging for uncertain diagnoses, suspected complications, or preoperative evaluation. 1, 2

Always assess for underlying allergic rhinitis, which is the most common predisposing factor for sinusitis and requires concurrent management. 2, 3

Red Flags for Complications

Examine carefully for signs of serious complications that require urgent intervention:

• Orbital involvement: periorbital swelling, diplopia, or proptosis 1
• Intracranial extension: severe headache, mental status changes, fever 1, 4
• Facial swelling overlying affected sinuses 1

These complications, though rare, can cause significant morbidity and mortality and demand immediate recognition and treatment. 4

Recurrent vs. Chronic Patterns

• Recurrent acute sinusitis: four or more discrete episodes per year, each lasting less than 4 weeks 1, 2
• Chronic sinusitis: symptoms persisting for 8-12 weeks or longer, often with more subtle symptoms than acute disease 1, 5