Treatment of Viral Sinusitis

Viral sinusitis should be managed with symptomatic relief only—antibiotics are completely ineffective and should never be prescribed. 1

Distinguishing Viral from Bacterial Sinusitis

Before treating, you must confirm this is truly viral sinusitis:

Viral rhinosinusitis (VRS) presents with symptoms lasting less than 10 days with gradual improvement, typically peaking within 3 days 1, 2
Colored nasal discharge does NOT indicate bacterial infection—coloration reflects neutrophils, not bacteria 1
Suspect bacterial sinusitis only if: symptoms persist beyond 10 days without improvement, severe symptoms at onset (high fever ≥38.3°C/101°F with purulent discharge and facial pain), or "double worsening" (initial improvement followed by worsening within 10 days) 1, 2

Analgesics/antipyretics: Acetaminophen or ibuprofen for pain and fever relief 1, 2
Nasal saline irrigation: Use multiple times daily—provides low-risk relief of congestion and facilitates mucus clearance 1, 2
Topical intranasal corticosteroids: Provide modest symptom relief with number needed to treat of 14; adverse events are rare 1, 2

Oral decongestants (pseudoephedrine): May provide symptomatic relief if no contraindications exist (hypertension, anxiety) 1, 3
Topical nasal decongestants (oxymetazoline): Limit use to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 1, 4

Oral antihistamines: May relieve excessive secretions and sneezing, though clinical evidence is lacking for VRS 1
Guaifenesin and dextromethorphan: Commonly used but evidence of efficacy is lacking; use based on patient preference 1

Never prescribe antibiotics for viral sinusitis—they are ineffective for viral illness, provide no symptom relief, increase adverse events, and promote antimicrobial resistance 1, 2
Avoid systemic corticosteroids—they do not improve recovery at 7-14 days and have potential for harm 2
Do not use topical decongestants beyond 5 days—this causes rebound congestion 1, 4

Educate patients that:

Symptoms typically resolve within 10-14 days without antibiotics 1, 2
Comfort measures include adequate rest, hydration, warm facial packs, steamy showers, and sleeping with head elevated 1

Instruct patients to return if:

Symptoms worsen or fail to improve within 3-5 days 1, 2
High fever develops or persists 1, 2
Severe headache, facial swelling, or visual changes occur (potential complications) 1, 2

Children under 3 years: Avoid decongestants and antihistamines; focus on saline irrigation and analgesics 2
Patients with asthma or COPD: Monitor closely for symptom progression and consider earlier intervention if respiratory status deteriorates 2

Do not prescribe antibiotics based on colored nasal discharge alone—this is the most common error and reflects neutrophil presence, not bacterial infection 1, 2
Do not assume symptoms lasting 7-10 days indicate bacterial infection—viral rhinovirus infections commonly last 10-15 days 2, 5
Underutilizing simple measures like saline irrigation deprives patients of significant relief 2