Persistent Sore Throat Progressing to Nasal Congestion Without Fever
You likely have acute bacterial rhinosinusitis (ABRS) and should start amoxicillin 500mg three times daily for 10 days, along with supportive measures including intranasal corticosteroids, saline irrigation, and analgesics for symptom relief. 1, 2
Clinical Reasoning
Your symptom pattern—sore throat for weeks followed by nasal congestion without fever—strongly suggests progression from a viral upper respiratory infection to acute bacterial rhinosinusitis. When upper respiratory symptoms persist beyond 10 days without improvement, this meets diagnostic criteria for ABRS and warrants antibiotic therapy. 3, 2
Key Diagnostic Features Present
- Persistent symptoms >10 days: This is the single most important criterion distinguishing bacterial from viral infection 3
- Progression pattern: Initial sore throat (typical viral URI) followed by nasal congestion represents the classic evolution toward bacterial sinusitis 3
- Absence of fever: While fever can occur with ABRS, its absence does not rule out bacterial infection—nasal purulence and symptom duration are more predictive 3, 4
Why Antibiotics Are Indicated
Guidelines consistently recommend antibiotic treatment when symptoms persist ≥10 days, as this indicates probable bacterial rather than viral infection. 3, 1, 2 The American Academy of Otolaryngology, Infectious Diseases Society of America, and American College of Physicians all support this approach for patients meeting your clinical presentation. 3, 1, 2
Recommended Treatment Plan
First-Line Antibiotic Therapy
- Amoxicillin 500mg three times daily for 10 days is the preferred first-line agent based on efficacy, safety, and cost-effectiveness 2, 4
- Alternative if penicillin allergy: doxycycline or macrolides 2
- Do not use amoxicillin-clavulanate as first-line unless you develop severe symptoms (high fever >39°C, severe facial pain for ≥3 consecutive days) 3, 1
Essential Adjunctive Therapies
- Intranasal corticosteroids: Reduce inflammation and improve symptom resolution 3, 1, 2, 4
- Saline nasal irrigation: Helps clear secretions and purulent discharge 3, 2
- Analgesics: Acetaminophen or NSAIDs (ibuprofen) for facial discomfort 3, 2
- Supportive measures: Adequate hydration, rest, warm facial compresses, steamy showers, sleep with head elevated 1, 2
Critical Follow-Up Points
When to Reassess (3-5 Days)
You must monitor for improvement within 3-5 days of starting antibiotics. 1, 2 If symptoms fail to improve or worsen, this indicates:
- Possible antibiotic resistance requiring switch to amoxicillin-clavulanate 875mg/125mg twice daily 1, 2
- Need for clinical re-evaluation to exclude complications 1, 2
Red Flags Requiring Immediate Attention
Seek urgent medical care if you develop: 2
- High fever (>39°C)
- Severe headache
- Visual changes or periorbital swelling
- Severe facial pain or swelling
- Altered mental status
Important Caveats
Imaging Not Needed
Radiographic imaging (X-ray or CT) is not necessary for straightforward cases like yours and should be reserved for suspected complications, treatment failures, or recurrent episodes. 3, 1, 4 Your clinical presentation alone is sufficient for diagnosis. 4
Expected Timeline
- Symptom improvement should begin within 3-5 days of starting antibiotics 1, 2
- Complete resolution may take 10-14 days even with appropriate treatment 2
- Persistent symptoms beyond this timeframe warrant re-evaluation for chronic rhinosinusitis or alternative diagnoses 3, 4
Common Pitfall to Avoid
Do not assume all persistent upper respiratory symptoms are viral and self-limited. 3 The 10-day threshold is specifically designed to identify patients who have progressed from viral to bacterial infection and require antibiotic intervention. Delaying treatment in true ABRS prolongs symptoms unnecessarily, though it does not typically lead to serious complications in otherwise healthy adults. 3