Management of Viral Sinusitis

Viral sinusitis is a self-limited condition that requires only symptomatic treatment and should never be treated with antibiotics. 1, 2

Understanding Viral Sinusitis

Viral upper respiratory tract infections are associated with CT evidence of sinusitis in 40-90% of cases, and all resolve within 21 days without antibiotics 1
Viruses (rhinovirus, influenza, parainfluenza, adenovirus) are isolated in only 15% of antral aspirates, but antecedent viral infection is the most common predisposing cause of acute sinusitis 1
Symptoms typically peak within 3 days and resolve within 10-14 days 2
The key distinction from bacterial sinusitis is duration: symptoms persisting beyond 10 days without improvement suggest bacterial superinfection 1

Nasal saline irrigation is the cornerstone of treatment:

High-volume saline irrigation relieves congestion and facilitates clearance of nasal secretions 2, 3
This simple measure provides significant relief and should be emphasized to all patients 2

Analgesics/antipyretics for pain and fever control:

Acetaminophen or ibuprofen (NSAIDs) are recommended for symptomatic relief 1, 2
Pain relief is a major goal since discomfort is the primary reason patients seek care 2

Intranasal corticosteroids may provide modest benefit:

Topical intranasal corticosteroids can reduce mucosal inflammation 1, 2
The evidence for efficacy specifically in viral sinusitis is limited but supportive 2

Decongestants can be used cautiously:

Oral decongestants (pseudoephedrine) may provide symptomatic relief but should be used with caution in patients with hypertension or anxiety 1, 2
Topical nasal decongestants should be limited to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 1, 2

Supportive measures include:

Never prescribe antibiotics for viral sinusitis:

Antibiotics are completely ineffective for viral illness and provide no direct symptom relief 1, 2
Unnecessary antibiotic prescribing adds to treatment costs, puts patients at risk of adverse events, and contributes to antimicrobial resistance 2
Colored nasal discharge alone does NOT indicate bacterial infection and should not trigger antibiotic prescription 2

Avoid inappropriate use of antihistamines:

Newer generation non-sedating antihistamines are relatively ineffective for common cold symptoms 2
First-generation antihistamines combined with decongestants may provide some symptomatic relief through a drying effect, but evidence is limited 2

Consider bacterial superinfection only if:

Symptoms persist for ≥10 days without improvement 1, 3
"Double worsening" occurs (initial improvement followed by worsening within 10 days) 2, 3
Severe presentation with high fever (≥39°C), purulent nasal discharge, and facial pain lasting ≥3-4 consecutive days 1

At that point, bacterial sinusitis management applies:

Amoxicillin 1.5-4 g/day for 10-14 days becomes first-line therapy 3
High-dose amoxicillin-clavulanate (90 mg/kg amoxicillin and 6.4 mg/kg clavulanate, not to exceed 2 g every 12 hours) for treatment failures or high-resistance areas 1, 3

Do not prescribe antibiotics based on symptom duration <10 days - patients with symptoms for <7 days have low probability of bacterial infection 1, 2
Do not use sputum or nasal discharge color as an indication for antibiotics - color reflects neutrophil presence, not bacterial infection 2
Do not underutilize simple measures like saline irrigation and adequate hydration, which can provide significant relief 2
Do not use topical decongestants beyond 3-5 days to prevent rebound congestion 1, 2

Instruct patients to:

Expect symptoms to last 10-14 days, with some cases persisting up to 15 days without indicating bacterial infection 1, 2
Call if symptoms worsen (especially with severe headache or high fever) or fail to improve within 10 days 1
Avoid cigarette smoke, pollution, and other environmental irritants 1
Continue comfort measures throughout the illness course 1