What is the recommended treatment for a patient with acute rhinosinusitis, considering symptoms, medical history, and potential underlying conditions such as allergies or asthma?

Treatment of Acute Rhinosinusitis

For acute rhinosinusitis, most cases are viral and self-limiting—symptomatic treatment with saline irrigation, intranasal corticosteroids, and analgesics is the recommended first-line approach, reserving antibiotics only for patients meeting specific criteria for acute bacterial rhinosinusitis (ABRS): symptoms persisting ≥10 days without improvement, severe symptoms (fever ≥39°C with purulent discharge and facial pain for ≥3 consecutive days), or "double-sickening" (worsening after initial improvement). 1, 2

Distinguishing Viral from Bacterial Rhinosinusitis

The critical first step is determining whether antibiotics are indicated:

• Viral rhinosinusitis (most common): Symptoms lasting <10 days that gradually improve, no high fever, and no severe unilateral facial pain 2, 1
• Acute bacterial rhinosinusitis requires ONE of the following 2, 1:
  • Persistent symptoms ≥10 days without improvement 2
  • Severe symptoms: fever ≥39°C (102.2°F) with purulent nasal discharge AND facial pain/pressure for ≥3 consecutive days 2
  • "Double-sickening": initial improvement followed by worsening within 10 days (new fever ≥38°C or substantial worsening of discharge/cough) 2

Common pitfall to avoid: Purulent (colored) nasal discharge alone does NOT indicate bacterial infection—it reflects neutrophil presence during both viral and bacterial infections and should never be used as the sole criterion for prescribing antibiotics 2, 3. The 2020 EPOS guidelines explicitly advise against antibiotics for post-viral rhinosinusitis based on moderate-quality evidence showing no benefit and significantly more adverse events (RR 1.28,95% CI 1.06-1.54) 1.

First-Line Symptomatic Treatment (All Patients)

These interventions should be offered to ALL patients regardless of suspected etiology 1:

• Saline nasal irrigation: Provides symptomatic relief and facilitates mucus clearance 1, 2
• Analgesics/antipyretics: Acetaminophen or ibuprofen for pain and fever control 1, 3
• Intranasal corticosteroids: Modest but clinically meaningful benefit (number needed to treat = 14), increasing symptom resolution from 66% to 73% at 15-21 days 1. Options include mometasone, fluticasone, or over-the-counter triamcinolone 1

Additional Symptomatic Options

• Oral decongestants (pseudoephedrine, phenylephrine): May provide relief but use with caution in patients with hypertension, cardiac arrhythmia, cerebrovascular disease, glaucoma, or hyperthyroidism 1
• Topical nasal decongestants: Limit to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa) 1, 3
• Ipratropium bromide nasal spray: Effective for rhinorrhea specifically, with minimal side effects 1

What NOT to use 1:

• Antihistamines: No proven benefit in acute rhinosinusitis unless concurrent allergic rhinitis is present (very low quality evidence shows no additive effect over antibiotics alone) 1
• Systemic corticosteroids: The 2020 EPOS guidelines explicitly advise AGAINST their use—no benefit at 7-14 days, only small effect on facial pain at days 4-7 (with two-thirds of placebo patients improving anyway), and potential for harm 1
• Guaifenesin, dextromethorphan: Commonly used but lack evidence of clinical efficacy 1

Antibiotic Therapy (When ABRS Criteria Are Met)

First-Line Antibiotics for Uncomplicated ABRS

For patients without recent antibiotic exposure (past 6 weeks) or penicillin allergy 4, 5:

• Amoxicillin 1.5-4g/day for 10-14 days 4, 5
• Amoxicillin-clavulanate 1.75-4g/250mg per day for 10-14 days 4, 5

For penicillin-allergic patients 4, 5:

• Doxycycline (dose per standard guidelines) 4
• Trimethoprim-sulfamethoxazole (note: 20-25% bacteriologic failure rate) 4, 5

Second-Line Antibiotics

For moderate disease, recent antibiotic use, or failure to improve after 72 hours 1, 5:

• High-dose amoxicillin-clavulanate 1
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) 1, 5
• Cefuroxime, cefpodoxime, cefprozil, or cefdinir 1

Severe Disease or Treatment Failure

Ceftriaxone 1g/day IM or IV for 5 days is recommended for 4:

• Moderate disease when oral options are not appropriate (90-92% predicted clinical efficacy) 4
• Treatment failures not responding after 72 hours 4
• Severe infections requiring parenteral therapy 4

Critical caveat: Broad-spectrum parenteral antibiotics like ceftriaxone-sulbactam should NOT be used for uncomplicated acute rhinosinusitis—this promotes antimicrobial resistance and is not cost-effective 4.

Treatment Duration and Follow-Up

• Antibiotic duration: 10-14 days for most cases 5, 1
• Reassess at 72 hours: Lack of improvement warrants reevaluation or change in therapy 4, 1
• Consider referral to otolaryngology if 1, 6:
  • Symptoms persist after 21-28 days of appropriate antibiotic treatment
  • Recurrent acute rhinosinusitis (≥3 episodes per year)
  • Suspected complications (orbital cellulitis, meningitis, abscess)
  • CT evidence of ostiomeatal obstruction despite aggressive medical management

Special Considerations for Underlying Conditions

Allergic Rhinitis

• Evaluate for IgE sensitization to inhalant allergens 1
• Emphasize environmental control, pharmacotherapy with intranasal corticosteroids, and consider allergen immunotherapy in selected patients 1
• Antihistamines may help concurrent allergic symptoms but do not treat the sinusitis itself 1

Asthma

• Treatment of allergic rhinitis may improve asthma control in patients with coexisting conditions 1
• Monitor closely for worsening respiratory symptoms 3

Immunodeficiency

• Referral to allergist-immunologist is indicated for chronic/recurrent rhinosinusitis associated with otitis media, bronchitis, bronchiectasis, or pneumonia 1
• Evaluation may include quantitative serum immunoglobulins and specific antibody responses 1

Key Clinical Pitfalls to Avoid

1. Prescribing antibiotics for viral rhinosinusitis: 40-60% of cases resolve spontaneously; inappropriate prescribing drives antimicrobial resistance 1, 4
2. Using colored nasal discharge as sole criterion: This reflects inflammation, not bacterial infection 2, 3
3. Routine imaging: Sinus radiography and CT are NOT recommended for uncomplicated acute rhinosinusitis due to high false positive rates 1, 2
4. Ignoring warning signs: Periorbital edema, diplopia, severe headache, or altered mental status require immediate evaluation for complications 2, 6
5. Prolonged topical decongestant use: Beyond 3-5 days causes rebound congestion 1, 3