What is the best course of treatment for a 36-year-old female patient with hoarseness, cough, colds, ear pain, and a history of migraines, who presents with thick clear nasal discharge, glabellar and post-auricular tenderness, and no improvement with initial medication?

Acute Viral Upper Respiratory Infection with Sinusitis

This patient has an acute viral upper respiratory infection (URI) with secondary rhinosinusitis that does NOT meet criteria for bacterial sinusitis—antibiotics are not indicated at this time. 1, 2

Why This is NOT Bacterial Sinusitis

Your patient's symptoms have been present for only 1 day, which falls far short of the diagnostic criteria for acute bacterial rhinosinusitis (ABRS). 3, 1, 2

Bacterial sinusitis requires one of three patterns: 1, 2, 4

• Persistent symptoms ≥10 days without clinical improvement
• Severe symptoms (fever ≥39°C with purulent nasal discharge) for ≥3 consecutive days
• "Double worsening"—initial improvement followed by worsening within 10 days

This patient has none of these patterns. The thick clear nasal discharge, glabellar pain, and ear discomfort are classic features of viral rhinosinusitis, which affects 98-99.5% of acute rhinosinusitis cases. 1, 4

Recommended Treatment Plan

Symptomatic Management (First-Line)

Analgesics for pain control: 1, 4

• Acetaminophen or NSAIDs (ibuprofen, naproxen) for glabellar pain and ear discomfort
• This addresses her most bothersome symptoms and is more important than any other intervention

Intranasal corticosteroids: 1, 4

• Mometasone, fluticasone, or budesonide twice daily
• Reduces mucosal inflammation and improves symptom resolution
• Strong evidence from multiple randomized controlled trials supports this intervention

Saline nasal irrigation: 1, 4

• High-volume saline irrigation provides symptomatic relief and removes mucus
• Can be performed 2-3 times daily

Decongestants (optional): 1, 4

• Pseudoephedrine 30-60 mg every 4-6 hours as needed
• Topical decongestants (oxymetazoline) for no more than 3 days to avoid rebound congestion
• Evidence for efficacy is limited, but may provide symptomatic relief

When to Reassess for Antibiotics

Instruct the patient to return or call if: 1, 2, 4

• Symptoms persist ≥10 days without improvement
• Symptoms worsen at any time after initial improvement ("double worsening")
• Development of severe symptoms: fever ≥39°C with purulent discharge for ≥3 consecutive days

At that point, if bacterial sinusitis is confirmed, prescribe: 1, 4

• Amoxicillin-clavulanate 875 mg/125 mg twice daily for 5-10 days as first-line therapy
• This provides coverage against β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis

Expected Timeline for Viral URI

Natural history without antibiotics: 1, 4

• Most viral rhinosinusitis resolves spontaneously within 7-10 days
• By day 7, approximately 73-85% of patients show clinical improvement even without any treatment
• The hoarseness, cough, and nasal symptoms should gradually improve over the next week

Critical Red Flags Requiring Immediate Evaluation

Send to emergency department immediately if: 2, 4

• Severe worsening headache or visual changes
• Periorbital swelling or erythema (suggests orbital cellulitis)
• High fever with altered mental status
• Severe facial swelling
• Neurological symptoms (suggests intracranial complications)

Addressing the Migraine History

The patient's history of "constant migraines" with various PRN pain medications deserves attention. The glabellar pain she's experiencing now is likely sinus pressure from the viral URI, not a migraine. However, if she has frequent migraines requiring multiple medications, consider: 1

• Evaluating for underlying allergic rhinitis (which predisposes to recurrent sinusitis)
• Ensuring she has appropriate migraine prophylaxis rather than relying solely on PRN medications
• Distinguishing between true migraines and recurrent sinus headaches

Why Antibiotics Would Be Harmful Now

Prescribing antibiotics at this stage would: 1, 4

• Provide no clinical benefit (98-99.5% of cases at this stage are viral)
• Expose the patient to unnecessary adverse effects (diarrhea occurs in 40-43% of patients on amoxicillin-clavulanate) 5, 6
• Contribute to antimicrobial resistance
• Cost more than symptomatic treatment alone

The number needed to treat with antibiotics for acute rhinosinusitis is 10-15, meaning you would need to treat 10-15 patients to get one additional person better compared to placebo. 1 At day 1 of symptoms, this benefit is essentially zero.

Post-Auricular Tenderness: Not Mastoiditis

The left post-auricular tenderness with intact tympanic membrane and no hearing loss suggests referred pain from Eustachian tube dysfunction secondary to the viral URI, not mastoiditis. 3 True mastoiditis would present with:

• Fever
• Erythema and swelling over the mastoid
• Displacement of the auricle
• Systemic toxicity

None of these are present in your patient.