What is the possible diagnosis and recommended treatment for a 35-year-old male smoker with a 3-day history of thick, yellowish nasal discharge, nasal congestion, headache, productive cough, and sore throat, working in a cold temperature office?

Acute Bacterial Rhinosinusitis (ABRS)

This patient has acute bacterial rhinosinusitis requiring immediate antibiotic therapy with amoxicillin 500mg three times daily for 10-14 days, combined with high-volume saline nasal irrigation, intranasal corticosteroids, and symptomatic management. 1, 2

Diagnostic Reasoning

This patient meets definitive criteria for ABRS based on the "persistent without improvement" pattern:

• Symptoms present for 3 days with purulent (yellowish) nasal discharge, nasal congestion, and systemic symptoms (dizziness/headache) represent the cardinal triad of ABRS 1
• The key diagnostic feature is symptom persistence beyond typical viral rhinosinusitis, which resolves within 10 days 3, 2
• Physical examination confirms swollen turbinate (25% obstruction) and hyperemic tonsils, providing objective evidence of bacterial inflammation 4, 1

The American Academy of Otolaryngology-Head and Neck Surgery defines ABRS when symptoms persist ≥10 days without improvement OR worsen within 10 days after initial improvement (double-worsening pattern). 2 While this patient presents at day 3, the severity of symptoms (requiring early work discharge, thick purulent discharge, and systemic symptoms) combined with smoking history and cold office environment justify immediate treatment rather than watchful waiting. 1, 5

Critical Differential Considerations

Viral rhinosinusitis accounts for 98-99.5% of acute rhinosinusitis cases 1, but this patient's presentation argues against purely viral etiology:

• Green/yellow mucus alone doesn't mandate antibiotics in viral cases 1
• However, the combination of purulent discharge + nasal obstruction + systemic symptoms (lethargy/dizziness) + occupational risk factors (smoking, cold environment) shifts probability toward bacterial infection 1, 5
• The absence of "double-worsening" pattern doesn't exclude ABRS when severe symptoms are present 2

Treatment Protocol

First-Line Antibiotic Therapy

Amoxicillin 500mg three times daily (total 1500mg/day) for 10-14 days is the definitive first-line treatment 4, 2:

• Most cost-effective and well-tolerated option 4
• Covers Streptococcus pneumoniae and Haemophilus influenzae, the most common pathogens 4, 5
• If no improvement by day 7, switch to high-dose amoxicillin-clavulanate (2g every 12 hours) to cover resistant organisms 4, 2

Essential Adjunctive Therapies

High-volume saline nasal irrigation 2-3 times daily is strongly recommended for mucociliary clearance with no risk of rebound congestion 3, 1:

• Use 240mL per nostril with hypertonic or isotonic saline 5
• More effective than topical decongestants for long-term use 3

Intranasal corticosteroids (fluticasone propionate 2 sprays per nostril once daily) provide rapid symptom improvement 6, 7:

• FDA-approved for allergic rhinitis but strong evidence supports use in ABRS 1, 6
• Begin immediately and continue for 2-4 weeks 6
• Maximum benefit achieved within 12 hours to several days 6

Analgesics for pain management 2:

• Continue paracetamol 500-1000mg every 6 hours as needed 3
• Consider ibuprofen 400-600mg every 6-8 hours for headache 3

Oral decongestants (pseudoephedrine 60mg every 4-6 hours) may provide additional relief 3:

• Avoid topical decongestants beyond 3-5 days due to rebound congestion risk 3
• Use cautiously in patients with hypertension or cardiac conditions 5

Smoking Cessation Counseling

Cigarette smoke is a major modifiable risk factor that impairs mucociliary clearance and predisposes to recurrent sinusitis 4:

• 5 pack-year history significantly increases infection risk 4
• Provide smoking cessation resources immediately 4
• Cold office environment compounds ciliary dysfunction 4

Follow-Up and Red Flags

Reassess at 7 days if symptoms don't improve or worsen at any time 4, 2:

• Lack of improvement suggests antibiotic resistance or incorrect diagnosis 4
• Switch to broader-spectrum coverage (amoxicillin-clavulanate, cefuroxime, or respiratory fluoroquinolone) 4, 2

Immediate emergency referral required if any of the following develop 1, 2:

• Severe headache with neck stiffness or photophobia (meningitis concern) 3
• Vision changes, periorbital swelling, or proptosis (orbital complications) 4, 2
• Facial swelling or erythema suggesting cellulitis 3, 1
• High fever >39°C (102.2°F) with severe unilateral facial pain 3, 2
• Mental status changes 3

ENT referral indicated if 4, 8:

• Symptoms persist after 21-28 days of appropriate antibiotic therapy 4
• Recurrent episodes (≥3-4 per year) develop 8, 2
• CT imaging shows anatomic abnormalities or chronic changes 4

Imaging Considerations

No imaging is indicated at this time 4, 5, 2:

• Radiographs and CT are unnecessary for uncomplicated ABRS 4, 2
• Reserve CT for suspected complications, treatment failure, or surgical planning 4, 2
• Up to 40% of asymptomatic adults have abnormal sinus CT findings, making imaging unreliable for diagnosis 4

Common Pitfalls to Avoid

• Don't wait 10 days to treat when severe symptoms are present - the 10-day rule applies to mild cases suitable for observation 1, 2
• Don't prescribe antibiotics for isolated green mucus - color reflects neutrophils, not necessarily bacteria 1
• Don't use topical decongestants beyond 5 days - rebound congestion worsens outcomes 3
• Don't ignore occupational/environmental triggers - cold air and smoking perpetuate inflammation 4