What are the symptoms and treatment options for bacterial sinusitis, particularly in patients with a history of allergies or asthma?

Bacterial Sinusitis: Symptoms and Clinical Recognition

Suspect acute bacterial sinusitis when upper respiratory symptoms persist beyond 10-14 days without improvement, when symptoms worsen after initial improvement at 5-7 days, or when severe symptoms (high fever ≥39°C with purulent discharge) occur for 3-4 consecutive days. 1, 2

Three Diagnostic Patterns

The diagnosis requires one of three distinct clinical presentations 3, 2:

• Persistent illness pattern: Symptoms lasting ≥10 days without improvement—this is the most common presentation 2
• Worsening course pattern: New symptoms or worsening after 5-7 days of initial improvement from a viral URI—this allows for the earliest diagnosis 3, 2
• Severe onset pattern: High fever (≥39°C/102.2°F) with purulent nasal discharge for 3-4 consecutive days—this justifies immediate antibiotic treatment 3, 2

Cardinal Symptoms

The most prominent symptoms include 1, 2:

• Purulent rhinorrhea (thick nasal discharge)
• Nasal congestion
• Facial-dental pain (especially unilateral)
• Postnasal drainage
• Headache
• Cough (often worse at night)

The combination of persistent purulent rhinorrhea and facial pain has the strongest correlation with bacterial disease, with sensitivity of 69% and specificity of 64%. 1, 2

Additional Supporting Symptoms

Less frequent but supportive findings include 1, 2:

• Fever, malaise, and fatigue
• Halitosis (bad breath)
• Sore throat
• Hyposmia/anosmia (reduced or absent sense of smell)
• Ear pressure or fullness
• Decreased appetite 1

Physical Examination Findings

Clinical signs on examination include 1, 2:

• Sinus tenderness on palpation
• Mucosal erythema (redness)
• Purulent nasal secretions visible on examination
• Increased pharyngeal secretions
• Periorbital edema (swelling around the eyes) 1, 4

Special Considerations for Patients with Allergies or Asthma

Allergic rhinitis is a major predisposing factor for bacterial sinusitis and can complicate the clinical picture. 1 Key distinguishing features include:

• Allergic rhinitis clues: Family history of atopy, seasonal occurrences, pruritic (itchy) eyes and nasal mucosa, prominent nasal crease, allergic shiners, cobblestoning of conjunctiva or pharyngeal wall, pale nasal mucosa 1
• Sinusitis can trigger asthma: Infected sinuses may stimulate parasympathetic nerves leading to bronchial smooth muscle contraction and asthma exacerbation 5
• Nasal polyps: More common when sinusitis complicates allergic rhinitis, and even more common in nonallergic rhinitis 1, 5

Pediatric Presentation Differences

In children, symptoms are similar but often include 1, 2:

• Increased irritability
• More prolonged cough
• Vomiting associated with gagging on mucus 1

Critical Pitfalls to Avoid

Do not diagnose bacterial sinusitis based on colored nasal discharge alone—mucopurulent secretions occur normally after a few days of viral infection due to neutrophil influx and are not specific for bacterial disease. 1, 2 The key is persistence beyond 10-14 days or worsening after initial improvement. 1, 2

Do not routinely order imaging studies (plain films, CT, MRI, or ultrasound) to distinguish bacterial sinusitis from viral URI—imaging should be reserved for treatment failures, confusing presentations, suspected complications, or surgical planning. 1, 3, 2

Red Flags Requiring Urgent Evaluation

Facial swelling with sinusitis may indicate serious complications requiring emergency assessment 4:

• Orbital involvement: Look for diplopia (double vision), proptosis (eye bulging), or vision changes 4
• Soft tissue infection: Facial swelling with fever and systemic symptoms 4
• Intracranial complications: Severe headache, mental status changes, cranial nerve palsies 1, 4

Differential Diagnosis

Alternative diagnoses to consider include 1, 2:

• Allergic rhinitis
• Eosinophilic nonallergic rhinitis
• Vasomotor rhinitis
• Vascular headaches/migraines 1

Treatment Approach for Patients with Allergies/Asthma

Once bacterial sinusitis is diagnosed, empirical antibiotics are recommended, with amoxicillin 500mg three times daily for 7-10 days as first-line therapy. 3 For patients with risk factors for resistance (recent antibiotic use, hospitalization, immunocompromised status), amoxicillin-clavulanate is preferred. 3

Adjunctive management is particularly important in allergic patients 3, 5:

• Intranasal saline irrigation 3
• Intranasal corticosteroids (e.g., flunisolide) to decrease inflammation and promote drainage 3, 5
• Oral and topical decongestants 5
• Avoid antihistamines—they have no role in treating sinusitis and may thicken secretions 6

For patients with underlying allergic rhinitis or asthma, continued individualized allergy management after acute treatment is beneficial to prevent recurrence. 1