What are the typical symptoms and treatment options for bacterial sinusitis?

Symptoms of Bacterial Sinusitis

Bacterial sinusitis should be diagnosed when a viral upper respiratory infection either persists beyond 10 days without improvement, worsens after 5-7 days of initial improvement (the "double-sickening" pattern), or presents with severe onset (high fever ≥39°C/102°F plus purulent nasal discharge for 3-4 consecutive days). 1, 2

Three Diagnostic Patterns

The diagnosis requires recognizing one of three distinct clinical presentations:

• Persistent illness: Symptoms lasting ≥10 days without any improvement—this is the most common presentation but requires the longest observation period before diagnosis 1, 2
• Worsening course: New symptoms or worsening after 5-7 days of initial improvement—this "double-sickening" pattern allows for the earliest diagnosis at 5-7 days 1, 2
• Severe onset: High fever (≥39°C/102.2°F) with purulent nasal discharge for 3-4 consecutive days—this can be recognized within the first 3-4 days of illness 1, 2

Cardinal Symptoms

The most prominent symptoms that suggest bacterial rather than viral infection include:

• Purulent (thick, colored) nasal discharge—the absence of purulent discharge makes bacterial sinusitis unlikely, even when other symptoms are present 1, 2
• Nasal congestion/obstruction 3, 2
• Facial pain or pressure, especially when unilateral and focused over a particular sinus (maxillary, frontal, or ethmoid regions) 3, 2, 4
• Maxillary dental pain—particularly suggestive when unilateral 3, 2
• Postnasal drainage 3, 2

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

Supporting Symptoms

Additional symptoms that support the diagnosis when present with the cardinal features:

• Fever—though fever alone at day 10 is not suggestive of bacterial infection 3, 2
• Cough—can persist 10+ days even in uncomplicated viral infections 3, 1
• Hyposmia/anosmia (reduced or absent sense of smell) 3, 2
• Ear pressure or fullness 3, 2
• Fatigue and malaise 3, 2
• Headache 2
• Halitosis (bad breath) 2

Physical Examination Findings

When examining patients, look for:

• Purulent nasal secretions visible on anterior rhinoscopy or endoscopy 2
• Sinus tenderness on palpation over the maxillary or frontal sinuses 2
• Mucosal erythema 2
• Periorbital edema 2
• Increased pharyngeal secretions 2

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 3, 1, 2

Do not diagnose bacterial sinusitis if symptoms are present for fewer than 10 days without worsening—approximately 87% of adults with acute URI symptoms show sinus inflammation on CT scan, yet 79% improve without antibiotics after 2 weeks 1

Recognize that cough and nasal drainage can persist 10+ days in 40% of uncomplicated viral infections—duration beyond 7 days is moderately sensitive but relatively nonspecific for bacterial infection 3, 1

Avoid routine imaging studies—X-rays, CT, and MRI do not contribute to diagnosis in uncomplicated cases and show abnormalities in 87% of viral URIs 1, 5

Distinguishing Viral from Bacterial Infection

Key temporal patterns help differentiate:

• Viral URIs typically peak at days 3-6, with fever and myalgia resolving within 24-48 hours, though nasal congestion and cough may persist into weeks 2-3 3, 1
• Bacterial sinusitis shows either no improvement by day 10, worsening after initial improvement at days 5-7, or severe onset with high fever plus purulent discharge for 3-4 days 1, 2
• Steady improvement without a biphasic pattern suggests viral URI, not bacterial sinusitis 1

Pediatric Considerations

In children, the presentation is similar but may include:

• Increased irritability 2
• More prolonged cough 2
• Vomiting associated with gagging on mucus 2
• Children experience 3-8 viral URIs per year, creating high potential for inappropriate antibiotic use 3

When to Suspect Complications

Red flags requiring immediate evaluation include:

• Proptosis (bulging eye) 5
• Vision changes 5
• Facial swelling or erythema 3, 5
• Severe unilateral pain out of proportion to other symptoms 3

These suggest orbital or intracranial complications requiring urgent imaging and specialist consultation 5