Likely Diagnosis: Acute Bacterial Rhinosinusitis (ABRS)
Your presentation of unilateral right-sided head pain, ear symptoms, and congestion strongly suggests acute bacterial rhinosinusitis, particularly if symptoms have persisted beyond 10 days or worsened after initial improvement. 1, 2
Clinical Reasoning
The constellation of unilateral symptoms you describe—head pain, ear fullness/pressure, and congestion—represents classic features of ABRS when accompanied by purulent nasal drainage. 1 The unilateral nature is particularly significant, as facial pain-pressure that is unilateral and focused in a particular sinus region has higher specificity for bacterial infection. 1
Key diagnostic criteria for ABRS require one of two patterns: 1, 2
- Symptoms persisting 10 days or more without improvement following upper respiratory infection onset
- Symptoms that worsen within 10 days after initial improvement (the "double worsening" pattern)
Your ear pressure/fullness is a recognized symptom of ABRS due to the continuity of upper respiratory tract mucosa, where sinus inflammation affects the middle ear through eustachian tube dysfunction. 1, 2
Critical Diagnostic Considerations
You must have purulent (cloudy or colored) nasal discharge to diagnose ABRS—facial pain alone is insufficient. 1 Check for:
- Purulent drainage in the nasal cavity or posterior pharynx on examination 1
- Nasal obstruction (congestion, blockage, stuffiness) 1
- Unilateral facial pain-pressure-fullness 1
Important pitfall to avoid: Migraine headaches and tension-type headaches commonly mimic sinus pain and are vastly overdiagnosed as "sinus headache." 3, 4, 5 However, the absence of purulent nasal discharge excludes ABRS by definition. 1 Studies show that 68% of patients with self-described "sinus headache" actually have migraine, and 27% have tension-type headache. 5
When to Diagnose ABRS vs. Viral Rhinosinusitis
If your symptoms are less than 10 days and not worsening, this is viral rhinosinusitis (VRS), not bacterial. 1, 6 Only 0.5-2% of viral upper respiratory infections progress to bacterial sinusitis. 1 Viral infections cause sinus inflammation in 87% of cases, but these resolve without antibiotics within 2 weeks. 6
Recommended Treatment for ABRS
First-line antibiotic therapy is amoxicillin 500 mg three times daily for 7-10 days (or continue for 7 days after symptoms resolve). 1, 2, 7 This provides adequate coverage for the most common pathogens: Streptococcus pneumoniae and Haemophilus influenzae. 1, 7
- Start amoxicillin for 3-5 days
- If improving, complete 10-14 day course (or 7 days after symptom resolution)
- If no improvement after 3-5 days, switch to high-dose amoxicillin-clavulanate or cefuroxime axetil
Adjunctive symptomatic therapy includes: 1, 2
- Intranasal corticosteroids (may be helpful though efficacy not definitively proven) 1
- Nasal saline irrigation 2, 6
- Oral analgesics for pain 2, 6
- Oral or topical decongestants 1
Red Flags Requiring Urgent Evaluation
Seek immediate evaluation if you develop: 1
- Orbital swelling, pain, or diplopia (double vision)
- Swelling of the forehead
- Visual changes or proptosis (eye bulging)
- Abnormal neurologic signs suggesting intracranial involvement
- Periorbital inflammation, edema, or erythema
These suggest complications requiring urgent specialist consultation. 1
If Symptoms Are Less Than 10 Days
If your symptoms have been present less than 10 days and are not worsening, treat as viral URI with symptomatic management only: 6
- Nasal saline irrigation
- Oral decongestants
- Analgesics
- Reassess in 4 days for worsening or persistence beyond 10 days
Do not use antibiotics for viral rhinosinusitis—this contributes to antibiotic resistance without benefit. 6
Imaging Considerations
Radiographs or CT scans are not necessary for typical ABRS presentations and should not be obtained to distinguish bacterial from viral infection. 2 Imaging is reserved for suspected complications or when diagnosis is uncertain after failed treatment. 1