What is the likely diagnosis and treatment for an adult with pain on the upper side of the head, ear, and congestion all on the right side?

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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

Treatment algorithm: 1, 2

  1. Start amoxicillin for 3-5 days
  2. If improving, complete 10-14 day course (or 7 days after symptom resolution)
  3. 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

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Acute Bacterial Sinusitis Diagnosis

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Sinus headaches: avoiding over- and mis-diagnosis.

Expert review of neurotherapeutics, 2009

Research

Causes of headache in patients with a primary diagnosis of sinus headache.

European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery, 2011

Guideline

Differential Diagnoses for Upper Respiratory Infections

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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