How should I initially manage sinusitis in an otherwise healthy adult presenting with sinus symptoms?

Initial Management of Sinusitis in Healthy Adults

For an otherwise healthy adult presenting with sinus symptoms, you should first determine whether this is viral acute rhinosinusitis (which requires only symptomatic treatment) or acute bacterial rhinosinusitis (which may warrant antibiotics), based on symptom duration and pattern—and when bacterial sinusitis is confirmed, either offer watchful waiting with assured follow-up or prescribe amoxicillin with or without clavulanate for 5-10 days. 1

Step 1: Confirm the Diagnosis of Acute Rhinosinusitis

• Diagnose acute rhinosinusitis (ARS) when the patient has up to 4 weeks of purulent (cloudy or colored, not clear) nasal drainage PLUS one or both of the following: 1

  • Nasal obstruction, congestion, or blockage
  • Facial pain, pressure, or fullness (in face, head, or around eyes)

• Do NOT diagnose ARS if purulent nasal drainage is absent—nasal obstruction alone or facial pain alone without purulent drainage does not meet criteria. 1

Step 2: Distinguish Viral from Bacterial Acute Rhinosinusitis

This is the critical decision point that determines antibiotic use.

Diagnose Acute Bacterial Rhinosinusitis (ABRS) when either: 1

• Persistent symptoms: ARS symptoms persist for ≥10 days without any evidence of improvement, OR
• "Double worsening": ARS symptoms worsen within 10 days after an initial improvement

Diagnose Viral Rhinosinusitis when: 1

• The patient has been symptomatic for <10 days AND is not worsening

Common pitfall: Most acute sinusitis is viral and self-limited. Antibiotics prescribed before 10 days contribute to unnecessary antibiotic use and resistance. 1, 2

Step 3: Initial Management Based on Diagnosis

For Viral Rhinosinusitis (symptoms <10 days, not worsening):

• Offer symptomatic relief only—no antibiotics. 1
• Options include: 1
  • Analgesics for pain
  • Topical intranasal corticosteroids
  • Saline nasal irrigation

For Acute Bacterial Rhinosinusitis (≥10 days persistent OR double worsening):

You have two evidence-based initial management options:

Option A: Watchful Waiting (Observation Without Antibiotics) 1

• This is appropriate ONLY when you can assure follow-up 1
• Provide symptomatic relief (analgesics, intranasal steroids, saline irrigation) 1
• Consider a "safety-net" or "wait-and-see" antibiotic prescription the patient can fill if not improving 1
• Reassess at 7 days: If the patient fails to improve or worsens at any time, initiate antibiotic therapy 1

Option B: Initial Antibiotic Therapy 1

First-line antibiotic: Amoxicillin with or without clavulanate for 5-10 days 1

For penicillin allergy: Prescribe doxycycline or a respiratory fluoroquinolone (such as levofloxacin or moxifloxacin) 1, 3, 4

• The American Academy of Allergy, Asthma, and Immunology recommends amoxicillin for 10-14 days (or until symptom-free for 7 days) 5
• High-dose amoxicillin-clavulanate or cefuroxime are second-line options if no improvement after 3-5 days 5

Adjunctive symptomatic therapy should still be offered (analgesics, intranasal steroids, saline irrigation). 1

Step 4: Reassessment for Treatment Failure

If the patient worsens OR fails to improve within 7 days of initial management (whether watchful waiting or antibiotics): 1

• Reassess to confirm ABRS diagnosis
• Exclude other causes of illness and detect complications (orbital or intracranial extension)
• If initially managed with observation: Start antibiotic therapy 1
• If initially managed with antibiotics: Switch to an alternate antibiotic 1

Critical Caveats

Do NOT obtain imaging (X-rays or CT) for uncomplicated acute rhinosinusitis 1

• Imaging is only indicated if you suspect a complication (orbital cellulitis, meningitis, abscess) or an alternative diagnosis 1

Recognize chronic or recurrent patterns:

• Symptoms ≥12 weeks = Chronic rhinosinusitis (CRS), which requires different management including objective documentation of sinonasal inflammation and consideration of non-infectious causes 1
• ≥3 episodes per year = Recurrent acute rhinosinusitis, which warrants assessment for underlying conditions (allergic rhinitis, immunodeficiency, anatomic abnormalities) 1

Fluoroquinolone caution:

The FDA label for moxifloxacin explicitly states that fluoroquinolones should be reserved for patients with no alternative treatment options for acute bacterial sinusitis, given their association with serious adverse reactions. 3

Shared decision-making:

The choice between watchful waiting and immediate antibiotics should involve the patient, considering illness severity, ability to follow up, and patient preference. 1