How should I manage a patient with approximately one week of persistent nasal congestion and headache suggestive of acute sinusitis?

Management of One Week of Persistent Nasal Congestion with Headache

At one week of symptoms, your patient likely has viral rhinosinusitis and should receive symptomatic treatment only—antibiotics are not indicated unless symptoms persist beyond 10 days or worsen after initial improvement. 1

Diagnostic Classification at One Week

Your patient's presentation fits viral rhinosinusitis (VRS), not acute bacterial rhinosinusitis (ABRS), based on the following criteria:

• Symptoms present for less than 10 days without worsening = presumed viral etiology 1
• The American Academy of Otolaryngology-Head and Neck Surgery defines ABRS as requiring either:
  • Symptoms persisting ≥10 days without improvement, OR
  • "Double worsening" (symptoms worsen within 10 days after initial improvement) 1
• Your patient at 7 days does not meet either criterion 1

Key pitfall to avoid: Do not prescribe antibiotics based solely on purulent nasal discharge or headache—these symptoms occur in both viral and bacterial rhinosinusitis and cannot distinguish between them 1, 2

Recommended Management: Symptomatic Treatment

First-Line Symptomatic Therapies

Intranasal corticosteroids are the most evidence-based symptomatic treatment:

• Mometasone furoate 200 μg twice daily significantly improves total symptom scores, headache, facial pain, and congestion compared to placebo 1
• The European Position Paper on Rhinosinusitis 2020 confirms nasal corticosteroids reduce symptoms in acute post-viral rhinosinusitis, though the effect size is modest 1
• Start immediately—no need to wait for the 10-day mark 1

Supportive measures to recommend:

• Saline nasal irrigation to improve mucociliary clearance 3
• Analgesics (acetaminophen or NSAIDs) for headache and facial pain 4
• Adequate hydration, rest, warm facial packs, steamy showers 1
• Sleep with head of bed elevated 1

Short-term decongestants (topical or oral) may provide temporary relief but should be limited to 3-5 days to avoid rebound congestion 4

When to Initiate Antibiotics

Reassess at 10 days or if symptoms worsen at any time:

Criteria for Starting Antibiotics

If at day 10-14 symptoms have not improved or if they worsen at any time, diagnose ABRS and initiate antibiotics 1, 4:

First-line antibiotic:

• Amoxicillin 500 mg three times daily for 10-14 days 1, 4
• This is the preferred agent due to efficacy, safety, and cost-effectiveness 1, 4, 2

Alternative antibiotics for penicillin allergy:

• Doxycycline 4
• Trimethoprim-sulfamethoxazole (adults only) 1, 4
• Macrolides 4

If no improvement after 3-5 days of amoxicillin:

• Switch to high-dose amoxicillin-clavulanate (90 mg/kg amoxicillin component, not to exceed 2 g every 12 hours) 1, 3
• This covers β-lactamase producing organisms (H. influenzae, M. catarrhalis) 5

Observation Option for Mild ABRS

Even when ABRS criteria are met at day 10, the American Academy of Otolaryngology-Head and Neck Surgery supports watchful waiting for up to 7 additional days if 1:

• Nonsevere illness (mild pain, temperature <38.3°C/101°F)
• Reliable follow-up is ensured
• Patient understands to return if symptoms worsen

This approach is reasonable because many bacterial cases resolve spontaneously 1, 2

Imaging: Not Indicated

Do not obtain sinus imaging for your patient 1:

• Plain radiographs and CT cannot distinguish viral from bacterial rhinosinusitis 1
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against imaging for uncomplicated acute rhinosinusitis 1
• Reserve CT for suspected complications (see below) 1

Red Flags Requiring Immediate Evaluation

Refer urgently or obtain CT if any of these complications are suspected 1:

• Periorbital edema, erythema, or swelling
• Proptosis or abnormal extraocular movements
• Visual changes
• Severe headache with altered mental status
• Cranial nerve palsies
• Facial swelling over involved sinus

These suggest orbital or intracranial extension requiring immediate specialist consultation 1

Patient Education Points

Inform your patient 1, 4:

• Viral rhinosinusitis typically resolves in 7-10 days with symptomatic treatment alone
• Complete resolution may take up to 2 weeks even with appropriate management 4
• Return if symptoms persist beyond 10 days total, worsen at any time, or if severe symptoms develop 4
• Antibiotics are not helpful for viral illness and contribute to resistance 1

Follow-Up Plan

Schedule reassessment at day 10-14 if symptoms have not resolved 4:

• At that point, if symptoms persist without improvement, initiate antibiotics as outlined above 1, 4
• If symptoms have improved but not completely resolved, continue symptomatic treatment 1
• Consider evaluation for underlying factors (allergic rhinitis, anatomic abnormalities) if episodes become recurrent 3