What over‑the‑counter treatments are recommended for an acute sinus infection in a patient without uncontrolled hypertension, severe heart disease, glaucoma, or monoamine‑oxidase inhibitor use?

Over-the-Counter Treatment for Sinus Infection

For acute sinus infection, use intranasal corticosteroids (like fluticasone or mometasone) twice daily combined with saline nasal irrigation 2-3 times daily, plus analgesics (acetaminophen or ibuprofen) for pain and fever—these provide the most effective symptom relief and are supported by strong evidence. 1

First, Confirm You Actually Need Treatment

• Most sinus infections (98-99.5%) are viral and resolve on their own within 7-10 days without any medication. 1
• Only consider bacterial infection if you have persistent symptoms ≥10 days without improvement, severe symptoms (fever ≥39°C with purulent discharge) for ≥3-4 consecutive days, or "double sickening" (worsening after initial improvement). 1
• If your symptoms have lasted less than 10 days and aren't severe, you likely have a viral infection that won't respond to antibiotics anyway. 1

Core Over-the-Counter Treatments (Use These First)

Intranasal Corticosteroid Sprays (Most Important)

• Fluticasone, mometasone, or budesonide nasal spray twice daily reduces mucosal inflammation and accelerates symptom resolution. 1
• These are now available over-the-counter and have strong evidence from multiple randomized controlled trials showing they work for both viral and bacterial sinusitis. 1
• Number needed to treat is 14—meaning for every 14 people who use nasal steroids, one additional person improves compared to placebo. 1
• Side effects are minimal (occasional nosebleeds, nasal irritation) and far outweigh the modest cost. 1

Saline Nasal Irrigation

• Use 2-3 times daily with either normal saline or hypertonic saline solution. 1, 2
• Provides mechanical removal of mucus, reduces nasal congestion, and has no serious adverse effects. 1
• A Cochrane review showed minor improvements in nasal symptom scores, though the clinical significance is modest. 1
• This is safe, inexpensive, and can be used alongside any other treatment. 2

Analgesics for Pain and Fever

• Acetaminophen or ibuprofen (or other NSAIDs) for facial pain, headache, or fever. 1
• These provide direct symptom relief and are appropriate for both viral and bacterial infections. 1

Additional Over-the-Counter Options (Weaker Evidence)

Oral Decongestants

• Pseudoephedrine may provide symptomatic relief of nasal congestion. 1
• Do not use if you have uncontrolled hypertension, severe heart disease, glaucoma, or are taking MAO inhibitors—these are absolute contraindications. 1
• Evidence for efficacy is limited, but clinical experience suggests benefit. 1

Topical Decongestants

• Oxymetazoline (Afrin) or similar sprays can provide rapid relief of nasal congestion. 1
• Critical warning: Do not use for more than 3-5 days to avoid rebound congestion (rhinitis medicamentosa). 1
• Use only for short-term relief during the worst symptoms. 1

Antihistamines (Limited Role)

• First-generation antihistamines (like diphenhydramine or chlorpheniramine) may help with excessive secretions and sneezing due to their anticholinergic effects. 1
• No clinical studies support their use in acute viral rhinosinusitis, but they may provide symptomatic benefit. 1
• Sedation is the main side effect—consider taking at bedtime. 1

Expectorants and Cough Suppressants

• Guaifenesin (expectorant) and dextromethorphan (cough suppressant) are often used but lack evidence of clinical efficacy. 1
• Use is based largely on patient and provider preference rather than proven benefit. 1

What Does NOT Work

• Zinc lozenges, echinacea, vitamin C, and mist therapy have no proven benefit for acute bacterial rhinosinusitis. 3
• Mucus color alone does not indicate bacterial infection—discolored discharge reflects neutrophils (inflammation), not bacteria. 1

When to See a Doctor for Antibiotics

You need prescription antibiotics (not available over-the-counter) if:

• Symptoms persist ≥10 days without improvement 1
• Severe symptoms (fever ≥39°C with purulent discharge) for ≥3-4 consecutive days 1
• Worsening after initial improvement ("double sickening") 1
• Development of complications (severe headache, vision changes, facial swelling, altered mental status) 1

Practical Treatment Algorithm

Days 1-7 (Likely Viral):

• Intranasal corticosteroid spray twice daily 1
• Saline irrigation 2-3 times daily 1
• Acetaminophen or ibuprofen as needed for pain/fever 1
• Consider short-term topical decongestant (≤3 days) if severely congested 1

Days 7-10 (Still Symptomatic but Not Worsening):

• Continue the above treatments 1
• Most viral infections resolve by day 10-14 1

Day 10+ (Persistent Symptoms) or Severe Symptoms at Any Time:

• See a doctor for evaluation and possible antibiotics 1
• Continue OTC treatments as adjuncts 1

Critical Pitfalls to Avoid

• Don't assume you need antibiotics just because you have colored mucus—this is inflammation, not necessarily bacterial infection. 1
• Don't use topical decongestants beyond 3-5 days—you'll develop rebound congestion that's worse than the original problem. 1
• Don't use oral decongestants if you have hypertension, heart disease, glaucoma, or take MAO inhibitors—serious complications can occur. 1
• Don't skip the intranasal corticosteroids—they have the strongest evidence for benefit and are now available OTC. 1