What is the likely diagnosis and recommended management for a patient with sinus pressure and temple pain who has no fever or nasal discharge?

Likely Diagnosis: Viral Rhinosinusitis (Not Bacterial Sinusitis)

The absence of purulent nasal discharge makes acute bacterial rhinosinusitis (ABRS) highly unlikely, and this patient most likely has viral rhinosinusitis or another non-infectious cause of facial pain. 1

Why This Is NOT Bacterial Sinusitis

The diagnostic criteria for acute bacterial rhinosinusitis are very specific, and this patient does not meet them:

• Purulent nasal discharge is essential for diagnosis: The CPG:AS guidelines explicitly state that "a diagnosis of ABRS is unlikely in the absence of purulent nasal discharge, even when other cardinal symptoms are evident" 1
• Facial pain alone is insufficient: Isolated facial pain-pressure-fullness without purulent nasal discharge cannot establish a diagnosis of acute rhinosinusitis 1
• The absence of fever is not helpful: Guidelines indicate that the presence or absence of fever is not useful in differentiating bacterial from viral disease 1

Differential Diagnosis to Consider

Without purulent discharge, the differential diagnosis broadens significantly:

• Viral rhinosinusitis: Most likely if symptoms are present less than 10 days and not worsening 1
• Tension or migraine headaches: Can mimic rhinosinusitis pain, but absence of purulent nasal discharge excludes bacterial sinusitis 1
• Dental abscess: Can cause facial pain and sinus pressure 1
• Allergic rhinitis: The most common predisposing factor for sinusitis, can cause nasal congestion and facial pressure 2

Recommended Management Approach

Immediate Assessment

• Examine the nasal cavity and posterior pharynx: Look specifically for purulent (yellow-green, green, or gray) secretions, which are highly predictive of bacterial sinusitis 2
• Assess vital signs: Document temperature, though fever presence doesn't differentiate bacterial from viral disease 1
• Palpate sinuses: Check for maxillary and frontal sinus tenderness 2
• Document symptom duration precisely: Acute bacterial sinusitis requires symptoms persisting beyond 10 days OR worsening within 10 days after initial improvement ("double worsening") 1, 2

Treatment Based on Findings

If no purulent discharge is found on examination:

• Do NOT prescribe antibiotics: Only 0.5-2% of viral respiratory infections progress to bacterial sinusitis 1
• Provide symptomatic management: Most viral URIs resolve within 7-10 days without antibiotics 3
• Consider saline irrigation: Effective for symptom relief by improving mucous clearance 4
• Reassess if symptoms persist beyond 10 days: This is when bacterial superinfection should be reconsidered 2, 3

If purulent discharge IS present on examination AND symptoms have persisted >10 days or show double worsening:

• Then bacterial sinusitis becomes likely and antibiotic therapy would be appropriate 1, 2

Critical Pitfalls to Avoid

• Don't diagnose bacterial sinusitis before 10 days: Most viral URIs resolve within 5-7 days; bacterial sinusitis is suspected when symptoms persist beyond 10-14 days 2
• Don't prescribe antibiotics without purulent discharge: The specificity for ABRS increases dramatically when nasal obstruction or facial pain occurs in combination with purulent nasal discharge 1
• Don't order imaging routinely: Plain radiographs are not recommended due to significant false-positive and false-negative results; CT is reserved for uncertain diagnosis or suspected complications 2