What is the likely diagnosis and recommended management for a patient with four months of sinus pressure and temple pain after moving into a new home, whose cohabitant has similar symptoms?

Environmental Rhinosinusitis with Likely Indoor Allergen or Irritant Exposure

The simultaneous onset of sinus pressure and temple pain in both the patient and cohabitant after moving into a new home strongly suggests environmental rhinosinusitis triggered by indoor allergens or irritants in the shared living space, requiring immediate environmental assessment and allergen avoidance measures alongside medical management. 1

Diagnostic Classification

This 4-month duration definitively classifies as chronic rhinosinusitis (symptoms ≥8 weeks), not acute or subacute disease. 1 The key diagnostic features include:

• Sinus pressure and temple pain persisting for 4 months 1
• Temporal relationship to new home occupancy 1
• Shared symptoms with cohabitant, indicating common environmental exposure 1

Critical Environmental Investigation Required

Conduct an immediate and thorough environmental survey of the new home, specifically assessing: 1

• Pets (current or previous tenant's animals - dander persists in carpets/upholstery) 1
• Carpet, curtains, and upholstered furniture (allergen reservoirs) 1
• Age and composition of mattress, pillows, and bedding 1
• Mold or water damage (particularly relevant given geographic prevalence in southeast/southwest regions) 1
• Heating and air conditioning systems (dust accumulation, mold in ducts) 1
• Tobacco smoke exposure (active or residual from previous occupants) 1
• Insects (cockroach allergen) 1

Diagnostic Workup

Initial Clinical Assessment

Document the following specific symptoms: 1

• Nasal congestion, rhinorrhea (clear vs. purulent), postnasal drainage 1
• Facial/sinus pain or pressure 1
• Anosmia or hyposmia 1
• Ocular symptoms (redness, tearing, itching) 1
• Throat symptoms (soreness, dryness) 1
• Cough 1
• Sleep quality impairment 1

Allergy Testing

Test for IgE sensitization to inhalant allergens to identify specific triggers in the home environment. 2 This is essential given the strong temporal relationship to the new residence and shared symptoms. 1

Imaging Considerations

Obtain coronal sinus CT with cuts through the ostiomeatal complex if symptoms persist after 4 weeks of appropriate medical therapy to confirm chronic sinusitis and assess for structural abnormalities. 1, 2 CT is superior to plain radiographs for chronic disease. 2

Management Algorithm

First-Line Medical Therapy

Intranasal corticosteroids are the cornerstone of treatment for chronic rhinosinusitis, particularly when allergic or eosinophilic inflammation is suspected. 1, 2

Nasal saline irrigation to mechanically remove allergens and improve mucociliary clearance. 3, 2

Antibiotic Considerations

Do NOT initiate antibiotics empirically without evidence of bacterial infection (purulent discharge, fever). 2 The shared symptoms between cohabitants and environmental trigger strongly suggest non-infectious chronic hyperplastic eosinophilic sinusitis rather than bacterial disease. 1, 2

If purulent discharge is present, consider amoxicillin-clavulanate 500mg three times daily for 4-8 weeks minimum (not the 10-14 day courses used for acute sinusitis). 2 However, poor response to prolonged antibiotics should prompt reconsideration of non-infectious etiology. 2

Corticosteroid Trial for Non-Infectious Disease

If antibiotics fail or purulent features are absent, prescribe oral corticosteroids (prednisone 30-60mg daily for 5-7 days) to address chronic hyperplastic eosinophilic sinusitis. 1, 2 This non-infectious form is marked by eosinophilic inflammation and does not respond to antibiotics. 1, 2

Environmental Control Measures (CRITICAL)

Implement aggressive allergen avoidance immediately: 1

• Remove or thoroughly clean carpets, curtains, and upholstered furniture 1
• Encase mattresses and pillows in allergen-impermeable covers 1
• Use HEPA filtration in HVAC systems 1
• Maintain indoor humidity <50% to prevent mold growth 1
• Professional mold remediation if water damage identified 1
• Remove pets if present and sensitization confirmed 1

Immunotherapy Consideration

Allergen immunotherapy should be explored if specific IgE sensitizations are identified and symptoms persist despite environmental control and pharmacotherapy. 1 This provides long-term immunomodulation rather than symptom suppression alone. 1

Indications for ENT Referral

Refer to otolaryngology if: 2

• Failure to improve after 4 weeks of optimal medical therapy (intranasal corticosteroids + saline irrigation ± antibiotics if indicated) 2
• CT evidence of ostiomeatal complex obstruction despite aggressive medical management 1, 2
• Nasal polyps identified on examination 1
• Anatomic abnormalities (septal deviation compressing middle turbinate) 1, 2

Critical Pitfalls to Avoid

Do not treat with short 10-14 day antibiotic courses - this is inadequate for chronic sinusitis and promotes resistance. 2 Chronic bacterial sinusitis requires 4-8 weeks minimum. 2

Do not assume all chronic sinusitis is infectious - eosinophilic disease requires corticosteroids, not prolonged antibiotics. 1, 2 The shared environmental exposure in this case strongly suggests non-infectious etiology. 1

Do not rely on plain radiographs - CT is far superior when imaging is needed for chronic disease. 2

Do not use topical decongestant sprays beyond 3-5 days to prevent rhinitis medicamentosa. 2

Do not overlook the cohabitant's symptoms - this shared presentation is the strongest clue to environmental causation and should drive aggressive environmental investigation and remediation. 1