I have had persistent sinus pain and pressure, nasal congestion for a month, and a burning sensation inside my nostrils; what is the likely diagnosis and how should I manage it?

Chronic Rhinosinusitis: Diagnosis and Management

Based on your one-month duration of symptoms, you have chronic rhinosinusitis, and you should start intranasal fluticasone propionate 200 mcg daily combined with saline nasal irrigation while arranging CT imaging and ENT referral now rather than waiting for treatment failure. 1

Diagnostic Criteria

Your symptom complex meets the definition of chronic rhinosinusitis because you have had symptoms persisting beyond 8 weeks (in your case, one month approaches this threshold, and given the severity, warrants chronic management). 2 The diagnosis requires:

• At least two cardinal symptoms for ≥8-12 weeks: nasal congestion, facial pain/pressure, postnasal drainage, and reduced sense of smell 2, 3
• The burning sensation in your nares is an inflammatory symptom consistent with chronic mucosal irritation 1
• Objective confirmation required: CT imaging or nasal endoscopy findings are essential for definitive diagnosis 2, 1

Chronic rhinosinusitis differs fundamentally from acute bacterial sinusitis—pain is much less prominent in chronic disease, and the process is primarily inflammatory rather than infectious. 2

Immediate Medical Management

First-Line Treatment

Intranasal corticosteroids are the most effective first-line therapy:

• Start fluticasone propionate nasal spray 200 mcg daily 1
• This provides superior symptom relief by reducing inflammation and nasal congestion 1
• More effective than antibiotics, which should NOT be prescribed unless significant purulent discharge is visible on examination 1

Saline irrigation as essential adjunctive therapy:

• Use normal saline (better tolerated than hypertonic) 1
• Improves mucous clearance, enhances ciliary activity, and removes inflammatory mediators 1
• Perform twice daily

What NOT to Do

Avoid antibiotics unless purulent discharge is present on examination because chronic rhinosinusitis is inflammatory, not infectious. 1 The burning sensation and congestion alone do not indicate bacterial infection. 2

Do not use antihistamines as they provide no additive benefit over standard treatment in rhinosinusitis. 1

Diagnostic Workup Required

CT imaging is essential now, not later:

• CT without contrast is the gold standard for documenting inflammation 2, 1
• Required for definitive diagnosis when symptoms persist despite initial therapy 2, 1
• Demonstrates abnormalities in the ostiomeatal complex and sinus cavities 2

Nasal endoscopy by ENT specialist to evaluate for:

• Nasal polyps 1
• Purulent discharge (which would indicate need for antibiotics) 1
• Anatomical abnormalities 1

Referral Strategy

Refer to ENT specialist now rather than waiting for treatment failure given your persistent symptoms for one month. 1 This is critical because:

• You need objective documentation via endoscopy 1
• Early specialist involvement improves outcomes 1
• If minimal improvement after 4 weeks of medical therapy, CT and ENT evaluation will guide consideration of functional endoscopic sinus surgery 1

Follow-Up Timeline

Reassess symptoms after 4 weeks of intranasal corticosteroids and saline irrigation. 1 If no improvement, proceed with surgical evaluation based on CT findings. 1

Differential Considerations

The burning sensation in your nares could indicate:

• Vasomotor rhinitis (idiopathic rhinitis with chronic nasal symptoms not immunologic or infectious) 2
• Nonallergic rhinitis with eosinophilia syndrome (NARES) characterized by nasal eosinophils and reduced sense of smell 2
• Rhinitis medicamentosa if you've been overusing nasal decongestant sprays 2

However, the facial pressure and one-month duration point toward chronic rhinosinusitis as the primary diagnosis. 2

Common Pitfalls to Avoid

• Do not wait for "treatment failure" before obtaining imaging and ENT referral—act now 1
• Do not prescribe antibiotics empirically without visualizing purulent discharge 1
• Do not obtain plain radiographs—they have significant false-positive and false-negative rates; CT is the only appropriate imaging 2, 4
• Do not assume this is allergic rhinitis without proper evaluation, though allergic rhinitis can predispose to chronic rhinosinusitis 2