A 53‑year‑old female presents 3 days prior to consultation with watery rhinorrhea and dull crushing frontal sinus pain radiating from the temples, unresponsive to antihistamine/decongestant; 2 days prior with dry cough and undocumented fever; now feels phlegm stuck in the throat and chest pain only when coughing. Past medical history includes type 2 diabetes mellitus on metformin, hypertension on losartan, hyperuricemia on febuxostat, and non‑alcoholic fatty liver disease; she is exposed to second‑hand smoke from neighbors. Vitals show blood pressure 140/90 mmHg, otherwise normal. What is the most likely diagnosis and what are the recommended next steps in management?

Diagnosis: Acute Viral Rhinosinusitis (Likely Progressing to Post-Viral Upper Airway Cough Syndrome)

This 53-year-old woman has acute viral rhinosinusitis that has not yet met criteria for bacterial superinfection, and her current symptoms should be managed with intranasal corticosteroids, symptomatic therapy, and close monitoring for progression to acute bacterial rhinosinusitis (ABRS) at the 10-day mark. 1

Clinical Reasoning

Why This Is NOT Bacterial Rhinosinusitis Yet

• Symptoms have been present for only 3 days, well below the 10-day threshold required for ABRS diagnosis. 1, 2 The American Academy of Otolaryngology-Head and Neck Surgery requires either ≥10 days of symptoms without improvement OR a "double worsening" pattern (initial improvement followed by worsening) to diagnose bacterial disease. 1, 2

• The progression from watery to more viscous discharge with chest discomfort when coughing represents typical viral evolution, not bacterial superinfection. 3 The sensation of phlegm stuck in the throat with chest pain only during cough is consistent with post-viral upper airway cough syndrome beginning to develop. 3

• Her blood pressure of 140/90 mmHg on current losartan is suboptimal but not acutely dangerous and should be addressed separately after the acute illness resolves. 1

Key Diagnostic Features Present

• Bilateral temporal-to-frontal headache (7/10, dull crushing quality) is characteristic of viral rhinosinusitis with sinus pressure. 3 The bilateral nature and lack of severe unilateral facial pain argue against bacterial disease. 4

• Failure to respond to over-the-counter antihistamine/decongestant combination is expected in viral rhinosinusitis, as these provide only modest symptomatic relief. 1

• The undocumented fever 2 days ago was likely low-grade and viral in origin. 1 High fever (>38.3°C) with severe symptoms would suggest bacterial infection. 5

Immediate Management Plan

First-Line Pharmacologic Therapy

Start intranasal corticosteroid immediately—do not wait until day 10. 1

• Mometasone furoate 200 µg (2 sprays per nostril) twice daily provides significant improvement in headache, facial pain, congestion, and total symptom scores compared to placebo. 1 This is supported by moderate-quality randomized trial evidence and endorsed by the European Position Paper on Rhinosinusitis (EPOS 2020). 1

• Saline nasal irrigation 2-3 times daily enhances mucociliary clearance and has no rebound effect, unlike topical decongestants. 1, 3 Use high-volume irrigation (240 mL per nostril) with isotonic or hypertonic saline. 2

• Ibuprofen 400-600 mg every 6-8 hours as needed for headache and facial pain. 3 Acetaminophen is an alternative if NSAIDs are contraindicated. 1

• First-generation antihistamine plus oral decongestant (e.g., dexbrompheniramine 6 mg + pseudoephedrine 120 mg sustained-release twice daily) for 7-10 days. 3 The anticholinergic effect of first-generation antihistamines reduces non-histamine-mediated rhinorrhea. 3 Avoid newer-generation antihistamines (loratadine, cetirizine), as they lack anticholinergic activity and are ineffective for post-viral symptoms. 3

• If using topical decongestant spray (oxymetazoline), limit strictly to 3-5 days maximum to prevent rebound congestion (rhinitis medicamentosa). 1, 3

Supportive Measures

• Adequate hydration, rest, warm facial compresses, steamy showers, and sleeping with the head of the bed elevated at 30-45 degrees. 6, 1 These measures enhance sinus drainage and patient comfort. 6

Smoking Cessation Counseling

Address her second-hand smoke exposure immediately. 2 Cigarette smoke—including passive exposure—impairs mucociliary clearance, prolongs viral illness, and significantly increases the risk of bacterial superinfection and recurrent sinusitis. 2 Counsel her to avoid exposure to neighbors' smoke and consider environmental modifications (air purifiers, keeping windows closed). 6

Critical Decision Point: When to Start Antibiotics

Reassess at day 10-14 (or sooner if symptoms worsen at any time). 1, 2

Criteria for Initiating Antibiotics (ABRS Diagnosis)

Start antibiotics if any of the following occur:

1. Symptoms persist ≥10 days without improvement 1, 2
2. "Double worsening"—initial improvement followed by worsening of symptoms 1, 2
3. Severe symptoms at any time: high fever (>38.3°C), severe unilateral facial pain, or systemic toxicity 1, 5

Antibiotic Regimen When Indicated

• First-line: Amoxicillin 500 mg three times daily for 10-14 days. 1, 2 This covers Streptococcus pneumoniae and Haemophilus influenzae, the most common bacterial pathogens. 2, 7

• If no improvement after 3-5 days of amoxicillin, switch to high-dose amoxicillin-clavulanate (875 mg/125 mg twice daily or 2000 mg/125 mg extended-release twice daily) to cover β-lactamase-producing organisms (H. influenzae, Moraxella catarrhalis). 1, 2

• For true penicillin allergy: doxycycline 100 mg twice daily, trimethoprim-sulfamethoxazole DS twice daily (adults only), or a macrolide (azithromycin 500 mg day 1, then 250 mg daily × 4 days). 1, 3

Imaging: Not Indicated

Do not order sinus radiographs or CT scan for this uncomplicated presentation. 6, 1, 2, 5 Routine imaging cannot distinguish viral from bacterial disease, and up to 40% of asymptomatic adults have abnormal sinus CT findings. 6, 2 Reserve CT for suspected complications or treatment failure after 21-28 days of appropriate antibiotic therapy. 6, 2

Red-Flag Symptoms Requiring Urgent Evaluation

Instruct the patient to return immediately or go to the emergency department if she develops any of the following: 6, 1, 3, 2

• Periorbital edema, erythema, swelling, proptosis, abnormal eye movements, or vision changes (orbital complications) 6, 1, 3
• Severe headache with altered mental status, neck stiffness, cranial nerve deficits, or seizures (intracranial extension) 6, 1, 3
• Facial swelling or erythema over the involved sinus (osteomyelitis or facial cellulitis) 3, 2
• High fever >39°C with severe unilateral facial pain 3, 5
• Worsening tachycardia, hypotension, or signs of sepsis 3

Follow-Up Plan

• Telephone follow-up at day 5-7 to assess symptom trajectory. 1 If symptoms are improving, continue symptomatic therapy. If worsening or no improvement, advance to in-person reassessment. 1

• In-person reassessment at day 10-14 if symptoms have not resolved. 1, 2 At that visit, if symptoms persist without improvement, diagnose ABRS and initiate amoxicillin as outlined above. 1, 2

• If symptoms have improved but not fully resolved by day 10-14, continue intranasal corticosteroids and supportive measures for an additional week. 6, 1

• If recurrent episodes develop (≥3 episodes per year), evaluate for underlying allergic rhinitis, anatomic abnormalities (deviated septum, polyps), or immunodeficiency. 6, 1 Consider referral to otolaryngology or allergy/immunology. 6

Comorbidity Considerations

Diabetes Management

• Her diabetes (on metformin 500 mg) is a risk factor for more severe bacterial infection if ABRS develops. 6 Ensure glucose control is optimized during illness. 6

Hypertension

• Her blood pressure of 140/90 mmHg on losartan 50 mg indicates suboptimal control. Consider uptitrating losartan to 100 mg daily or adding a second agent (e.g., amlodipine 5 mg daily) once the acute illness resolves. Pseudoephedrine in the decongestant may transiently elevate blood pressure; monitor closely. 3

Hyperuricemia and Fatty Liver

• Continue febuxostat 40 mg and hepatoprotective therapy (Hepatek) without interruption. These conditions do not alter the management of acute rhinosinusitis. 6

Common Pitfalls to Avoid

• Do not prescribe antibiotics at this 3-day mark. 1, 2 Only 0.5-2% of viral rhinosinusitis cases progress to bacterial infection, and 60% of presumed ABRS cases resolve spontaneously without antibiotics. 2 Premature antibiotic use drives resistance and exposes the patient to unnecessary adverse effects. 1

• Do not assume purulent discharge or green mucus indicates bacterial infection. 1, 2 Color reflects neutrophils and desquamated epithelium from normal viral inflammation, not bacterial invasion. 3, 2

• Do not overlook the possibility of asthma or COPD if cough persists beyond 2 weeks despite appropriate UACS treatment. 3 Obtain spirometry and consider a bronchodilator trial if cough becomes the dominant symptom. 3

• Do not ignore her second-hand smoke exposure. 2 This is a major modifiable risk factor for recurrent and chronic rhinosinusitis. 2

Patient Education

• Viral rhinosinusitis typically resolves within 7-10 days with symptomatic care; complete resolution may take up to 2 weeks. 1, 3

• Antibiotics are ineffective for viral illness and contribute to antimicrobial resistance. 1, 2

• Return for evaluation if symptoms persist beyond 10 days, worsen at any time, or if any red-flag symptoms develop. 1, 3

• Avoid exposure to second-hand smoke and consider environmental modifications to reduce future risk. 6, 2