Acute Viral Rhinosinusitis (Likely Progressing to Acute Bacterial Rhinosinusitis)
This 23-year-old male most likely has acute bacterial rhinosinusitis (ABRS) based on persistent purulent nasal discharge, nasal congestion, and headache for 5 days with worsening symptoms including fever, meeting clinical diagnostic criteria for ABRS. 1
Clinical Diagnosis
The patient meets two of three cardinal symptoms required for acute rhinosinusitis diagnosis 1:
- Purulent nasal discharge (thick yellowish, occasionally clear watery) – present
- Nasal obstruction/congestion (swollen turbinates on exam, right > left) – present
- Facial pain/pressure (glabellar and temple headache) – present
The 5-day symptom duration with fever development represents the critical decision point between viral and bacterial etiology 1. While symptoms persisting ≥10 days without improvement are the clearest indicator of ABRS, this patient demonstrates worsening symptoms (new-onset fever at day 5) after initial symptom onset, which is an alternative diagnostic criterion for presumed ABRS 1.
The concurrent presentation of fever (38°C) with purulent nasal discharge suggests possible "severe onset" ABRS, though the fever is not high-grade (would need ≥39°C for definitive severe onset classification) 1.
Critical Hypertension Management Issue
The blood pressure of 130/90 mmHg is concerning because the patient took phenylephrine-containing Bioflu 2, 3. Phenylephrine and other oral decongestants cause systemic vasoconstriction and can elevate blood pressure by approximately 1 mmHg on average, with significant individual variation 3. In a young hypertensive patient already on dual therapy (losartan + amlodipine), this represents a reversible cause of inadequate blood pressure control 4.
Immediate Action Required:
- Discontinue Bioflu (phenylephrine-containing product) immediately 4
- Recheck blood pressure in 24-48 hours after decongestant discontinuation 4
- Never prescribe oral decongestants (pseudoephedrine, phenylephrine) to hypertensive patients 2, 3
Next Steps: Diagnostic Approach
No imaging or laboratory studies are required for uncomplicated acute rhinosinusitis 1. The diagnosis is clinical, based on history and physical examination findings already obtained 1.
Radiographic imaging is NOT indicated except in cases of suspected complications (orbital cellulitis, intracranial extension) or when an alternative diagnosis is suspected 1. This patient has no warning signs such as:
- Unilateral symptoms suggesting foreign body 1
- Severe unilateral facial/tooth pain 1
- Orbital symptoms (periorbital edema, vision changes) 1
- Severe headache suggesting intracranial complications 1
Nasal cultures are not recommended for acute bacterial rhinosinusitis 1. Middle meatus cultures do not reliably correlate with maxillary sinus aspirate cultures, and maxillary sinus aspiration is reserved for complicated or refractory cases 1.
Treatment Algorithm
Step 1: Decide Between Observation vs. Immediate Antibiotics
For persistent ABRS (symptoms >10 days), either antibiotic therapy OR additional 3-day observation is acceptable 1. However, this patient is at day 5 with worsening course (new fever), which shifts the recommendation toward antibiotics 1.
Antibiotic therapy is recommended because 1:
- Worsening symptoms after initial onset (new fever at day 5)
- Patient already failed symptomatic therapy (levodropropizine, Bioflu)
- Young patient with hypertension as comorbidity
Step 2: Antibiotic Selection
First-line: Amoxicillin-clavulanate is the preferred agent for ABRS 1. The major bacterial pathogens are:
Dosing: Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days (or high-dose 2000/125 mg twice daily if risk factors for resistance exist) 1.
Alternative if penicillin allergy: Respiratory fluoroquinolone (levofloxacin, moxifloxacin) or doxycycline 1.
Step 3: Symptomatic Management (CRITICAL for Hypertensive Patients)
Intranasal corticosteroids are the ONLY recommended symptomatic therapy 2, 5:
- Mometasone furoate 2 sprays each nostril once daily OR
- Fluticasone propionate 2 sprays each nostril once daily 2
- Provides rapid symptom improvement within 12 hours 2
- No cardiovascular effects – completely safe in hypertension 2
- Superior to oral decongestants for nasal congestion 4
Nasal saline irrigation as adjunctive therapy 2, 4:
Continue paracetamol for fever/headache as needed (safe in hypertension) 3.
Step 4: What to AVOID in This Hypertensive Patient
NEVER prescribe oral decongestants 2, 3, 4:
- ❌ Pseudoephedrine
- ❌ Phenylephrine
- ❌ Phenylpropanolamine
AVOID topical decongestants (oxymetazoline) unless absolutely necessary, and then ONLY for maximum 3 days to prevent rhinitis medicamentosa 2, 4.
AVOID NSAIDs (ibuprofen, naproxen) for pain/fever, as they can elevate blood pressure by ~3/1 mmHg and blunt antihypertensive effects 3. Use paracetamol instead 3.
AVOID first-generation antihistamines (chlorphenamine in Bioflu) – they cause sedation and anticholinergic effects without addressing the underlying inflammation 4.
Follow-Up Plan
Recheck in 48-72 hours to assess:
- Clinical improvement of rhinosinusitis symptoms 1
- Blood pressure after decongestant discontinuation 4
Failure to improve after 72 hours of antibiotics warrants consideration of:
- Antibiotic resistance (switch to broader spectrum) 1
- Complications (imaging if new warning signs develop) 1
- Alternative diagnosis 1
Common Pitfalls to Avoid
Do not combine multiple sympathomimetic agents (e.g., if patient self-medicates with additional decongestants) – this can precipitate hypertensive crisis 3, 4.
Do not assume colored nasal discharge alone indicates bacterial infection – viral URIs commonly produce purulent discharge 1. The key is persistence ≥10 days OR worsening course, both of which this patient demonstrates 1.
Do not prescribe antibiotics for isolated nasal congestion or facial pain without purulent discharge – specificity for ABRS requires purulent discharge PLUS obstruction or facial pain 1.
Educate the patient that intranasal corticosteroids require consistent use – full benefit takes up to 2 weeks, though symptom improvement begins within 12 hours 2, 4.
Teach proper intranasal spray technique – direct sprays away from nasal septum toward lateral nasal wall to minimize irritation and bleeding 4.