I have facial pain, pressure, nasal congestion, thick yellow‑green nasal discharge, reduced sense of smell, and fever—how should I evaluate and treat my sinusitis?

Evaluation and Treatment of Acute Bacterial Rhinosinusitis

Based on your symptoms—facial pain, pressure, nasal congestion, thick yellow-green discharge, reduced smell, and fever—you meet clinical criteria for acute bacterial rhinosinusitis (ABRS) and should start antibiotic therapy immediately with amoxicillin 500 mg three times daily for 10–14 days. 1

Clinical Diagnosis

Your symptom constellation confirms ABRS without need for imaging:

• Purulent nasal discharge (thick yellow-green) plus nasal obstruction plus facial pain/pressure constitutes the diagnostic triad for ABRS. 2
• Fever, reduced sense of smell (anosmia), and headache are additional supportive features. 2
• The presence of purulent discharge alone does NOT distinguish bacterial from viral infection—duration and pattern matter more. 1 However, your combination of severe symptoms including fever strongly suggests bacterial disease.

Key Diagnostic Criteria

ABRS is diagnosed when symptoms persist ≥10 days without improvement, worsen within 10 days after initial improvement ("double worsening"), or are particularly severe (high fever >39°C, purulent discharge, facial pain) in the first 3–4 days. 2, 1

Immediate Antibiotic Treatment

First-Line Therapy

Amoxicillin 500 mg orally three times daily for 10–14 days is the preferred initial antibiotic because of proven efficacy, safety, and cost-effectiveness. 1 This targets the most common bacterial pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 3

If Penicillin Allergy

• Doxycycline 1
• A respiratory fluoroquinolone (levofloxacin 500 mg daily for 10–14 days or 750 mg daily for 5 days) 4, 5
• Trimethoprim-sulfamethoxazole (adults only) 1

Escalation for Treatment Failure

If no improvement after 3–5 days of amoxicillin, switch to high-dose amoxicillin-clavulanate (2000 mg amoxicillin/125 mg clavulanate twice daily) to cover β-lactamase-producing organisms. 1, 3 Many H. influenzae and M. catarrhalis strains produce β-lactamase and require this combination. 3

Adjunctive Symptomatic Therapy

Start intranasal corticosteroid (mometasone furoate 200 µg twice daily) immediately—do not wait. 1 This significantly improves facial pain, headache, and congestion compared to placebo. 1

Saline nasal irrigation improves mucociliary clearance and should be used as adjunctive therapy. 1, 5

Analgesics (acetaminophen or NSAIDs) for facial pain and headache. 1

Supportive measures: adequate hydration, rest, warm facial compresses, steamy showers, and sleeping with head elevated 30–45°. 1

Short-term topical decongestants (oxymetazoline, xylometazoline) may provide temporary relief but limit use to 3–5 days to avoid rebound congestion. 1

Imaging: When and Why

Routine sinus imaging (plain radiographs or CT) is NOT indicated for uncomplicated ABRS because imaging cannot reliably distinguish viral from bacterial disease, and up to 40% of asymptomatic adults show abnormal sinus CT findings. 2, 1

Reserve CT for suspected complications only: periorbital swelling/erythema, proptosis, vision changes, severe headache with altered mental status, cranial nerve deficits, or treatment failure after 21–28 days of appropriate therapy. 2, 1

Red-Flag Symptoms Requiring Urgent Evaluation

Seek immediate specialist referral and/or emergent CT if you develop:

• Periorbital edema, erythema, swelling, proptosis, abnormal eye movements, or vision changes (orbital complications) 1, 6
• Severe headache with altered mental status, neck stiffness, cranial nerve palsies, or seizures (intracranial extension) 1
• Facial swelling or erythema over the involved sinus 1, 6
• High fever >39°C with severe unilateral facial pain and systemic toxicity 1

These findings suggest orbital cellulitis, meningitis, or abscess—rare but serious complications. 5

Follow-Up Plan

Reassess at 3–5 days: If symptoms have not improved, escalate to high-dose amoxicillin-clavulanate. 1

Complete the full 10–14 day antibiotic course even if symptoms improve earlier. 1

If symptoms persist beyond 4 weeks despite appropriate antibiotic therapy, reclassify as subacute sinusitis and consider CT imaging to evaluate for anatomic obstruction, nasal polyps, or chronic sinusitis. 2

For recurrent episodes (≥3 per year), evaluate for underlying allergic rhinitis, anatomic abnormalities (deviated septum), or immunodeficiency, and consider referral to otolaryngology or allergy/immunology. 2, 1

Common Pitfalls to Avoid

Do not prescribe antibiotics based solely on purulent discharge or headache—these occur in viral infections too. 1 Duration and severity pattern are key.

Do not order sinus X-rays—they are inaccurate and have been supplanted by CT when imaging is truly needed. 2

Do not use antihistamines routinely unless allergic rhinitis is documented—they can thicken secretions and impair drainage. 7

Avoid prolonged topical decongestant use (>5 days) due to rebound rhinitis medicamentosa. 1

Recognize that most viral upper respiratory infections involve the sinuses (up to 87%), so maxillary sinus tenderness alone does not confirm bacterial infection. 1