What is the diagnosis and recommended management for a 19‑year‑old female with acute viral upper‑respiratory infection presenting with thick yellow nasal discharge, glabellar headache, ear pressure, boggy non‑erythematous tonsils and odynophagia?

Diagnosis and Management of Acute Viral Upper Respiratory Infection with Post-Nasal Drainage

Primary Diagnosis: Acute Viral Rhinosinusitis (Common Cold)

This 19-year-old female has a self-limited viral upper respiratory infection that does not require antibiotics. The clinical presentation—3 days of thick yellowish nasal discharge that has now resolved, transient ear fullness (resolved), non-erythematous boggy tonsils, and mild watery nasal discharge—is entirely consistent with the natural progression of a viral URI. 1, 2

Why This Is Viral, Not Bacterial

• Symptom duration < 10 days: The patient is only 3 days into her illness. Bacterial rhinosinusitis requires either persistent symptoms ≥10 days without improvement, severe symptoms (fever ≥39°C with purulent discharge) for ≥3-4 consecutive days, or "double sickening" (worsening after initial improvement). None of these criteria are met. 1, 3, 2

• Natural progression of nasal discharge color: The transition from clear to thick yellowish discharge over 2-3 days is a normal feature of viral colds, reflecting neutrophil influx and desquamated epithelium—not bacterial infection. Purulent nasal discharge alone does not indicate bacterial infection. 1, 2, 4

• Resolution of key symptoms: The nasal discharge and ear fullness have already resolved by the time of consultation, indicating the viral illness is improving naturally. 2, 4

• Absence of severe features: No high fever (≥39°C), no severe unilateral facial pain, no periorbital swelling, and vital signs are normal. 1, 3

• Epidemiology: Approximately 98-99.5% of acute rhinosinusitis cases are viral and resolve spontaneously within 7-10 days without antibiotics. 1, 3, 5

Clinical Features Explained

• Boggy, non-erythematous tonsils: This reflects reactive lymphoid hyperplasia from viral pharyngitis, not bacterial tonsillitis. The absence of erythema, exudate, or significant odynophagia argues against Group A Streptococcus. 2, 4

• Ear pressure/fullness: Eustachian tube dysfunction from nasal congestion is common in viral URIs and typically resolves as nasal inflammation subsides. The fact that it has already resolved confirms this was transient and benign. 1

• Late inspiratory sound ("tight passage of air"): This likely represents mild laryngeal irritation or post-nasal drainage causing transient upper airway narrowing—common in viral URIs with post-nasal drip. 6, 7

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Management: Symptomatic Treatment Only

First-Line Symptomatic Therapies

• Analgesics for pain and fever control:

  • Paracetamol (acetaminophen) 1000 mg every 4-6 hours (maximum 4000 mg/24 hours) is the preferred first-line agent due to superior safety profile—no gastrointestinal bleeding risk, no renal toxicity, no cardiovascular effects. 4, 8
  • Ibuprofen 400 mg every 6-8 hours is an alternative if paracetamol is insufficient, but carries higher risk of GI and renal adverse effects. 4, 8

• Intranasal saline irrigation 2-3 times daily provides symptomatic relief by clearing mucus and reducing nasal congestion. This is safe, inexpensive, and evidence-based. 1, 3, 4, 5

• Intranasal corticosteroids (e.g., mometasone, fluticasone, budesonide) twice daily may reduce nasal inflammation and improve symptoms, though evidence for benefit in uncomplicated viral URIs is limited. Consider if symptoms are particularly bothersome. 3, 4, 5

• Oral decongestants (pseudoephedrine) or topical decongestants (oxymetazoline) may be used for severe nasal congestion, but limit topical agents to ≤3 days to avoid rebound congestion (rhinitis medicamentosa). 4, 5

What NOT to Do

• Do NOT prescribe antibiotics. This patient does not meet criteria for bacterial rhinosinusitis. Antibiotics are ineffective against viral infections, provide no benefit, increase adverse effects (diarrhea in 40-43% of patients on amoxicillin-clavulanate), and promote antimicrobial resistance. 1, 3, 2, 4, 9, 5

• Do NOT obtain imaging (X-ray or CT). Radiography is not indicated for uncomplicated acute rhinosinusitis. Up to 87% of viral URIs show sinus abnormalities on imaging, leading to unnecessary interventions. 1, 3, 5

• Do NOT prescribe antihistamines or combination cold medications unless the patient has significant allergic rhinitis. Evidence for benefit in viral URIs is poor, and these agents can cause sedation and anticholinergic side effects. 4, 5

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Patient Education and Follow-Up

Expected Course

• Symptoms typically last up to 2 weeks and are self-limited. Respiratory symptoms (nasal congestion, cough) peak between days 3-6 and then gradually improve. 2, 4, 8

• The illness will resolve without antibiotics, even when purulent nasal discharge is present. 2, 4

When to Return for Reassessment

• Persistent symptoms ≥10 days without improvement (purulent nasal discharge with obstruction or facial pain). 1, 3, 2

• Severe symptoms: High fever ≥39°C with purulent discharge and facial pain for ≥3-4 consecutive days. 1, 3, 2

• "Double sickening": Initial improvement followed by worsening symptoms (new fever, increased nasal discharge, worsening cough). 1, 3, 2

• Red-flag symptoms: Severe headache, visual changes, periorbital swelling, altered mental status, or cranial nerve deficits (suggest complications such as orbital cellulitis or meningitis). 1, 3, 5

Infection Control

• Hand hygiene is the most effective method to reduce transmission. 4

• Avoid close contact with others while symptomatic to prevent spread. 4

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Common Pitfalls to Avoid

• Do not prescribe antibiotics based on purulent nasal discharge alone. This is a normal feature of viral colds and does not indicate bacterial infection. 1, 2, 4

• Do not assume "thick yellow discharge" means bacterial infection. Viral infections naturally progress from clear to purulent discharge over several days due to neutrophil influx. 1, 2

• Do not use symptom duration < 10 days as a reason to prescribe antibiotics. The patient must meet one of the three bacterial criteria (persistent ≥10 days, severe ≥3-4 days, or double sickening). 1, 3, 2

• Do not obtain throat cultures or rapid strep tests unless the patient has classic features of streptococcal pharyngitis (tonsillar exudate, tender anterior cervical lymphadenopathy, absence of cough). This patient has rhinorrhea and cough, which argue against strep throat. 2, 4

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Summary Algorithm

1. Confirm viral etiology: Symptom duration < 10 days, no severe features, natural resolution of nasal discharge and ear fullness. 1, 2

2. Provide symptomatic treatment: Paracetamol for pain/fever, saline nasal irrigation, consider intranasal corticosteroids or decongestants. 4, 8, 5

3. Educate patient: Symptoms last up to 2 weeks, illness is self-limited, antibiotics are not needed. 2, 4

4. Safety-net advice: Return if symptoms persist ≥10 days, worsen after initial improvement, or develop red-flag features. 1, 3, 2

5. Do NOT prescribe antibiotics unless the patient meets bacterial criteria on reassessment. 1, 3, 2, 4, 9, 5