Can acute sinusitis present without rhinorrhea, nasal congestion, or post‑nasal drip?

Can You Have Sinusitis Without Nasal Symptoms?

No, you cannot have acute sinusitis without at least one of the cardinal nasal symptoms—nasal blockage/congestion or nasal discharge (including postnasal drip)—as these are required diagnostic criteria according to current guidelines. 1

Diagnostic Requirements for Acute Rhinosinusitis

The European Position Paper on Rhinosinusitis (EPOS 2020) establishes clear diagnostic criteria that mandate specific symptoms:

• Acute rhinosinusitis requires "two or more symptoms, one of which SHOULD BE either nasal blockage/obstruction/congestion OR nasal discharge (anterior/posterior nasal drip)" 1
• Additional symptoms may include facial pain/pressure or reduction/loss of smell, but these alone are insufficient for diagnosis 1
• This requirement applies to both adults and children, though children may also present with cough as an alternative symptom 1

Why Nasal Symptoms Are Mandatory

The requirement for nasal symptoms is based on fundamental pathophysiology:

• The mucosa of the nose and sinuses are contiguous, and sinusitis without rhinitis is rare 1
• Rhinitis typically precedes sinusitis, making isolated sinus inflammation without nasal involvement extremely uncommon 1
• Symptoms have high sensitivity but low specificity, which is why objective findings (endoscopy or CT) are needed to confirm the diagnosis 1

Clinical Presentations That May Seem Atypical

Nosocomial Sinusitis

• In patients with prolonged nasotracheal intubation, clinical features except for unexplained fever may be relatively silent 1
• However, this represents a special circumstance where nasal symptoms cannot manifest due to intubation, not true absence of nasal involvement 1

Chronic Sinusitis

• Symptoms are usually less intense but more protracted than acute sinusitis, with fever being uncommon 1
• Fatigue, malaise, and irritability can be more prominent than local nasal symptoms 1
• However, nasal congestion, facial pain, or postnasal drip remain part of the diagnostic criteria even when subtle 1

Isolated Sphenoid Sinusitis

• This rare presentation (1-3% of sinonasal diseases in children) may have vague and nonspecific symptoms 1
• Headache, severe ocular signs, or oculomotor palsy can be the initial presentation 1
• Even in these cases, careful history typically reveals some nasal symptoms, though they may not be the chief complaint 1

Common Diagnostic Pitfalls

Do not diagnose sinusitis based solely on facial pain, headache, or loss of smell without nasal symptoms. These presentations more likely represent:

• Tension headache or migraine 1
• Primary rhinitis (if younger than 35 years with seasonality and allergen triggers) 1
• Other neurological conditions (especially with isolated sphenoid involvement) 1

Imaging abnormalities alone are insufficient for diagnosis:

• More than 50% of patients with strong history of chronic sinusitis had normal CT scans 1
• Conversely, 87% of young adults recovering from a cold showed significant maxillary sinus abnormalities on CT 1
• In children, 68% with viral upper respiratory infection and 42% of healthy children had significant sinus abnormalities on MRI 1

Practical Clinical Algorithm

When evaluating a patient for possible sinusitis without obvious nasal symptoms:

1. Specifically ask about subtle nasal symptoms: postnasal drip (throat clearing, mucus sensation), mild congestion, or any nasal discharge 1

2. If truly no nasal symptoms exist, consider alternative diagnoses before labeling as sinusitis 1

3. For suspected complications (orbital involvement, intracranial extension), imaging is warranted regardless of symptom profile 1, 2

4. In elderly patients, presentation may be subtle with distinct lack of symptoms, but most will still have nasal obstruction and purulent postnasal drip on careful examination 3