One-liner#

Distinguish viral URI (most common, self-limited) from acute bacterial rhinosinusitis (ABRS) requiring antibiotics, and identify chronic rhinosinusitis or complications needing ENT referral.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Periorbital edema, erythema, or proptosis (orbital cellulitis/abscess)
• Visual changes: diplopia, decreased acuity, painful eye movements
• Severe headache with fever and altered mental status (intracranial extension)
• High fever with toxic appearance
• Frontal swelling (“Pott’s puffy tumor”—frontal bone osteomyelitis)
• Meningeal signs: neck stiffness, photophobia
• Immunocompromised patient with rapidly progressive symptoms

Key history#

Duration—critical for diagnosis:

• <10 days: Viral URI (most likely)
• 10+ days without improvement: Consider ABRS
• “Double-sickening”: Initial improvement then worsening at day 5-7 suggests bacterial superinfection

• 12 weeks: Chronic rhinosinusitis (CRS)

Symptom pattern:

• Nasal congestion/obstruction
• Purulent nasal discharge (anterior or posterior)
• Facial pain/pressure/fullness (worse with bending forward)
• Hyposmia/anosmia
• Cough (especially post-nasal drip)
• Headache location (frontal, maxillary, periorbital)

Features suggesting bacterial infection:

• Symptoms ≥10 days without improvement
• Severe symptoms: high fever (≥39°C) + purulent discharge for 3-4 consecutive days
• “Double-sickening”: worsening after initial improvement
• Unilateral facial pain or tooth pain

Features suggesting allergic rhinitis:

• Seasonal pattern or known triggers
• Bilateral symptoms
• Sneezing, itchy eyes/nose
• Clear rhinorrhea
• Personal/family history of atopy

Features suggesting chronic rhinosinusitis:

• Symptoms >12 weeks
• Nasal polyps (anosmia, nasal obstruction)
• Prior sinus surgery
• Asthma (especially aspirin-exacerbated respiratory disease)

Relevant history:

• Recent dental work or tooth pain (odontogenic sinusitis)
• Immunocompromised status
• Smoking
• Prior episodes and treatments
• Allergies and current medications

Focused exam#

• Vitals: Temperature (high fever suggests bacterial or complication)
• General: Toxic appearance, periorbital swelling
• Nasal: Mucosal edema, turbinate hypertrophy, purulent discharge, polyps, septal deviation
• Facial: Tenderness over maxillary or frontal sinuses (low sensitivity/specificity)
• Oropharynx: Post-nasal drip, cobblestoning
• Eyes: Periorbital edema, erythema, proptosis, extraocular movements, visual acuity
• Teeth: Percussion tenderness of upper molars (odontogenic source)
• Ears: Otitis media (concurrent infection)
• Neck: Lymphadenopathy

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Clinical diagnosis—imaging NOT routinely indicated:

• ABRS is a clinical diagnosis based on symptom duration and pattern
• Imaging does not distinguish viral from bacterial (both cause mucosal thickening)
• Sinus X-rays are not recommended (poor sensitivity/specificity)

When to order CT sinus (non-contrast):

• Chronic rhinosinusitis (>12 weeks) failing medical management
• Suspected complication (orbital, intracranial)
• Recurrent acute sinusitis (≥4 episodes/year)
• Pre-operative planning for sinus surgery
• Unilateral symptoms concerning for mass or anatomic abnormality

When to order labs:

• Not routinely indicated for acute sinusitis
• Consider CBC if concerned about immunocompromise or complication
• Consider IgE, specific IgE panels if allergic rhinitis suspected and not responding to empiric treatment

When NOT to image or test:

• Acute symptoms <10 days (viral URI)
• First episode of ABRS responding to treatment
• Typical allergic rhinitis responding to treatment

Nasal endoscopy (ENT):

• Chronic rhinosinusitis evaluation
• Suspected polyps
• Unilateral symptoms
• Recurrent infections

Initial management#

Viral URI / acute rhinosinusitis (<10 days):

• Supportive care: saline irrigation, decongestants, analgesics
• NO antibiotics—will not help and cause harm
• Reassurance: symptoms typically peak day 3-4, resolve by day 10

Acute bacterial rhinosinusitis (meets criteria):

• First-line: Amoxicillin-clavulanate
• Duration: 5-7 days (as effective as 10-14 days)
• Adjunctive: saline irrigation, intranasal steroids

Watchful waiting option for ABRS:

• If symptoms 10+ days but not severe, can offer watchful waiting with close follow-up
• Provide “safety net” antibiotic prescription to fill if not improving in 7 days
• Appropriate for reliable patients with mild-moderate symptoms

Allergic rhinitis:

• Intranasal corticosteroids (first-line)
• Second-generation antihistamines
• Allergen avoidance
• Consider immunotherapy referral if refractory

Management by diagnosis#

Viral URI / Acute viral rhinosinusitis#

Education:

• This is a viral infection (“cold”) that will get better on its own
• Antibiotics will not help and can cause side effects
• Colored mucus does NOT mean you need antibiotics—it’s a normal part of the immune response
• Symptoms typically last 7-10 days

Treatment:

Rhinitis medicamentosa (rebound congestion): Caused by >3-5 days of topical decongestant use. Management: Stop oxymetazoline; substitute intranasal steroid (fluticasone 2 sprays BID); oral decongestant bridge for 3-5 days if needed. Symptoms improve over 1-2 weeks. | Acetaminophen | 650-1000 mg Q6H PRN | Liver disease | None | $ | For pain/fever | | Ibuprofen | 400-600 mg Q6H PRN | GI bleed, CKD, CV disease | None | $ | For pain/fever; may help with inflammation |

Follow-up: No routine follow-up. Return if symptoms worsen, persist >10 days, or “double-sickening” occurs.

Acute bacterial rhinosinusitis (ABRS)#

Education:

• Bacterial sinus infection that needs antibiotics
• You should start feeling better within 3-4 days
• Complete the full course even if you feel better
• Saline rinses help clear mucus and speed recovery

Treatment:

Why NOT azithromycin? High resistance rates (30-40% of S. pneumoniae); poor coverage of H. influenzae. Not recommended by IDSA guidelines for ABRS.

Pregnancy considerations: Amoxicillin-clavulanate is safe. Avoid doxycycline and fluoroquinolones. Intranasal steroids (budesonide preferred) are safe. | Intranasal fluticasone | 2 sprays per nostril daily | None | None | $ | Adjunctive; reduces inflammation; continue 2-4 weeks | | Saline irrigation | 240 mL per nostril 1-2x daily | None | None | $ | Adjunctive; improves symptoms and drainage |

Follow-up: If not improving after 3-4 days of antibiotics, reassess. Consider broader coverage or ENT referral.

Allergic rhinitis#

Education:

• Allergies cause inflammation in the nose that leads to congestion, sneezing, and drainage
• Nasal steroid sprays are the most effective treatment but take 1-2 weeks for full effect
• Avoiding triggers (if known) helps reduce symptoms
• This is a chronic condition—ongoing treatment often needed

Treatment:

Follow-up: 4-6 weeks to assess response. If inadequate, consider allergy testing and immunotherapy referral.

Chronic rhinosinusitis (CRS)#

Education:

• Chronic inflammation of the sinuses lasting >12 weeks
• Often requires long-term management, not just antibiotics
• Nasal saline irrigation and steroid sprays are the foundation of treatment
• May need CT scan and ENT evaluation if not improving

Treatment:

Follow-up: 4-8 weeks. If failing medical management, obtain CT sinus and refer to ENT for consideration of surgery.

Odontogenic sinusitis#

Recognition: Unilateral maxillary symptoms, foul smell, upper molar pain, recent dental work.

PCP role:

• Recognize the dental source
• Start antibiotics with anaerobic coverage
• Urgent dental referral for source control

Treatment:

Follow-up: Dental evaluation within 1-2 days. Antibiotics alone will not resolve without dental treatment.

Follow-up#

• Viral URI: No routine follow-up; return if >10 days or worsening
• ABRS: If not improving after 3-4 days of antibiotics, reassess
• Allergic rhinitis: 4-6 weeks to assess treatment response
• Chronic rhinosinusitis: 4-8 weeks; ENT referral if failing medical management
• Recurrent ABRS (≥4 episodes/year): CT sinus and ENT referral

Return precautions (all patients):

• Swelling around the eye or changes in vision
• Severe headache, stiff neck, or confusion
• High fever not responding to treatment
• Symptoms worsening despite antibiotics (if prescribed)
• Forehead swelling

Patient instructions#

• Most sinus symptoms are caused by viruses and get better in 7-10 days without antibiotics.
• Rinse your nose with saline (salt water) 1-2 times daily—this helps clear mucus and reduces symptoms.
• Use a humidifier and drink plenty of fluids to keep mucus thin.
• Over-the-counter decongestants can help but should not be used for more than 3-5 days.
• Colored mucus (yellow or green) does NOT mean you need antibiotics.
• If you were prescribed antibiotics, take them as directed and complete the full course.
• Call or return immediately if you develop swelling around your eye, vision changes, severe headache, stiff neck, or high fever.

Smartphrase snippets#

Viral URI (no antibiotics): Nasal congestion and rhinorrhea x [X] days, consistent with viral URI. No criteria for bacterial sinusitis (symptoms <10 days, no double-sickening, no severe symptoms). Discussed supportive care with saline irrigation and symptomatic treatment. Antibiotics not indicated. Return precautions given.

Acute bacterial rhinosinusitis: Nasal congestion with purulent discharge x [X] days with [double-sickening/no improvement after 10 days/severe symptoms]. Meets criteria for acute bacterial rhinosinusitis. Started amoxicillin-clavulanate 875/125 mg BID x 5-7 days. Adjunctive saline irrigation and intranasal fluticasone. Return if not improving in 3-4 days.

Allergic rhinitis: Chronic nasal congestion with sneezing, clear rhinorrhea, and [seasonal pattern/known triggers]. Consistent with allergic rhinitis. Started intranasal fluticasone 2 sprays per nostril daily + cetirizine 10 mg daily. Discussed allergen avoidance. Follow-up in 4-6 weeks to assess response.

Chronic rhinosinusitis referral: Nasal congestion and drainage >12 weeks despite medical management. CT sinus ordered. Referred to ENT for evaluation of chronic rhinosinusitis and consideration of surgical intervention.

Coding/billing notes#

• Document duration of symptoms and specific criteria met for ABRS diagnosis
• If not prescribing antibiotics, document why (e.g., “symptoms <10 days, consistent with viral URI”)
• For chronic rhinosinusitis, document duration (>12 weeks) and treatments tried
• Document red flag assessment (no periorbital swelling, vision changes, etc.)

Related pages#

• Allergic Rhinitis (problem) — chronic allergic rhinitis management with intranasal steroids and immunotherapy