ENT

Acute rhinosinusitis

Inflammation of the nasal mucosa and paranasal sinuses that follows blockage of their narrow drainage pathways, almost always viral and self-limiting, with antibiotics reserved for the minority who develop true bacterial superinfection or complications.

In a nutshell

Acute rhinosinusitis usually follows a viral upper-respiratory infection and lasts two to three weeks. Use symptom duration and severity to guide antibiotics: most need self-care, prolonged uncomplicated disease may need no or back-up antibiotics, and orbital or intracranial signs need hospital referral.

Classic presentation

Nasal blockage or discharge with facial or dental pain or pressure and reduced smell after a cold; assess the duration, trajectory, systemic illness and eye or neurological signs.

Key points

Most cases resolve over two to three weeks without antibiotics; symptoms for around 10 days or less should not receive an antibiotic.
Bacterial disease is more likely when prolonged symptoms, purulent discharge, severe unilateral pain, fever and marked deterioration cluster, but no single feature is diagnostic.
For prolonged symptoms without improvement, consider a high-dose intranasal corticosteroid for 14 days in adults and children aged 12 years or over.
A back-up antibiotic is used if symptoms fail to improve within 7 days or worsen rapidly or significantly; reassess rather than automatically repeating treatment.
Periorbital oedema, a displaced eye, double vision, ophthalmoplegia or reduced vision requires hospital referral.
Frontal-bone swelling, meningism, severe frontal headache or focal neurological signs suggests intracranial complication and requires hospital referral.
Topical nasal decongestants should not be used for more than 5 days.

First-line investigation

Clinical assessment alone for uncomplicated disease; arrange hospital assessment and specialist-led imaging when orbital or intracranial complications are suspected.

Management

Identify complications first

Refer to hospital for severe systemic infection, orbital signs, newly reduced vision, frontal-bone swelling, meningism, severe frontal headache or focal neurological signs.¹

Use self-care for short uncomplicated illness

For symptoms around 10 days or less, explain the usual two- to three-week course, provide appropriate analgesia and fever advice, and do not offer an antibiotic.^1,3

Consider a nasal corticosteroid for prolonged symptoms

For adults and children aged 12 years or over with symptoms for around 10 days or more without improvement, consider a high-dose intranasal corticosteroid for 14 days and explain its modest symptomatic benefit.^1,3

Use no, back-up or immediate antibiotics appropriately

For prolonged uncomplicated disease, consider no antibiotic or a back-up prescription; give an immediate antibiotic when the person is systemically very unwell, has a serious illness or is at high risk of complications, using the current NICE table and BNF.^1,2,3

Safety-net and reassess trajectory

Explain that a back-up prescription is used if symptoms do not improve within 7 days or worsen rapidly or significantly; reassess if symptoms persist beyond 3 weeks, deteriorate despite treatment or suggest dental, allergic, structural or other disease.^1,4

Exam traps

Antibiotics are not first-line for most acute rhinosinusitis, since the great majority is viral and self-limiting.
A 'double-sickening' pattern raises the likelihood of bacterial disease but does not replace assessment for severe illness or complications.
Periorbital swelling or eye signs require hospital referral, not simply escalation of oral antibiotics in the community.
High-dose intranasal corticosteroid treatment is a consideration for prolonged symptoms in people aged 12 years or over, not routine treatment from day one.

Illustrations

Paranasal sinus anatomy and drainageDiagram of the paranasal sinuses and the ostiomeatal complex showing normal mucus drainage pathways into the nasal cavity.PassFinals · original

Blocked sinus ostium with mucus retentionCross-sectional illustration comparing a patent sinus ostium with one obstructed by inflamed mucosa, trapping mucus within the sinus.PassFinals · original

Orbital cellulitis complicating maxillary sinusitis on CTAxial CT showing right maxillary sinusitis and adjacent orbital inflammatory swelling, highlighted by arrows.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.