Acute Rhinosinusitis

  • Diagnosed clinically using symptoms and signs >7d duration
    • Must have one of "OD" and one other "PODS" symptom
      • Facial Pain (or pressure), Nasal Obstruction, Discharge, Smell loss
    • Assess symptom severity based on tolerability/function
  • Radiological imaging usually not required (unless diagnosis unclear)
    • X-ray (3 views) diagnosis with air/fluid level or complete opacification
    • CT scan if complication
  • Most are viral and resolve spontaneously within 10-14d
    • Suspect bacterial if
      • Deterioration of symptoms 5-7d after improvement (biphasic)
      • Persistent symptoms without improvement >10-14d as per INESSS
        • >7d without improvement (or >10d persisting symptoms) as per Canadian guidelines
    • Treat bacterial if severe symptoms impacting function/sleep


  • Alarm symptoms - Consider urgent referral to ER
    • Toxic, altered mental status
    • Persistent fever (>38C)
    • Periorbital erythema/swelling or decreased visual acuity
    • Meningeal signs/severe headache or neuro signs
  • Symptoms: PODS, other (headache, cough, dental/ear pain, halitosis)
  • Predisposing conditions
    • Recent viral URTI
    • History of allergic/nonallergic/medication-induced rhinitis
    • Concomitant conditions (pregnancy, immunodeficiency, migraine)
    • Anatomic causes (deviated septum, enlarged tonsils, nasal polyp)
  • Response to medication, decongestant
  • Exposure and previous antibiotics
  • Facial pain increasing with leaning forward

Physical Exam

  • Tenderness on palpation/percussion of sinus
    • Maxillary floor from palate
    • Lateral ethmoid wall from medial angle of eye
    • Frontal floor from roof of orbit
    • Anterior maxillary wall from cheek
    • Anterior front wall from supraorbital skull
  • Maxillary teeth tenderness (using tongue depressor)
  • Purulent secretions in middle meatus (using otoscope or nasal speculum)
  • Posterior pharynx for purulent secretions (use pharyngeal mirror)


  • Prevention: Smoking cessation, hand hygiene
  • Symptom management:
    • Analgesics (acetaminophen, NSAIDs)
    • Saline irrigation BID
    • Oral decongestants <10d (when worse congestion, eg. night)
      • Topical decongestants <3d (risk of rebound congestion)
  • Consider topical intranasal corticosteroids (eg. nasonex) in mild-moderate ARS (NNT 15)
    • If no improvement after 72h, consider antibiotics


  • Consider treatment for suspected acute bacterial rhinosinusitis (as above) with severe symptoms or mild-moderate not responsive to INCS after 72h (NNT 17, NNH 8)
      • Amoxicillin 500mg PO q8h x 5-10 days
      • Second-line (or first-line if suspect resistance, immunosuppressed, frontal/sphenoidal sinusitis due to higher rates of complications)
        • Amoxicillin/Clavulanate 875/125mg PO BID x 7d
        • Moxifloxacin 400mg PO daily x 5d
        • Levofloxacin 500mg PO daily x 10d
      • If non-severe penicillin allergy, consider cefuroxime 250 BID x7d or cefixime 400 daily x10d
        • If anaphylaxis, consider clarithromycin, doxycycline or TMP-SMX


  • Lack of response within 72h suggests treatment failure
  • Referral to ENT if (and consider CT if long waiting time)
    • Complications
    • Persists >8w
    • Recurrent rhinosinusutis >3 episodes per year

Chronic rhinosinusitis

  • Definition
    • Inflammation in paranasal sinuses and nasal passages >12 weeks despite medical treatment
  • Treatment
    • Oral glucocorticoids PLUS empiric oral antibiotics x 4w
      • Prednisone 20mg PO BID x 5d, then 20mg daily x 5 days (total 10 days)
      • Amoxicillin-clavulanate 875mg PO BID or Clindamycin 450 mg PO TID
    • Topical glucocorticoid spray and intranasal saline irrigation or sprays