Adult acute rhinosinusitisBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2687 (Published 10 May 2013) Cite this as: BMJ 2013;346:f2687
- J Bird, core trainee year 1, ENT1,
- TC Biggs, core trainee year 2, ENT1,
- M Thomas, professor of primary care research2,
- RJ Salib, senior lecturer in rhinology; consultant otorhinolaryngologist13
- 1Department of Otolaryngology/Head & Neck Surgery, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- 2University of Southampton, Aldermoor Health Centre, Southampton
- 3Clinical Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton
- Correspondence to: J Bird
- Accepted 28 December 2012
A 35 year old woman presents to her general practitioner with a 10 day history of worsening nasal congestion, purulent nasal discharge, and frontal headaches.
What you should cover
Rhinosinusitis (including nasal polyps) is an inflammatory condition of the nose and paranasal sinuses. Diagnosis requires at least two symptoms, one of which must be nasal discharge or obstruction, with the others comprising facial pain or smell disturbance.
Acute rhinosinusitis is defined as symptoms lasting less than 12 weeks with complete resolution and can be subdivided into
Acute viral rhinosinusitis (common cold)—Defined by duration of symptoms of less than 10 days.
Acute non-viral rhinosinusitis—Defined by an increase in symptoms after 5 days or persistent symptoms after 10 days.
Acute bacterial rhinosinusitis—Suggested by the presence of at least three symptoms or signs of
Discoloured discharge (with unilateral predominance) and purulent secretions
Severe local pain (with unilateral predominance)
Elevated erythrocyte sedimentation rate or C reactive protein
“Double sickening” (that is, a deterioration after an initial milder illness).
Chronic rhinosinusitis (with or without polyps) is defined as more than 12 weeks of symptoms without complete resolution.
The following points are important within the history in acute rhinosinusitis:
Nasal blockage, obstruction, or congestion—Is the blockage unilateral or bilateral? Acute rhinosinusitis is usually associated with bilateral symptoms. With unilateral symptoms, bear in mind the possibility (albeit rare) of an underlying malignancy.
Nasal discharge (anterior or posterior nasal drip)—Attempts should be made to assess and record the character, amount, and pattern of nasal discharge over time.
Facial pain or pressure—Facial pain without nasal obstruction or discharge is highly unlikely to be due to sinusitis. Purely unilateral facial pain is unlikely to be sinogenic, most commonly it is dental in origin.
Change, reduction, or loss of sense of smell.
Resolution of symptoms—Frequent short lasting episodes with complete resolution are likely to be associated with acute viral rhinosinusitis, whereas infrequent long lasting episodes with no resolution are suggestive of chronic rhinosinusitis.
Respiratory symptoms—These may include pharyngeal, laryngeal, or tracheal irritation causing sore throat, change in voice, and cough.
Systemic symptoms—Malaise, headache, and fever may also occur.
If the patient seems to be systemically unwell then heart rate, blood pressure, and temperature should be assessed. A fever of >38°C is more likely to be associated with bacterial infection.
Percussion over the maxillary, ethmoid, and frontal sinuses or leaning forward may exacerbate facial pain or pressure. However, the sensitivity and specificity of these signs in the identification of acute bacterial rhinosinusitis have not been established, and they are not diagnostic in isolation.
Perform anterior rhinoscopy (with an otoscope or Thudichum’s nasal speculum with headlight, depending on availability) and look for
Mucopurulent discharge or nasal polyps (polyps can sometimes be confused with an engorged inferior turbinate, but they are insensate, in contrast to the inferior turbinate)
Other nasal pathology (such as a neoplasm, particularly in the presence of unilateral polyp or mass and associated bloody nasal discharge)
In case of diagnostic doubt (that is, symptoms suggestive of neoplasm as mentioned above), patients should be referred for nasal endoscopy (rigid or fibreoptic), which is currently the optimum method for nasal examination.
A plain radiograph of the sinuses is not recommended for the diagnosis and management of acute rhinosinusitis
Computed tomography is the primary investigation carried out by otolaryngologists if complications are suspected or when planning endoscopic sinus surgery.
Differential diagnosis of acute rhinosinusitis
Differential diagnosis of acute rhinosinusitis to exclude on history and examination:
Dental pain (particularly in cases of unilateral facial pain)
Neuralgic (atypical) facial pain
Temporomandibular joint pain
What you should do
Management (see figure⇓)
Acute rhinosinusitis is common, with an annual prevalence of 6-15%, although it is often self managed without medical care being sought. The primary cause of acute rhinosinusitis is viral, with only 0.5-2% developing secondary acute bacterial rhinosinusitis. Acute rhinosinusitis is usually self limiting, as evidenced in most randomised trials. Therefore, antibiotics should not be routinely prescribed as they are unlikely to affect the duration or severity of illness. Antibiotic therapy should be reserved for patients with progressive or worsening symptoms or for those who are systemically unwell (for example, fever >38°C or worsening facial pain), with a 5-7 day course being most appropriate. Amoxicillin-clavulanate (rather than amoxicillin alone because of emergence of antimicrobial resistance among respiratory pathogens) is recommended as empirical therapy for non-penicillin allergic adults at a dose of 500 mg/125 mg orally three times daily. In penicillin-allergic patients, doxycycline (100 mg orally twice daily) or clarithromycin (500 mg orally twice daily) would be reasonable choices.
Additional treatment with a systemic decongestant (such as pseudoephedrine) or topical nasal decongestant (such as xylometazoline) or nasal saline douche (such as Sterimar or Sinus Rinse) may have modest benefits, and patients can be advised to purchase these over the counter if necessary. Intranasal corticosteroids in short courses (such as mometasone furoate 50 μg nasal spray twice daily for 7-14 days) are effective as monotherapy for moderate disease and in combination with antibiotics for severe disease. Nasal decongestants should not be used for more than 10 days as they can induce rebound rhinitis (rhinitis medicamentosa). Antihistamines do not have a role in the treatment of acute rhinosinusitis. Steam inhalations have not shown consistent benefit in the treatment of acute rhinosinusitis, but some clinical trials have shown symptomatic relief. Signs of impending complications (orbital, intracranial, etc) should prompt immediate specialist referral.
In summary, most cases of uncomplicated acute rhinosinusitis will settle with conservative measures. General practitioners should advise patients to keep well hydrated and to use analgesia and nasal or systemic decongestants. Topical nasal steroids and nasal saline douches can be trialled if a patient wishes. In systemically unwell patients whose symptoms have increased after five days or persisted after 10 days, a five day trial of antibiotics in conjunction with nasal decongestants or douches and topical steroids should be considered. If there is no improvement after having taken antibiotics for 48 hours or if signs of impending complications (orbital or intracranial) have developed, a referral to ear, nose, and throat (ENT) services (urgent in the latter scenario) should be made. For a more detailed management approach, refer to the algorithm (figure⇑).
When to refer immediately
The sinuses are in close anatomical proximity to the orbits and brain. As such, acute rhinosinusitis can lead to complications associated with substantial morbidity or even mortality. Such complications are thankfully rare but are more commonly encountered in the paediatric population. Immediate referral (same day) for urgent investigation and intervention should therefore be considered in the following circumstances:
Periorbital oedema or cellulitis
Reduced visual acuity
Signs of meningitis or focal neurological signs.
Thomas M, Yawn BP, Price D, Lund V, Mullol J, Fokkens W, et al. EPOS primary care guidelines: European position paper on the primary care diagnosis and management of rhinosinusitis and nasal polyps 2007—a summary. Prim Care Respir J 2008;17:79-89.
Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European position paper on rhinosinusitis and nasal polyps 2012. Rhinol Suppl 2012;(23):3 p preceding table of contents, 1-298.
Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. EPOS 2012 European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology 2012;50(1):1-12
Cite this as: BMJ 2013;346:f2687
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed.