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Source: C, Frei B, Zhanel G. Upper Respiratory Tract Infections. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed July 15, 2012.

  • Rhinosinusitis

  • Inflammation and/or infection of paranasal sinus mucosa
    • Acute: lasts <30 days with complete resolution of symptoms.
    • Chronic: episodes of inflammation lasting >3 months with persistence of respiratory symptoms.

  • Majority of cases viral
    • Consider bacterial infection if symptoms persist for ⩾7 days or become severe.
  • Bacterial causes: S. pneumoniae and H. influenza
    • Responsible for ~70% of bacterial causes of acute sinusitis in both adults and children.

  • Acute bacterial sinusitis usually preceded by viral respiratory tract infection that causes mucosal inflammation.

  • Most cases have viral etiology yet antibiotics prescribed for adults and children.

  • Viral respiratory tract infection

  • Nonspecific upper respiratory tract infection that persists beyond 7–14 days

Signs and Symptoms

  • Acute
    • Adults
      • Nasal discharge/congestion
      • Maxillary tooth pain, facial or sinus pain
        • May radiate (unilateral in particular)
        • Deteriorates after initial improvement
      • If severe or persists beyond 7 days, most likely bacterial and should be treated with antimicrobials.
    • Children
      • Indications for antimicrobial therapy
        • Nasal discharge and cough for >10–14 days or
        • Severe signs and symptoms such as temperature 39°C (102.2°F) or
        • Facial swelling or pain
  • Chronic
    • Similar symptoms as with acute sinusitis but more nonspecific
    • Rhinorrhea with acute exacerbations
    • Chronic unproductive cough, laryngitis, and headache
    • Chronic/recurrent infections occur 3–4 times a year
      • Unresponsive to steam and decongestants.

Means of Confirmation and Diagnosis

  • Gold standard: Sinus puncture with recovery of bacteria in high density
    • Not routinely performed since invasive procedure.
  • Diagnosis based on clinical findings.

Laboratory Tests

  • Gram stain, culture, and sensitivities of draining fluid or aspirated fluid if sinus puncture performed.


  • Sinus radiography
    • Not routinely used for uncomplicated sinusitis.

Diagnostic Procedures

  • Sinus puncture

  • Reduce signs and symptoms.
  • Achieve and maintain patency of ostia.
  • Limit antimicrobial treatment to those who may benefit.
  • Eradicate bacterial infection with appropriate antimicrobial therapy.
  • Minimize duration of illness.
  • Prevent complications.
  • Prevent progression from acute disease to chronic disease.

  • Delineate viral and bacterial sinusitis.
    • Based on disease duration
      • Viral: typically improves in 7–10 days.
      • Bacterial: persistent symptoms ⩾10 days or worsening of symptoms after 5–7 days.

  • Irrigation of nasal cavity with saline and steam inhalation to increase mucosal moisture
  • Mucolytics (e.g., guaifenesin) to decrease viscosity of nasal secretions
  • Nasal decongestant sprays such as phenylephrine and oxymetazoline
    • Reduce inflammation by vasoconstriction
    • Limit use to no more than 3 days to prevent rebound congestion.
  • Oral decongestants may also aid in nasal or sinus patency.
  • Avoid use of antihistamines.

  • Amoxicillin first-line treatment for acute bacterial sinusitis. Approach to treating acute bacterial sinusitis in Table 1. Dosing guidelines in Table 2.
    • Treat for 10–14 days, or at least 7 days after ...

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