Acute rhinosinusitis
Acute rhinosinusitis is inflammation of the nasal cavity and paranasal sinuses lasting up to 4 weeks, presenting with purulent nasal discharge plus nasal obstruction or facial pain/pressure/fullness. Most cases are viral and treated with acetaminophen/ibuprofen plus nasal saline irrigation alone; a minority are bacterial, identified by persistence beyond 10 days, a biphasic worsening course, or severe onset, and treated with amoxicillin-clavulanate 875/125 mg PO every 12 hours for 5 to 7 days.
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What this article covers
- Overview
Definition: acute rhinosinusitis is inflammation of the nasal cavity and paranasal sinuses lasting less than 4 weeks, presenting with purulent nasal discharge plus nasal obstruction or facial pain/pressure/fullness.
- Epidemiology
Seasonality: episodes are more common during winter, tracking the seasonal burden of viral upper respiratory infection.
- Risk factors
Antecedent viral upper respiratory infection: the dominant risk factor; viral mucosal injury and ostial edema set up the bacterial superinfection that defines ABRS.
- Pathophysiology
Viral phase: respiratory viruses infect and damage nasal and sinus mucosal epithelium, triggering edema, hypersecretion, and impaired ciliary clearance.
- Clinical features
Purulent nasal discharge plus nasal obstruction or facial pain/pressure/fullness: this combination, present for no more than 4 weeks, constitutes the clinical diagnostic criteria for acute rhinosinusitis; no test is required.
- Differential diagnosis
Acute viral rhinosinusitis (the common cold): the same symptom complex but without the 10-day persistence, double-sickening pattern, or severe onset that mark a bacterial course; managed with supportive care alone.
- Diagnosis
This is a clinical diagnosis: established by up to 4 weeks of purulent nasal discharge plus nasal obstruction or facial pain/pressure/fullness; no imaging or laboratory test is required.
- Management
First, for all patients, since most disease is viral: acetaminophen 650 mg PO every 6 hours or ibuprofen 400 mg PO every 6 hours as needed until symptoms resolve (up to about 2 weeks), plus nasal…
- Complications
Orbital cellulitis and orbital abscess: proptosis, painful/decreased extraocular movement, and diplopia from direct spread of infection into the orbit.
- Prognosis
Excellent for viral cases: acute viral rhinosinusitis is self-limited, resolving with supportive care alone.
- Prevention
Hand hygiene: frequent hand washing or alcohol-based hand rubs limit transmission of the respiratory viruses that precede most episodes.
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Related articles
- Chronic rhinosinusitis
Chronic rhinosinusitis is inflammation of the paranasal sinuses lasting 12 weeks or longer, confirmed by nasal endoscopy or CT, and treated first with intranasal corticosteroids and saline irrigation before escalation to antibiotics, oral steroids, biologics, or surgery.
- Acute invasive fungal rhinosinusitis
Acute invasive fungal rhinosinusitis is an angioinvasive infection of the sinonasal mucosa by Mucorales species or Aspergillus in immunocompromised or diabetic ketoacidosis patients that causes vascular thrombosis and tissue necrosis. It is a surgical and infectious disease emergency requiring same-day biopsy, emergent debridement, and high-dose liposomal amphotericin B, with mortality up to 60-80% even with therapy.
- Allergic rhinitis
Allergic rhinitis is an IgE-mediated inflammation of the nasal mucosa causing sneezing, rhinorrhea, congestion, and itch on allergen exposure, classified as seasonal or perennial. Diagnosis is clinical, supported by skin or specific IgE testing to identify allergens, and treatment is allergen avoidance with intranasal corticosteroids first-line, escalating to combination therapy and allergen immunotherapy.
- Orbital cellulitis
Orbital cellulitis is infection of the fat and muscle posterior to the orbital septum, most often from spreading sinusitis, that causes proptosis, painful ophthalmoplegia, and vision loss and can progress to cavernous sinus thrombosis. It is a vision- and life-threatening emergency treated with admission, blood and tissue culture, orbital/sinus CT or MRI, and immediate empiric IV vancomycin plus ceftriaxone with ophthalmology and ear, nose, and throat (ENT) involvement.
- Cavernous sinus thrombosis
Septic thrombosis of the cavernous sinus from spreading facial, sinus, or orbital infection, marked by fever, proptosis, chemosis, and cranial nerve palsies that classically become bilateral. It is a neuro-ophthalmic emergency treated with immediate broad-spectrum IV antibiotics, source control, and consideration of anticoagulation.
- Brain abscess
Brain abscess is a focal, ring-enhancing suppurative infection of the brain parenchyma most often from contiguous sinus, ear, or dental spread or hematogenous seeding, diagnosed by contrast MRI and image-guided aspiration and treated with predisposing-source-directed empiric antibiotics plus drainage of abscesses larger than 2.5 cm.
- Nasal polyps
Nasal polyps are benign, typically bilateral outgrowths of edematous nasal mucosa driven by chronic mucosal inflammation, most often arising with chronic rhinosinusitis, aspirin-exacerbated respiratory disease, or cystic fibrosis. Unilateral polyps or a mass that does not respond to treatment must be biopsied to exclude tumor.
- Streptococcal pharyngitis
Streptococcal pharyngitis is an acute infection of the tonsils and pharynx caused by group A Streptococcus pyogenes, presenting with rapid-onset sore throat, fever, tonsillar exudates, and tender anterior cervical lymphadenopathy without cough; diagnosis relies on the Centor criteria to guide rapid antigen testing, and treatment with penicillin or amoxicillin prevents suppurative complications and acute rheumatic fever.
- Acute otitis media
Acute otitis media is a suppurative middle ear infection, mostly in young children, diagnosed by otoscopy showing a bulging, erythematous tympanic membrane with an effusion, and it is treated with observation or amoxicillin depending on age and severity.