Sinus Infection Symptoms: Recognition & When to Seek Care

Acute Sinusitis (Rhinosinusitis): Symptom Profile & Clinical Decision-Making

Sinusitis = inflammation of paranasal sinuses. Viral (90–98%) > bacterial. Duration defines acuity.

Cardinal Symptoms (≥2 required for diagnosis)

• Purulent nasal discharge (anterior or postnasal)
• Nasal obstruction/congestion
• Facial pain/pressure/fullness (site-specific: maxillary → cheek/teeth; frontal → forehead; ethmoid → periorbital; sphenoid → vertex/occipital)
• Hyposmia/anosmia (reduced/lost smell)

Associated Symptoms

• Headache (often frontal, worse bending forward)
• Postnasal drip → cough (worse at night), throat clearing
• Halitosis (bad breath)
• Fatigue, malaise
• Fever (more common in bacterial, especially children)
• Dental pain (maxillary sinus → upper molars)
• Ear fullness/pain (Eustachian tube dysfunction)

Viral vs. Bacterial Differentiation

Chronic Sinusitis (>12 weeks)

• Persistent symptoms + objective evidence (CT/endoscopy: mucosal thickening, polyps, obstruction)
• Subtypes: With/without nasal polyps (CRSwNP/CRSsNP)
• Comorbidities: Asthma, aspirin-exacerbated respiratory disease (AERD), allergy, immunodeficiency

Red Flags: Urgent ENT/ER Referral

• Periorbital edema, proptosis, ophthalmoplegia, vision change (orbital complication)
• Severe headache, neck stiffness, altered mental status (intracranial spread)
• Immunocompromised + sinus symptoms
• Recurrent acute (>4 episodes/year)

Evidence-Based Management

• Viral/Uncomplicated: Supportive – saline irrigation, intranasal corticosteroids, analgesics, hydration. Antibiotics NOT indicated.
• Bacterial (meeting criteria): Amoxicillin-clavulanate 500/125 mg TID × 5–7 days (IDSA). Doxycycline/respiratory fluoroquinolone if penicillin allergic.
• Adjuncts: High-volume saline irrigation, INCS, short-course oral steroids (severe congestion)
• Chronic: INCS long-term, saline, biologics (anti-IL4/5/13) for CRSwNP, surgery (FESS) if medical failure

Antibiotic stewardship: Most "sinus infections" are viral. Unnecessary antibiotics drive resistance and C. difficile risk.

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Feature	Viral (Common Cold)	Acute Bacterial Sinusitis
Duration	<10 days, improving	>10 days without improvement
"Double worsening"	No	Yes (improve then worsen)
Fever	Low-grade, early	High, persistent (>39°C)
Discharge	Clear → colored	Purulent throughout
Facial pain	Mild	Severe, unilateral
ESR/CRP	Normal/mildly elevated	Elevated