History and exam

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Richtlijn acute rinosinusitisPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2023Guide de pratique clinique rhinosinusite aiguëPublished by: Groupe de travail Développement de recommandations de première ligneLast published: 2023

Key diagnostic factors

common

symptoms <10 days (acute viral rhinosinusitis)

Symptoms that are present for less than 10 days suggest acute viral rhinosinusitis. The symptoms usually peak early and gradually resolve.[1][4][17]​​

symptoms >10 days but <4 weeks (acute bacterial rhinosinusitis)

Symptoms present for more than 10 days without improvement may indicate a bacterial infection, although these patients are less likely to benefit from antibiotic therapy compared with those with severe symptoms at the onset or those with symptoms that worsen after initial improvement.[1][3]

symptoms that worsen after an initial improvement (acute bacterial rhinosinusitis)

Symptoms that worsen after an initial improvement (so-called "double sickening") suggest secondary bacterial infection. The typical scenario is a patient who experiences symptoms of viral rhinosinusitis and improves after 5 days, only to worsen 2-3 days later.[1][3][4]​​[17]​​

purulent nasal discharge

Refers to cloudy or discolored (brown, yellow, green) nasal mucus. May be reported by patient, or observed on physical exam (e.g., in the nasal cavity, middle meatus, or posterior pharynx). A nonspecific symptom that may be present in viral or bacterial rhinosinusitis.

nasal obstruction

Refers to congestion, stuffiness, or blockage. Swollen septal or turbinate mucosa may be seen on exam. Nonspecific symptom that may be associated with viral or bacterial rhinosinusitis as well as allergic rhinitis.

facial pain/pressure

Reported by the patient as headache or discomfort in the anterior face or periorbital region.[1] Nonspecific symptom that may be associated with viral or bacterial rhinosinusitis.[1]

uncommon

severe symptoms at onset (acute bacterial rhinosinusitis)

Symptoms that are severe at the onset of illness suggest bacterial infection.[17]

dental pain

May be reported by patient or observed on physical exam with percussion of the maxillary teeth. Suggests acute maxillary sinusitis.

Other diagnostic factors

common

cough

May present secondary to postnasal drainage or exacerbation of asthma caused by rhinosinusitis; particularly common in children.

sore throat

May be present in both acute viral and bacterial rhinosinusitis.

hyposmia

Loss of sense of smell may be present in both acute viral and bacterial rhinosinusitis.

edematous turbinate

Associated with any inflammation of the nasal cavity lining, whether allergic, viral, or bacterial in etiology. Decongestion of the turbinate is essential prior to inspection of the middle meatus for purulence.[18]

uncommon

fever

May occur in acute viral rhinosinusitis but is more common in children than adults. Bacterial rhinosinusitis is less common than viral rhinosinusitis, but abrupt onset of fever and worsening symptoms after an initial improvement in acute rhinosinusitis suggests bacterial rhinosinusitis.

Risk factors

strong

viral upper respiratory tract infection

Most cases of acute rhinosinusitis in adults and children are of viral etiology.[10] In some cases, inflammation triggered by a viral upper respiratory tract infection can facilitate the development of a secondary bacterial infection.[11]​[16]​​

allergic rhinitis

Leads to mucosal inflammation, which can cause blockage of the sinus ostium, preventing normal ventilation and drainage of the sinus.[10] Treatment of allergic rhinitis may reduce this risk.

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