Acute rhinosinusitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

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

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

suspected acute viral rhinosinusitis

1st line – supportive therapy

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1st line –

supportive therapy

Viral rhinosinusitis is suspected when symptoms are stable and present for less than 10 days.

Generally a self-limiting disease, and treatment is primarily symptomatic.

Adequate rest and hydration and warm facial packs may be useful, as well as use of vitamin C and zinc.[4]

Treatments should be tried for 5-10 days before reassessing the patient.

Consider – analgesic/antipyretic

Back

Consider –

analgesic/antipyretic

Treatment recommended for SOME patients in selected patient group

Recommended for pain and/or fever. Selection of agent depends on the subjective level of pain the patient is experiencing.

Codeine is contraindicated in children younger than 12 years of age, and it is not recommended in adolescents 12 to 18 years of age who are obese or have conditions such as obstructive sleep apnea or severe lung disease as it may increase the risk of breathing problems.[32] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[33][34]

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

acetaminophen/codeine: children ≥12 years of age: consult specialist for guidance on dose; adults: 30-60 mg orally every 4-6 hours when required

Consider – decongestant

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Consider –

decongestant

Treatment recommended for SOME patients in selected patient group

May provide symptomatic relief of nasal congestion.[1][15]

Topical agents (e.g., oxymetazoline) are often preferred over systemic agents (e.g., pseudoephedrine) because of increased potency and less risk of adverse effects.

Pseudoephedrine-containing medications are associated with a risk of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome. These are rare conditions with potentially serious and life-threatening complications. Pseudoephedrine-containing medications should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[36]

Topical agents should only be used for up to 3-5 days, to prevent the occurrence of rebound congestion.

Primary options

oxymetazoline nasal: children 2-5 years of age: (0.025%) 2-3 sprays/drops into each nostril twice daily when required; children >5 years of age and adults: (0.05%) 1-2 sprays/drops into each nostril twice daily when required

Secondary options

pseudoephedrine: adults: 30-60 mg orally every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal corticosteroid

Back

Consider –

intranasal corticosteroid

Treatment recommended for SOME patients in selected patient group

Recommended in patients with congestion. Considered beneficial and has a low incidence of systemic adverse effects.[1][37][38][39] [ ]

At least 1 month of therapy is usually recommended; however, this will depend on the disease course.

Primary options

fluticasone propionate nasal: (50 micrograms/spray) children ≥4 years of age and adults: 1-2 sprays in each nostril once daily

mometasone nasal: (50 micrograms/spray) children 2-11 years of age: 1 spray in each nostril once daily; children ≥12 years of age: 2 sprays in each nostril once daily; adults: 2 sprays in each nostril once or twice daily

ciclesonide nasal: (50 micrograms/spray) children ≥6 years of age and adults: 2 sprays in each nostril once daily; (37 micrograms/spray) children ≥12 years of age and adults: 1 spray in each nostril once daily

Consider – ipratropium

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Consider –

ipratropium

Treatment recommended for SOME patients in selected patient group

Topical anticholinergics such as ipratropium can be used in patients with rhinorrhea.[40]

Primary options

ipratropium bromide nasal: children ≥6 years of age: (0.03%) 42 micrograms (2 sprays) in each nostril two or three times daily; adults: (0.06%) 84 micrograms (2 sprays) in each nostril three times daily

Consider – intranasal saline

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Consider –

intranasal saline

Treatment recommended for SOME patients in selected patient group

Saline sprays may be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing medication use.

Saline nasal irrigations may be helpful in relieving nasal symptoms; however, they should be used cautiously as patients who have not had an endoscopic sinus surgery may develop facial pressure or discomfort when the saline irrigations get trapped in the nonoperated sinuses.[41]

A home-prepared saline irrigation may be helpful for patients. University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis Opens in new window

Primary options

saline nasal: children and adults: 1-2 sprays/drops into each nostril every 2-3 hours or when required

suspected acute bacterial rhinosinusitis

immunocompromised or with severe illness

1st line – antibiotic therapy

Back

1st line –

antibiotic therapy

Guidelines generally recommend antibiotic therapy for immunocompromised patients or those with severe illness. Indicators of severe illness include fever (>102.2°F [>39°C]); moderate to severe facial or dental pain; unilateral sinus tenderness; periorbital edema; worsening of symptoms after 3-5 days; or lack of improvement after 7-10 days of observation.[1][3][45][49]

Although guidelines may vary in their recommendations for empiric antibiotics, studies have not demonstrated a difference in clinical outcomes between various antibiotic regimens.[51]

High-dose amoxicillin/clavulanate is recommended as a first-line agent for people who have severe disease or are immunocompromised, owing to the increased endemic rates of beta-lactamase-producing S pneumoniae.[1] High-dose amoxicillin/clavulanate is effective against pneumococci of variable susceptibilities.[61]

For penicillin-allergic patients, a reasonable alternative is therapy with clindamycin plus an oral third-generation cephalosporin (e.g., cefixime, cefpodoxime).[2][54] There is a risk of cross-sensitivity with cephalosporins in these patients, although this risk is low if the allergic manifestation is simply a rash without respiratory involvement.[55]

Doxycycline is a suitable alternative in adults with allergies to beta-lactam antibiotics; however, its use is not recommended in children due to risk of tooth discoloration and dental enamel hypoplasia.[56]

Fluoroquinolones should only be used in patients with acute bacterial rhinosinusitis who do not have other treatment options.[57] They may be tried in adults if treatment with a penicillin or cephalosporin is not possible. Fluoroquinolones should be used with caution in children due to risk of musculoskeletal adverse effects.[58] Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to, tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[59] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.

The recommended treatment course is unclear.[45] However, 10-14 days is reasonable, particularly for immunocompromised patients or those with severe disease.[1][3]

If there is no improvement in symptoms after 3-5 days of antibiotic treatment, an alternative should be considered.[3] Another consideration should be an ear, nose, and throat specialist consultation.

Intravenous antibiotics (e.g., third-generation cephalosporin, fluoroquinolone) may be required in patients with an infection that requires hospitalization.

Primary options

amoxicillin/clavulanate: children: 90 mg/kg/day orally given in 2 divided doses; adults: 2000 mg orally (extended-release) twice daily

Secondary options

clindamycin: children: 30-40 mg/kg/day orally given in 3 divided doses; adults: 150-450 mg orally three times daily

-- AND --

cefixime: children: 8 mg/kg/day orally given in 1-2 divided doses; adults: 400 mg orally once daily

cefpodoxime proxetil: children: 10 mg/kg/day orally given in 2 divided doses; adults: 200 mg orally twice daily

doxycycline: adults: 100 mg orally twice daily, or 200 mg orally once daily

ceftriaxone: children: 50 mg/kg/day intravenously given in divided doses every 12 hours; adults: 1-2 g intravenously every 12-24 hours

cefotaxime: children: 100-200 mg/kg/day intravenously given in divided doses every 6 hours; adults: 2 g intravenously every 4-6 hours

Tertiary options

moxifloxacin: children: consult specialist for guidance on dose; adults: 400 mg orally/intravenously once daily

levofloxacin: children: consult specialist for guidance on dose; adults: 500 mg orally/intravenously once daily

Plus – ear, nose, and throat specialist referral

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Plus –

ear, nose, and throat specialist referral

Treatment recommended for ALL patients in selected patient group

The specialist may adjust antibiotic therapy to cover less common causative microorganisms (e.g., add metronidazole or clindamycin to cover anaerobes), reevaluate the patient for underlying conditions or anatomic abnormalities, or consider surgery.[3]

Plus – supportive therapy

Back

Plus –

supportive therapy

Treatment recommended for ALL patients in selected patient group

Adequate rest and hydration and warm facial packs may be useful, as well as use of vitamin C and zinc.[4] Selection of therapy will depend on the specific symptoms.

Consider – analgesic/antipyretic

Back

Consider –

analgesic/antipyretic

Treatment recommended for SOME patients in selected patient group

Recommended for pain and/or fever. Selection of agent depends on the subjective level of pain the patient is experiencing.

Codeine is contraindicated in children younger than 12 years of age, and it is not recommended in adolescents 12-18 years of age who are obese or have conditions such as obstructive sleep apnea or severe lung disease as it may increase the risk of breathing problems.[32] It is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[33][34]

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

acetaminophen/codeine: children ≥12 years of age: consult specialist for guidance on dose; adults: 30-60 mg orally every 4-6 hours when required

Consider – decongestant

Back

Consider –

decongestant

Treatment recommended for SOME patients in selected patient group

May provide symptomatic relief of nasal congestion.[1]

Topical agents (e.g., oxymetazoline) are often preferred over systemic agents (e.g., pseudoephedrine) because of increased potency and less risk of adverse effects.

Topical agents should only be used for up to 3-5 days, to prevent the occurrence of rebound congestion.

Primary options

Secondary options

pseudoephedrine: adults: 30-60 mg orally every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal corticosteroid

Back

Consider –

intranasal corticosteroid

Treatment recommended for SOME patients in selected patient group

Recommended in patients with congestion.

Considered beneficial and has a low incidence of systemic adverse effects.[1][37][39] [ ]

At least 1 month of therapy is usually recommended; however, this will depend on the disease course.

Primary options

fluticasone propionate nasal: (50 micrograms/spray) children ≥4 years of age and adults: 1-2 sprays in each nostril once daily

Consider – intranasal saline

Back

Consider –

intranasal saline

Treatment recommended for SOME patients in selected patient group

Saline sprays may be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing medication use.

A home-prepared saline irrigation may be helpful for patients. University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis Opens in new window

Primary options

saline nasal: children and adults: 1-2 sprays/drops into each nostril every 2-3 hours or when required

immunocompetent nonsevere

1st line – watchful waiting for up to 10 days, or immediate commencement of antibiotics, and supportive therapy

Back

1st line –

watchful waiting for up to 10 days, or immediate commencement of antibiotics, and supportive therapy

Some guidelines recommend watchful waiting for up to 10 days with symptomatic therapy before instituting subsequent antibiotic therapy, as the majority of nonsevere cases will resolve without them.[1][44] However, immediate antibiotic therapy can shorten the duration of symptoms, so may be used if the benefits (i.e., eradication of infection, improvement in symptoms, reduced duration of illness) outweigh the risks (i.e., adverse effects, cost, need for follow-up, increased bacterial resistance) of therapy.[1][3][45]

For supportive therapy, adequate rest and hydration and warm facial packs may be useful, as well as use of vitamin C and zinc.[4] Selection of therapy will depend on the specific symptoms.

Consider – antibiotic therapy

Back

Consider –

antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Antibiotics are not usually recommended immediately in patients who are immunocompetent and who have nonsevere illness (i.e., absence of fever, mild facial or dental pain), as the majority of cases will resolve without them.[1][44]

However, immediate antibiotic therapy can shorten the duration of symptoms, so may be used if the benefits (i.e., eradication of infection, improvement in symptoms, reduced duration of illness) outweigh the risks (i.e., adverse effects, cost, need for follow-up, increased bacterial resistance) of therapy.[1][3][45]

Amoxicillin or amoxicillin/clavulanate has generally been recommended as a first-line agent for nonsevere disease in immunocompetent people, owing to its safety, efficacy, and low cost.[1] One pediatric cohort study found there was no difference in treatment failure rates between the use of amoxicillin or amoxicillin/clavulanate for acute rhinosinusitis, but amoxicillin/clavulanate was associated with a higher risk of gastrointestinal symptoms and yeast infections.[52]

For penicillin-allergic patients, a reasonable alternative is therapy with clindamycin plus third-generation cephalosporin (e.g., cefuroxime, cefpodoxime).[2][54] There is a risk of cross-sensitivity with cephalosporins in these patients, although this risk is low if the allergic manifestation is simply a rash without respiratory involvement.[55]

Fluoroquinolones should not be used in nonsevere infections.[58][67]

The recommended treatment course is unclear.[45] However, a 5-7 day course for adults and 10-14 day course for children is reasonable.[1][3][60][Evidence A]

If there is no improvement in symptoms after 3-5 days of treatment, an alternative antibiotic should be considered.[3] Another consideration should be an ear, nose, and throat specialist consultation.

Primary options

amoxicillin: children: 45-90 mg/kg/day orally given in 2 divided doses; adults: 500-1000 mg orally three times daily, or 875 mg orally twice daily

amoxicillin/clavulanate: children: 45-90 mg/kg/day orally given in 2 divided doses; adults: 500-875 mg orally twice daily, or 2000 mg orally (extended-release) twice daily

Secondary options

clindamycin: children: 30-40 mg/kg/day orally given in 3 divided doses; adults: 150-450 mg orally three times daily

-- AND --

cefuroxime axetil: children: 30 mg/kg/day orally given in 2 divided doses; adults: 250-500 mg orally twice daily

cefpodoxime proxetil: children: 10 mg/kg/day orally given in 2 divided doses; adults: 200 mg orally twice daily

doxycycline: adults: 100 mg orally twice daily, or 200 mg orally once daily

Consider – analgesic/antipyretic

Back

Consider –

analgesic/antipyretic

Treatment recommended for SOME patients in selected patient group

Recommended for pain and/or fever. Selection of agent depends on the subjective level of pain the patient is experiencing.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

ibuprofen: children: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

acetaminophen/codeine: children ≥12 years of age: consult specialist for guidance on dose; adults: 30-60 mg orally every 4-6 hours when required

Consider – decongestant

Back

Consider –

decongestant

Treatment recommended for SOME patients in selected patient group

May provide symptomatic relief of nasal congestion.[1][15]

Topical agents (e.g., oxymetazoline) are often preferred over systemic agents (e.g., pseudoephedrine) because of increased potency and less risk of adverse effects.

Topical agents should only be used for up to 3-5 days, to prevent the occurrence of rebound congestion.

Primary options

Secondary options

pseudoephedrine: adults: 30-60 mg orally every 4-6 hours when required, maximum 240 mg/day

Consider – intranasal corticosteroid

Back

Consider –

intranasal corticosteroid

Treatment recommended for SOME patients in selected patient group

Recommended in patients with congestion.

Considered beneficial and has a low incidence of systemic adverse effects.[1][37][39] [ ]

At least 1 month of therapy is usually recommended; however, this will depend on the disease course.

Primary options

fluticasone propionate nasal: (50 micrograms/spray) children ≥4 years of age and adults: 1-2 sprays in each nostril once daily

Consider – intranasal saline

Back

Consider –

intranasal saline

Treatment recommended for SOME patients in selected patient group

Saline sprays may be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing medication use.

A home-prepared saline irrigation may be helpful for patients. University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis Opens in new window

Primary options

saline nasal: children and adults: 1-2 sprays/drops into each nostril every 2-3 hours or when required

Consider – ear, nose, and throat (ENT) specialist referral

Back

Consider –

ear, nose, and throat (ENT) specialist referral

Treatment recommended for SOME patients in selected patient group

Patients should be referred to an ENT specialist when condition is refractory to usual antibiotic treatment.[1][3]

suspected acute invasive fungal rhinosinusitis

1st line – immediate ear, nose, and throat specialist referral

Back

1st line –

immediate ear, nose, and throat specialist referral

Acute invasive fungal rhinosinusitis is a rare, rapidly progressive and life-threatening infection with a high mortality rate warranting immediate emergency referral and ENT consultation. Management consists of surgical debridement, systemic antifungal therapy, and correction of predisposing conditions.[3][66]

ONGOING

recurrent episodes

1st line – ear, nose, and throat (ENT) specialist referral

Back

1st line –

ear, nose, and throat (ENT) specialist referral

Patients should be referred to an ENT specialist when condition is recurrent (i.e., 4 or more episodes per year) or significantly affects quality of life.[1][3]

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Acute rhinosinusitis

Treatment algorithm

Your Organizational Guidance

suspected acute viral rhinosinusitis

supportive therapy

analgesic/antipyretic

Primary options

Secondary options

decongestant

Primary options

Secondary options

intranasal corticosteroid

Primary options

ipratropium

Primary options

intranasal saline

Primary options

suspected acute bacterial rhinosinusitis

antibiotic therapy

Primary options

Secondary options

Tertiary options

ear, nose, and throat specialist referral

supportive therapy

analgesic/antipyretic

Primary options

Secondary options

decongestant

Primary options

Secondary options

intranasal corticosteroid

Primary options

intranasal saline

Primary options

watchful waiting for up to 10 days, or immediate commencement of antibiotics, and supportive therapy

antibiotic therapy

Primary options

Secondary options

analgesic/antipyretic

Primary options

Secondary options

decongestant

Primary options

Secondary options

intranasal corticosteroid

Primary options

intranasal saline

Primary options

ear, nose, and throat (ENT) specialist referral

suspected acute invasive fungal rhinosinusitis

immediate ear, nose, and throat specialist referral

recurrent episodes

ear, nose, and throat (ENT) specialist referral