Sinusitis

🔍 When to Suspect

Nasal congestion accompanied by facial pain or pressure (worse on bending forward) and/or a thick, purulent nasal discharge, often with a reduced sense of smell

From the full topic in The Ocean Library: Sinusitis

🧭 When to suspect

Acute sinusitis (acute rhinosinusitis) is a self-limiting inflammation of the paranasal sinuses and nasal lining, almost always triggered by a viral upper respiratory tract infection.

• Acute: symptoms have lasted less than 12 weeks.

• Chronic: symptoms persist beyond 12 weeks without full resolution.

The overwhelming majority of acute cases are viral, settle within 2 to 3 weeks, and improve without antibiotics – and withholding antibiotics rarely leads to complications.

Suspect acute sinusitis when there is nasal blockage (obstruction/congestion) or nasal discharge (anterior or posterior nasal drip), together with at least one of:

• Facial pain or pressure (often frontal or maxillary, classically worse on bending forward, or headache)

• A reduced or lost sense of smell in adults

• A daytime and night-time cough in children

Discoloured (yellow or green) discharge is common in viral illness and does not, on its own, indicate a bacterial cause.

The two clinical tasks are to distinguish the rare bacterial case from the common viral one – which guides whether an antibiotic is ever appropriate – and to never miss a serious complication or a sinister unilateral presentation.

Viral acute sinusitis (the great majority)
• Follows a cold; symptoms peak early and settle over 2–3 weeks.
• Mild–moderate, often bilateral facial pressure and congestion.
• Discharge may be discoloured – not a reliable marker of bacterial infection.
• No high fever and no deterioration after an initial improvement.

Suggests a bacterial cause (≥ 2 features)
• Symptoms > 10 days with little improvement.
• Discoloured or purulent nasal discharge.
• Severe, localised unilateral pain (especially over the teeth or jaw).
• Fever > 38°C, or marked deterioration after an initial milder phase ("double-sickening").

🧠 Clinical pearl • Truly unilateral sinonasal symptoms should make you think beyond simple infection. • Consider an odontogenic (dental) cause – maxillary sinusitis arising from an infected upper molar. • In a young child, consider a foreign body. • Where symptoms are persistent with bloodstained discharge or crusting, consider a sinonasal malignancy. • NICE itself flags dental infection as the alternative diagnosis to reconsider whenever sinusitis fails to settle.

Source: NICE NG79

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