Bacterial Rhinosinusitis

📚Definitions 

• Acute Rhinosinusitis (ARS): Symptomatic inflammation of the nasal cavity and paranasal sinuses lasting <4 weeks.

   

• Acute Bacterial Rhinosinusitis (ABRS): Bacterial infection confirmed by:
  • Persistent symptoms ≥10 days, or
  • Severe onset (fever >102°F + purulent discharge/facial pain for 3–4 days), or
  • "Double sickening" (worsening after initial viral URI improvement).

🔑 Key Points 

• 98% of acute sinusitis is viral. Antibiotics are overprescribed (5th most common reason).
• Diagnosis is clinical. Imaging/cultures are rarely needed for uncomplicated cases.

✏️ Assessment  

History

• Symptoms: Nasal discharge (color/consistency), facial pain, fever, cough, tooth pain.

   

• Red flags: Severe headache, visual changes, periorbital swelling, meningeal signs.

   

• Risk factors: Immunocompromised, recent antibiotics, recurrent episodes (>4/year).

Examination (Telehealth Adaptations)

• General: Fever, toxic appearance.
• Facial: Tenderness over sinuses, periorbital edema.
• Nasal: Discharge, obstruction.
• Neurologic: Mental status, cranial nerve deficits.

💆 Treatment 

Symptomatic Management (Viral or Mild Bacterial)

• Adults:
  • Saline irrigation (Neti pot, sprays).
  • Intranasal corticosteroids (e.g., fluticasone).
  • Analgesics: NSAIDs/acetaminophen.
  • Avoid: Decongestants (>3 days), oral steroids (no evidence).

Antibiotics

Antimicrobial Therapy. The diagnosis of acute bacterial rhinosinusitis requires at least one of the following three criteria. If none of these criteria are met antibiotics should NOT be prescribed.

1. Persistent symptoms lasting 10 or more days without evidence of clinical improvement. Symptoms should include purulent nasal discharge unless drying agents are being used. Presence of fever, headache or facial pain is more variable.

    

2. Onset of severe symptoms or signs of high fever (> 102 F) and purulent nasal discharge or facial pain for at least 3-4 consecutive days at the beginning of illness.

    

3. Double sickening: Onset with worsening symptoms or signs (new onset fever, nasal discharge) following a typical viral URI that lasted 5-6 days and which were initially improving.

First-Line

• Adults:
  • Amoxicillin-clavulanate: 875/125 mg BID × 5–7 days.

  • Doxycycline: 100 mg BID × 5–7 days (penicillin allergy).

     

Second-Line (Resistance/Failure)

• Adults: Cefdinir (600 mg/day) or cefpodoxime (200 mg BID).

Avoid:

• Macrolides (azithromycin), TMP-SMX,

 📩 Referral Indicators   

• Urgent: Orbital edema, visual changes, meningeal signs, immunocompromised.
• Non-urgent: Chronic (>12 weeks) or recurrent (>4 episodes/year) sinusitis

 🔮 Follow Up 

• Improvement in 48–72h: Continue antibiotics to completion.
• No improvement: Reevaluate for complications/resistance.

📘 Coding

ICD-10 Codes: 

• J01.90: Acute sinusitis, unspecified
• J32.9: Chronic sinusitis, unspecified

If you have any questions or would like more information, please reach out to the Delegating Physician.