Treatment Guideline Chart
Rhinosinusitis is the mucosal inflammation of the nose and paranasal sinuses caused by bacteria lasting >10 days for up to 4 weeks, symptoms resolve completely and may either be persistent or severe.
It is often preceded by a viral upper respiratory tract infection.
Signs & symptoms are nonspecific and it is typically difficult to differentiate from viral upper respiratory tract infection.
Streptococcus pneumoniae is the most common cause followed by nontypeable Haemophilus influenzae.

Rhinosinusitis%20-%20acute,%20bacterial%20(pediatric) Diagnosis


  • Presumptive diagnosis and identification of bacterial versus viral rhinosinusitis may be made when the child has an acute upper respiratory tract infection (URTI) and with any of the following:
    • Persistent illness, eg, symptoms of nasal discharge (of any quality) or daytime cough or both lasting ≥10 days with no improvement
    • Severe onset, eg, concurrent fever (temperature ≥39°C/102.2°F) and purulent nasal discharge or facial pain for at least 3-4 consecutive days at the beginning of illness
    • At least 3 of the following: Discolored nasal discharge, severe local pain, fever, elevated erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP), and/or double sickening 
    • Worsening course, eg worsening or new onset of nasal discharge, daytime cough, headache or fever that lasted 5-6 days after initial improvement of a viral upper respiratory tract infection


Severity of Acute Bacterial Rhinosinusitis (ABRS)

  • The terms mild and moderate reflect the degree of patient discomfort (symptom complex and time course of disease) and the likelihood of spontaneous resolution of symptoms
  • Evaluation of disease severity is based on total severity visual analogue scale (VAS) score
    • Mild: VAS 0-3
    • Moderate: VAS >3-7
    • Severe: VAS >7-10
  • Differences in disease severity do not necessarily imply antimicrobial resistance


  • Document all relevant signs and symptoms including severity and time course
  • Most common presenting symptoms in children are cough, nasal discharge, and fever

Physical Examination

  • Nose should be examined for deviated septum, nasal polyps and foreign bodies
  • Examination of the ears for concomitant otitis media
  • Perform anterior rhinoscopy to look for erythematous nasal mucosa and to examine nasal turbinates for edema and purulent drainage
    • Change in the color, quantity and quality of the nasal discharge are not specific signs of bacterial infection
  • Fiberoptic endoscopy is done to visualize the middle meatus
    • May show nasal polyps, mucopurulent discharge, and/or edema or mucosal obstruction 
    • Culture of purulence in this area may be parallel with cultures from sinus aspirates
  • Local tenderness on percussion or direct pressure over the body of the frontal and maxillary sinuses with unilateral predominance may be present
  • Periorbital edema may indicate ethmoidal sinusitis
  • Tympanic membrane, pharynx and neck exam for lymph nodes may not support the diagnosis of acute bacterial rhinosinusitis (ABRS)

Laboratory Tests

Sinus Aspiration and Culture

  • Considered the gold standard for the diagnosis of acute bacterial rhinosinusitis (ABRS)
    • Bacterial recovery of ≥104 colony-forming units/mL is considered positive
    • Not recommended for routine diagnosis due to its invasiveness and technical skills it requires
  • Indications: Lack of response to conventional therapy, toxic-looking patient or presence of severe illness, suppurative or intracranial complications, and suspected rhinosinusitis in immunocompromised patient


  • May be useful in adolescents for assessing maxillary and frontal sinus disease, however shown to be unreliable in patients <10 years of age

Other Lab Tests

  • C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) may be used as a marker of bacterial infection, with correlation with CT scan results
  • Procalcitonin is also considered a potential biomarker for more serious bacterial infection


  • Imaging studies [eg plain radiographs or computed tomography (CT) scan] are nonspecific and do not distinguish bacterial from viral rhinosinusitis, thus it is discouraged to used these studies
    • CT studies may show mucosal changes within the ostiomeatal complex and/or sinuses
  • Radiologic studies should not be routinely done as part of initial management of uncomplicated acute bacterial rhinosinusitis (ABRS) and as confirmatory test in patients ≤6 years of age
    • Some support the use of radiographs in patients >6 years of age with persistent symptoms and in all patients with severe disease regardless of age
  • CT scan is indicated in the following patients with:
    • Recurrent or persistent rhinosinusitis
    • Signs of ABRS complications
    • Refractory rhinosinusitis in which surgery is being contemplated
  • Magnetic resonance imaging (MRI) scan is indicated in extra sinus local spread or intracranial complications, although this is uncommon
  • More data are needed to know the usefulness of ultrasound in diagnosing ABRS
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