Treatment Guideline Chart
Acute bacterial rhinosinusitis is the mucosal inflammation of the nose and paranasal sinuses caused by bacteria lasting ≥10 days for up to 4 weeks with no clinical improvement, severe signs or symptoms [eg high fever (39°C), purulent nasal discharge, facial pain] of ≥3-4 consecutive days, and worsening of symptoms within 10 days after initial improvement.
It is often preceded by a viral upper respiratory tract infection, rhinitis or other conditions that impair local or systemic immune function (eg nonallergic rhinitis, dental infection, mechanical obstruction of the nose, cystic fibrosis, ciliary dysfunction, immunodeficiency that impair the sinus drainage).
Signs and symptoms are nonspecific and typically difficult to differentiate from viral upper respiratory tract infection.
There is fever with nasal obstruction/congestion or anterior and/or posterior purulent drainage, with or without facial pressure/pain/fullness and reduction/loss of smell.
Streptococcus pneumoniae and unencapsulated strains of Haemophilus influenzae cause half of acute rhinosinusitis cases.

Rhinosinusitis%20-%20acute,%20bacterial Diagnosis


  • Targeted history and physical exam are both beneficial and cost-effective during initial diagnosis
  • Acute viral, non-infectious and allergic rhinosinusitis must be ruled out to prevent inappropriate antibiotic treatment
  • Most guidelines diagnose acute bacterial rhinosinusitis (ABRS) based on clinical presentation
    • Gold standard for ABRS diagnosis is ≥104 colony-forming units (CFU)/mL of bacteria from paranasal sinus cavity
  • Diagnosis should be based on at least 3 of 5 criteria:
    • Fever (>38°C)
    • Presence of severe local pain
    • With discolored discharge and purulent nasal secretion (nasal cavity)
    • Increased erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP)
    • Patients become worse at initial recovery or deterioration of signs and symptoms ("double-sickening")
  • A presumptive diagnosis of ABRS should be made if patient presents with any of the following:
    • Persistent illness: Presence of >10 days nasal discharge or daytime cough not relieved by medications
    • Worsening course: Worsening of resolved previous or new onset nasal discharge, daytime cough, headache or pyrexia
    • Severe onset of the disease: Fever ≥39°C with purulent nasal discharge or facial pain of ≥3 days duration


Severity of Acute Bacterial Rhinosinusitis (ABRS)

  • The severity of ABRS will reflect the need for antibiotic therapy
    • Mild ABRS may be managed with symptomatic therapy alone
      • Many patients with ABRS have self-limited disease which resolves without antibiotic treatment
    • Severe ABRS will need outright antibiotic management plus symptomatic medications
  • The severity assessment will also guide the analgesic therapy
  • Differences in severity do not necessarily imply antimicrobial resistance
  • The evaluation of disease severity will be dependent on clinical judgment
  • Evaluation of disease severity may be based on total severity visual analogue scale (VAS) score
    • Mild: VAS 0-3 cm
    • Moderate: VAS >3-7 cm
    • Severe: VAS >7-10 cm
  • Patients with moderate disease are more likely to need therapeutic intervention to achieve symptom resolution
    • Treatment failures will more likely be less tolerable in these patients
  • Severe or life-threatening illnesses [high, persistent fevers >38.9°C (>102°F), periorbital edema, inflammation, or erythema, cranial nerve palsies, abnormal extraocular movements, proptosis, vision changes (double vision or impaired vision), severe headache, altered mental status, or meningeal signs] should be referred to an emergency department (ED) or otorhinolaryngologist

Recent Antibiotic Use

  • Recent antibiotic use (within the last 4-6 weeks) is a major factor that is associated with increased risk of resistant pathogens


  • Persistent symptoms are moderately sensitive but are nonspecific predictors of ABRS
  • Pay particular attention on the speech which may indicate fullness of the sinuses
  • It is also important to include questions on allergic symptoms

Physical Examination

  • Examine the face for periorbital edema or other facial swelling
  • Perform anterior rhinoscopy when examining the nose 
    • Used for clinical assessment of patients suspected with acute rhinosinusitis (ARS) (primary care setting) 
    • May reveal inflammation, mucosal edema, purulent discharges, and incidental findings of polyps, tumors, foreign bodies and other anatomical abnormalities (eg deviated septum)
  • Examination of the ears may reveal concomitant otitis media
  • Percussion or direct pressure over the body of the frontal and maxillary sinuses may produce unilateral pain
  • Tapping of the maxillary teeth with a tongue depressor can be used to test for tenderness


Nasal Endoscopy
  • Rigid endoscopy is preferred because it provides clear images and is more comfortable for patients 
  • Facilitates culture and tissue sampling
  • Enables endoscopists to perform nasal toileting

Computed Tomography (CT) Scan

  • Gold standard in the evaluation of the paranasal sinuses
  • Can be used in quantifying the extent of inflammatory disease
    • This is based on the opacification of the paranasal sinuses
  • Indications for CT scan:
    • Presence of unilateral symptoms, blood-stained discharge, displacement of the eye and eye pain
    • Planning for a surgery
    • Failure of medical therapy
  • Contrast-enhanced CT scan rather than MRI is recommended for ABRS which is unresponsive to medical management, and those with suspected suppuration
    • Patients not responsive to empiric antimicrobial therapy should be referred to an Otorhinolaryngologist for decision to perform CT scan (See section on Otorhinolaryngologist Referral)

 Magnetic Resonance Imaging (MRI)

  • MRI with contrast of the paranasal sinuses may be considered for pediatric and adult patients suspected of orbital or central nervous system (CNS) involvement


  • Not required to diagnose ARS unless complications or alternative diagnoses are entertained
  • Waters view may be done to identify the existence of sinus opacification, air-fluid level or severe mucosal thickening and to evaluate response to medical treatment

Laboratory Tests

Culture and Susceptibility Test

  • Documents bacterial infection and resistance pattern
  • Cultures from direct aspiration of sinus are recommended in patients who have failed empiric therapy
    • Alternative could be culture from middle meatus via endoscopy
    • Nasopharyngeal swab culture is not recommended

Other Procedures

Maxillary Sinus Taps (MST) for Sinus Puncture and Aspiration

  • The gold standard in determining the etiology of ABRS
    • Due to its invasive nature, this procedure is performed by otorhinolaryngologists (See section on Otorhinolaryngologist Referral)

Endoscopically-Directed Middle Meatal Culture (EDMMC)

  • A less invasive procedure than MST and performed by otorhinolaryngologists (See section on Otorhinolaryngologist Referral)
  • Has comparable performance with a sinus CT scan
  • May also be used in obtaining the specimen for culture and susceptibility tests for unresolved cases of bacterial rhinosinusitis
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