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 Management

Symptomatic Therapy

  • Initial symptomatic management is the most cost-effective treatment strategy for many patients
  • Aims to relieve symptoms of nasal obstruction and rhinorrhea
  • Two-thirds of cases of acute rhinosinusitis resolve without antibiotic therapy
  • A course of 7 days of watchful waiting may be sufficient if the patient presents with mild pain or temperature <38.3°C or 101°F and ensures follow-up
    • Patients with uncomplicated ABRS may improve without being given antibiotics  
    • During the decision-making process, it is also important to consider patient’s age, general health, cardiopulmonary status and presence of comorbidities

Analgesics and Antipyretics

  • Useful in controlling pain as >50% of patients with ABRS report facial pain
  • Antipyretics may be used to relieve fever and pain

Cough Preparations

  • Routine prescription of mucolytics is not recommended
  • Guaifenesin is noted to be of some benefit but requires more studies

Corticosteroid Hormones

  • There is limited evidence to support use of oral corticosteroids in ARS beyond pain relief
  • Intranasal corticosteroid may be used as an adjunct to empiric antibiotic therapy in patients with allergic rhinitis history
    • Provides symptomatic relief by decreasing mucosal inflammation and allowing the sinuses to drain 
    • There is some evidence to the benefit of nasal Budesonide used with Erythromycin in ABRS, but only toward symptom reduction
  • In a randomized, double-blind, double-dummy study of patients with non-severe ABRS, twice-daily use of Mometasone nasal spray has been shown to significantly improve the symptom score compared to patients who received Amoxicillin and placebo
  • There are minimal adverse effects with short-term use of nasal corticosteroids

Decongestants (Oral/Intranasal)

  • Increase the ostial diameter by reducing turbinate swelling and mucosal edema; may promote sinus drainage
  • Oral and intranasal decongestants may be beneficial in ABRS
  • Overuse of intranasal decongestants or use for periods longer than 3-7 days is not recommended due to the risk of rebound vasodilation
  • Based on clinical experience, intranasal decongestants are more effective and penetrate rapidly than oral decongestants


  • Use of antihistamines is not recommended; may only be used as an adjunct to antibiotic therapy in patients with concomitant allergic rhinitis

Saline Irrigation

  • The use of nasal saline irrigation, alone or as adjunct, has been shown to reduce the symptoms and medication use
  • Facilitates removal of infective agents, mucus and inflammatory mediators
  • Decreases crusting in the nasal cavity
  • Increases mucociliary clearance
  • There is no difference in symptoms score when comparing isotonic with hypertonic saline, although hypertonic solutions have been shown to improve mucociliary clearance
  • In preparing the irrigant, use sterile water or distilled saline due to reports of amoebic encephalitis arising from the use of contaminated water and avoid the use of table salt because it contains additives

Otorhinolaryngologist Referral

Consider expert referral if any of the following occurs:

  • If no improvement from 1st- or 2nd-line agents especially in severely ill or immunocompromised patients with:
    • Uncontrolled diabetes
    • End-stage renal failure
    • Human immunodeficiency virus (HIV)
  • Recurrent bacterial rhinosinusitis (≥4 episodes/year)
  • Granulomatous disease or fungal sinusitis
  • Development of complications
  • Chronic rhinosinusitis with frequent acute bacterial rhinosinusitis (ABRS) exacerbations
  • Unusual opportunistic or resistant organisms
  • Anatomical anomalies that cause obstruction
  • Failure to respond to extended antibiotic courses
  • Presence of comorbidities
  • Hospital-acquired infection
  • Suspected malignancy
  • Need for special procedures such as:
    • Decision to perform CT scan
    • Maxillary sinus taps (MST) for sinus puncture and aspiration
    • Endoscopically-directed middle meatal culture (EDMMC)

Emergency specialist referral is needed if any of the following is present:

  • Periorbital cellulitis or preseptal edema
  • Displacement of orbital globe
  • Double vision
  • Eye pain/ophthalmoplegia
  • Reduced visual acuity
  • Severe unilateral or bilateral frontal headache
  • Frontal sinus swelling
  • Meningeal or focal neurologic signs (eg high fever, signs of meningeal irritation, altered mental status)
  • Signs of cavernous sinus thrombosis (eg bilateral lid drop, ophthalmic nerve neuralgia, retro-ocular headache, complete ophthalmoplegia, papilledema, prostration)
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