What is acute sinusitis

Acute sinusitis also known as acute rhinosinusitis, causes the cavities around your nasal passages (sinuses) to become inflamed and swollen. Acute sinusitis is a short-term inflammation of the sinuses, the four paired cavities (spaces) in your head. This interferes with drainage and causes mucus to build up.

Acute sinusitis is characterized by inflammation of nasal passages and sinuses, resulting in purulent nasal discharge, sinus tenderness, and facial pain. With acute sinusitis, it might be difficult to breathe through your nose. The area around your eyes and face might feel swollen, and you might have throbbing facial pain or a headache.

The American Academy of Otolaryngology–Head and Neck Surgery ¹ classifies rhinosinusitis into subtypes based on symptom duration ², ³:

1. Acute sinusitis, symptoms come on suddenly, which lasts up to 4 weeks
2. Subacute sinusitis, symptoms which lasts 4 to 12 weeks
3. Chronic sinusitis, symptoms last more than 12 weeks and can continue for months or even years
4. Recurrent sinusitis, with several attacks within a year, with four episodes lasting less than 4 weeks with complete symptom resolution between episodes

Acute rhinosinusitis is further categorized as bacterial or viral. Acute bacterial sinusitis can be differentiated from viral sinusitis using the following clinical guidance ⁴:

• Duration of symptoms for more than ten days
• High fever (over 39 °C or 102 °F) with purulent nasal discharge or facial pain that last for 3 to 4 consecutive days at the beginning of the illness
• Double worsening of symptoms within the first ten days

Acute sinusitis is mostly caused by the common cold (viral infection) or self-limiting bacterial infection, neither of which require treatment with antibiotics ⁵. Unless a bacterial infection develops, most cases resolve within a week to 10 days.

In most cases, home remedies are all that’s needed to treat acute sinusitis. However, persistent sinusitis can lead to serious infections and other complications. Sinusitis that lasts more than 12 weeks despite medical treatment is called chronic sinusitis.

Each year in the United States, rhinosinusitis affects one in seven adults, resulting in more than 30 million annual diagnoses ⁶. Rhinosinusitis is the fifth most common diagnosis for which antibiotics are prescribed in the United States ⁷. The management of acute and chronic sinusitis has a direct cost of more than $11 billion per year, not including the economic impact of lost productivity due to illness ⁷.

If symptoms worsen or if they recur with clearing between episodes, physicians should reevaluate the patient to confirm the diagnosis of acute bacterial rhinosinusitis, exclude other causes of illness, and detect complications ⁸. People who are immunocompromised, seriously ill, or continue to deteriorate despite an extended course of antibiotics should be referred to a subspecialist ¹. Complications of acute bacterial rhinosinusitis are estimated at approximately one in 1,000 episodes ⁸. Although rare in the United States, sinonasal cancer should also be included in the differential diagnosis ⁹. The box below summarizes indications for subspecialist referral in patients with acute bacterial rhinosinusitis ¹⁰.

How long does acute sinusitis last?

Acute sinusitis lasts less than a month. Your symptoms may go away by themselves within about 10 days, but it may take up to three or four weeks.

The sinuses

The paranasal sinuses are spaces in the bones of the skull which are mainly full of air. The paranasal sinuses include:

1. Sphenoid sinus – in the center of the head;
2. Maxillary sinuses – situated in the cheekbones;
3. Frontal sinuses – above the eyes; and
4. Ethmoidal sinuses – on either side of the nose.

Adults have four developed and paired sinus cavities. The ethmoid, sphenoid, frontal, and maxillary sinuses. In children, only the ethmoid and maxillary sinuses are present at birth. The ethmoid sinus separates from the orbit by only a thin layer of bone (the lamina papyrecia). Thus, orbital infections typically arise from the ethmoid sinus, which occurs more often in younger children. The frontal sinuses do not appear to develop until 5 to 6 years of age and do not reach full development until after puberty. Intracranial complications typically arise from the frontal sinuses and thus occur more often in older children or adults. The sphenoid sinus starts to pneumatize at 5 years of age but does not fully develop until 20 to 30 years of age.

Sinuses function to filter out pollutants, microorganisms, dust, and other antigens. The lining of the sinuses produces clear fluid – mucus – which cleans them. Sinuses fluid drain into the intranasal meatus through narrow drainage passages called ostia into the back of the nose and throat, from where it is swallowed.  This happens continually, although you are usually unaware of it. Because the drainage holes from the sinuses are narrow, they block up easily. So any excess mucus production can cause a blockage, and pressure builds up in the sinuses.

The maxillary, frontal, and anterior ethmoid sinuses drain into the middle meatus, creating a congested area called the osteomeatal complex. The posterior ethmoid and sphenoid sinuses drain into the superior meatus. Tiny hairs called “cilia” line the mucous membranes of the nasal cavity and nasopharynx, and work in an integrated and coordinated fashion to carry out this function of circulating mucus and filtered debris, ultimately leading them to the nasopharynx and oropharynx, where they are swallowed. Rhinosinusitis occurs when the sinuses and nasal passages cannot effectively clear out these antigens, leading to an inflammatory state. This condition usually results from three key factors: obstruction of the sinus ostia (i.e., anatomic causes such as a tumor or septal deviation), dysfunction of the cilia (i.e., Kartagener syndrome), or thickening of sinus secretions (cystic fibrosis). The most common cause of temporary obstruction of these outflow regions is local edema due to upper respiratory tract infections or nasal allergy, both of which predispose to rhinosinusitis. When this occurs, bacteria can remain in, gain access to, and proliferate within the usually sterile paranasal sinuses. Severe complications can occur when the sinus infection spreads to surrounding structures, such as the brain and orbit, via the valve-less diploic veins. These are veins located within the inner cancellous bone layer of the skull. This is thankfully a rare phenomenon, but important to remember.

The 2 main causes of excess mucus production are:

• Infection; and
• Allergy.

Figure 1. Paranasal sinuses

Complications of acute sinusitis

Acute sinusitis complications are uncommon. Complications are rare, occurring in about 1 out of every 1000 cases ⁴. Sinus infections may spread to the orbit (eye socket), bone, or intracranial cavities. Eighty percent of orbitocranial complications occur in the orbit. These complications can come with significant morbidity and mortality. The orbit (eye socket) is the most common site due to the very thin ethmoid bone that separates infections from the ethmoid to the orbit. The Chandler classification is the most common method or grading orbital complications of sinusitis infection (listed from least to most severe) ¹¹:

• Preseptal cellulitis
• Orbital cellulitis
• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis

Acute sinusitis complications might also include:

• Chronic sinusitis. Acute sinusitis may be a flare-up of a long-term problem known as chronic sinusitis. Chronic sinusitis lasts longer than 12 weeks.
• Meningitis. This infection causes inflammation of the membranes and fluid surrounding your brain and spinal cord.
• Other infections. Uncommonly, infection can spread to the bones (osteomyelitis) or skin (cellulitis).
• Partial or complete loss of sense of smell. Nasal obstruction and inflammation of the nerve for smell (olfactory nerve) can cause temporary or permanent loss of smell.
• Vision problems. If infection spreads to your eye socket, it can cause reduced vision or even blindness that can be permanent.

Intracranial complications can also occur. These include the development of a subdural hematoma, epidural hematoma, meningitis, or a subdural empyema (the latter comes with a high mortality rate). Pott puffy tumor is a subperiosteal abscess of the frontal bone, usually associated with osteomyelitis ¹². Both complications typically arise from frontal sinus infections, via hematogenous spread through the valveless diploic vein system.

Acute fungal sinusitis can occur in a noninvasive and invasive form ¹³. The invasive form can spread to surrounding structures. Early identification of this complication is vital to avoiding potentially devastating outcomes ¹⁴.

Acute sinusitis causes

Sinusitis is caused by too much mucus, or a swelling of the lining of the sinuses and nose, which can block the narrow channels. This can occur during a cold, or may be due to allergy (for example, hayfever) or irritation of the linings of the sinuses (for example, from chlorine in a swimming pool). Bacteria (germs) then grow inside the sinuses, causing pain, headache and sometimes fever. Mucus from infected sinuses can be yellow or green. Some people get sinusitis with most colds, while others get it rarely.

Acute sinusitis is often caused by a common cold or allergies. It can also be caused by a bacterial infection or fungus that causes the sinuses to swell and become blocked.

• Viruses are the most common cause of acute rhinosinusitis ¹². The viral sinusitis pathogens include rhinovirus, adenovirus, influenza virus, and parainfluenza virus. An estimated 0.5 to 2.0% of viral rhinosinusitis will develop into bacterial infections in adults and 5 to 10% in children ⁴.
• The most common causes of acute bacterial sinusitis are Streptococcus pneumoniae (38%), Haemophilus influenzae (36%), and Moraxella catarrhalis (16%) ¹⁵.
• Although rare, fungal infections can also cause acute rhinosinusitis, though this is almost exclusively seen in the immunosuppressed (uncontrolled diabetes mellitus, HIV positive, oncology patients undergoing active treatment, and patients on immunosuppressants for an organ transplant or rheumatologic conditions) ¹². Typical species include Mucor, Rhizopus, Rhizomucor, and Aspergillus. It is very important to understand the difference between acute invasive fungal sinusitis seen in these patients, and allergic fungal sinusitis which presents in immunocompetent individuals as a mass-like lesion occupying a sinus cavity and often causes chronic symptoms.

In the first three to four days of illness, viral rhinosinusitis cannot be differentiated from early acute bacterial rhinosinusitis ⁶. Figure 2 summarizes the natural course of signs and symptoms associated with rhinovirus infections ⁶. A pattern of initial improvement followed by a worsening of symptoms—called double sickening—between days 5 and 10 of the illness is consistent with acute bacterial rhinosinusitis ⁶.

Physicians should not rely solely on colored nasal drainage as an indication for antibiotic therapy because it does not predict the likelihood of sinus infection (positive likelihood ratio = 1.5; negative likelihood ratio = 0.5) ¹⁶. Local sinus pain with unilateral predominance in addition to purulent rhinorrhea had an overall reliability of 85% for diagnosing sinusitis according to one study ¹⁷. Another study showed that four signs and symptoms with a high likelihood ratio for acute bacterial sinusitis are double sickening, purulent rhinorrhea, an erythrocyte sedimentation rate greater than 10 mm per hour, and purulent secretion in the nasal cavity. A combination of at least three of these four signs and symptoms has a specificity of 81% and sensitivity of 66% for acute bacterial rhinosinusitis ¹⁸. Diagnosis of acute bacterial rhinosinusits is indicated when signs or symptoms of acute rhinosinusitis persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms ⁶. After 10 days of upper respiratory symptoms, the probability of bacterial rhinosinusitis is 60% ¹⁹.

Figure 2. Natural course of symptom prevalence for rhinovirus infections

Causes of infective sinusitis include:

Acute sinusitis is most often caused by the common cold, which is a viral infection. In some cases, a bacterial infection develops.

• Viral infections such as the common cold;
• Bacterial infections (usually a complication of viral sinusitis);
• Fungal infections (usually seen in people with an underlying problem with their sinuses or immune system).

Acute bacterial sinusitis

Acute bacterial rhinosinusitis is caused by various factors (Table 1). However, it is most often the result of a viral cause associated with upper respiratory infection ⁶. Sinus mucosa edema, sinus ostia obstruction, and decreased mucociliary activity are three key factors in the pathophysiology of rhinosinusitis. As a result, secretions stagnate, providing a favorable environment for bacterial growth ⁶. In adult patients with suspected acute maxillary sinusitis following a viral upper respiratory infection, about one-half were found to have pus or mucopus in the sinus aspirate, and one-third had bacterial pathogens growing in culture ²⁰, ²⁰. The most common bacterial organisms in community-acquired bacterial rhinosinusitis are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella (Branhamella) catarrhalis. The most common viruses in acute viral rhinosinusitis are rhinovirus, adenovirus, influenza virus, and parainfluenza virus ⁶, ²¹.

Table 1. Predisposing Factors for Acute Bacterial Sinusitis

Risk factors for sinusitis

Factors that can increase your risk of developing sinusitis include:

• obstruction in the nose or sinuses (due to problems such as nasal polyps – small benign growths in the nose, or a deviated septum after a fractured nose);
• allergy (hay fever, or allergic rhinitis);
• a medical condition such as cystic fibrosis;
• a common cold that affects your sinuses;
• exposure to smoke, either from smoking or through secondhand smoke exposure;
• problems with your immune system such as HIV/AIDS.

Prevention of acute sinusitis

Take these steps to help reduce your risk of getting acute sinusitis:

• Avoid upper respiratory infections. Minimize contact with people who have colds. Wash your hands frequently with soap and water, especially before your meals.
• Manage your allergies. Work with your doctor to keep symptoms under control.
• Avoid cigarette smoke and polluted air. Tobacco smoke and other pollutants can irritate and inflame your lungs and nasal passages.
• Use a humidifier. If the air in your home is dry, such as it is if you have forced-air heat, adding moisture to the air may help prevent sinusitis. Be sure the humidifier stays clean and free of mold with regular, thorough cleaning.

Acute sinusitis symptoms

Acute sinusitis symptoms often include:

• Drainage of a thick, yellow or greenish discharge from the nose or down the back of the throat (postnasal drainage)
• Nasal obstruction (blocked nose) or congestion, causing difficulty breathing through your nose with loss of smell and taste
• Pain, tenderness, swelling and pressure around your eyes, cheeks, nose or forehead that worsens when bending over

Other signs and symptoms can include:

• Ear pressure
• Headache
• Aching in your upper jaw and teeth
• Reduced sense of smell and taste
• Cough, which might be worse at night
• Bad breath (halitosis)
• Fatigue
• Fever 38° C (100.4° F) or more
• Tiredness;
• Pain in the upper jaw and/or teeth; A sinus infection (sinusitis) or inflammation can cause a toothache — specifically in the upper rear teeth, which are close to the sinuses.
• Nausea;
• Generally feeling unwell.

A sensation of partial deafness or blockage in the ear may also occur. This is because the Eustachian tube, which connects the middle ear to the back of the nose, blocks up in just the same way as the nearby sinus openings.

Signs of sinusitis in young children may also include irritability, difficulty feeding, and breathing through their mouth.

Acute sinusitis diagnosis

Acute sinusitis is usually diagnosed by discussing all of your symptoms and medical history with your doctor. In a physical exam, your doctor will feel for tenderness in your nose and face and look inside your ears, nose, and throat to check for any blockage, swelling, and drainage. If allergies are suspected, your doctor will can have an allergy test performed to determine what allergens might be the cause of your sinusitis.

During the past decade, expert panels have created evidence-based guidelines for the diagnosis (Table 2) and management of acute rhinosinusitis in adults ⁶.

Table 2. Summary of Guidelines for the Diagnosis of Acute Rhinosinusitis in Adults

Abbreviations: IDSA = Infectious Diseases Society of America; URI = upper respiratory infection

Other methods that might be used to diagnose acute sinusitis and rule out other conditions include:

• Nasal endoscopy. A thin, flexible tube (endoscope) with a fiber-optic light inserted through your nose allows your doctor to visually inspect the inside of your sinuses.
• Imaging studies. A CT scan shows details of your sinuses and nasal area. It’s not usually recommended for uncomplicated acute sinusitis, but imaging studies might help find abnormalities or suspected complications.
• Nasal and sinus samples. Lab tests aren’t generally necessary for diagnosing acute sinusitis. However, when the condition fails to respond to treatment or is worsening, tissue samples (cultures) from your nose or sinuses might help find the cause, such as a bacterial infection.
• Allergy testing. If your doctor suspects that allergies have triggered your acute sinusitis, he or she will recommend an allergy skin test. A skin test is safe and quick and can help pinpoint the allergen that’s causing your nasal flare-ups.

Laboratory tests

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are somewhat useful tests for diagnosing acute bacterial maxillary sinusitis. In a study of 173 patients using antral puncture as the reference standard, 30 of 38 (79%) of those with a CRP level greater than 49 mg per L (466.7 nmol per L) had acute maxillary sinusitis compared with 37 of 61 (61%) of those with a CRP level of 11 to 49 mg per L (104.8 to 466.7 nmol per L) and only 25 of 74 (34%) of those with a CRP level less than 11 mg/L ²⁰.

Imaging

Radiography is not recommended in the evaluation of acute uncomplicated rhinosinusitis ⁶. It is somewhat helpful in ruling out the presence of fluid when the results are negative. Positive results are not helpful because they cannot differentiate between viral and bacterial sinusitis.

For patients with recurrent acute or chronic rhinosinusitis, computed tomography (CT) of the sinuses without contrast media is the imaging method of choice ⁶. CT of the sinuses should be performed only after completing maximal medical therapy. CT is primarily used to define the anatomy of the sinuses before surgery, as well as to assess the extent, pattern, and a probable mechanical cause of the recurrent or chronic rhinosinusitis. A thickened mucosa of 5 mm or greater on CT is a significant sign of sinus infection ¹⁸. Antral puncture data from patients with CT evidence of fluid in the maxillary sinus were associated with demonstrated pus or mucopus by sinus lavage in 90% of patients reviewed ¹⁸.

Acute sinusitis treatment

Most cases of acute sinusitis, those caused by a viral infection, resolve on their own. Self-care techniques are usually all you need to ease symptoms.

Treatments to relieve symptoms

Your doctor may recommend treatments to help relieve sinusitis symptoms, including:

• Saline nasal spray, which you spray into your nose several times a day to rinse your nasal passages.
• Nasal corticosteroids. These nasal sprays help prevent and treat inflammation. Examples include fluticasone (Flonase, Veramyst), budesonide (Rhinocort), mometasone (Nasonex) and beclomethasone (Beconase AQ, Qnasl, others).
• Decongestants. These medications are available in over-the-counter (OTC) and prescription liquids, tablets and nasal sprays. Nasal decongestants should not be used for longer than 3 days or in young children. Otherwise they may cause the return of more severe congestion (rebound congestion).
• Hay fever treatment, including antihistamine nasal spray or tablets, is recommended when allergic rhinitis is contributing to sinusitis. Immunotherapy for ongoing hay fever is another treatment option.
• Pain relievers such as acetaminophen (paracetamol) and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen if you have significant pain.

Over-the-counter (OTC) pain relievers, such as aspirin, acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others).

Use caution when giving aspirin to children or teenagers. Children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin. This is because aspirin has been linked to Reye’s syndrome, a rare but potentially life-threatening condition, in such children.

Watchful waiting

Watchful waiting is appropriate in place of antibiotics for seven to 10 days after upper respiratory symptoms appear when there is assurance of follow-up ⁶. Antibiotic therapy should be considered if the patient’s condition does not improve by seven to 10 days after initial presentation or if symptoms worsen at any time ⁶. Symptomatic therapies should be offered to patients who are under observation. Physicians may also provide these patients with a safety net antibiotic prescription (also called a delayed prescription), with instructions describing when to fill the prescription ⁶. Watchful waiting is supported by four meta-analyses that were published after the 2007 American Academy of Otolaryngology–Head and Neck Surgery clinical practice guideline was released ²⁷, ²⁸, ²⁹, ³⁰. These studies did not provide evidence confirming or disproving the American Academy of Otolaryngology–Head and Neck Surgery position that patients with more severe acute bacterial rhinosinusitis should initially be treated with antibiotics.

A Cochrane review showed that the symptoms of bacterial rhinosinusitis had resolved in 47% of all patients after seven days with or without antibiotic therapy (Lemiengre MB, van Driel ML, Merenstein D, Young J, De Sutter AI. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012;(10):CD006089.()). In addition, approximately 70% of patients improved within two weeks without antibiotics ²⁹. Antibiotic therapy did increase cure rates for patients between seven and 15 days compared with placebo; however, the clinical benefit was small, with only 5% of patients having a faster cure ²⁹. Moreover, analysis of individual patient data found that it was not possible to identify which patients with rhinosinusitis would benefit from antibiotics based on the presence of common clinical signs and symptoms ²⁷. The number needed to treat was estimated to be 11 to 15.1,22,24 Adverse effects occurred more often with antibiotics than with placebo (number needed to harm = 8) ²⁸. The risk of harm outweighs the potential benefit of antibiotic therapy. As a result of this research, the 2015 American Academy of Otolaryngology–Head and Neck Surgery guideline recommends offering watchful waiting to patients regardless of illness severity ⁶.

Acute sinusitis antibiotics

Antibiotics usually aren’t needed to treat acute sinusitis, because it’s usually caused by a virus and not by bacteria. Even if your acute sinusitis is bacterial, it may clear up without treatment. Your doctor might wait and watch to see if your acute sinusitis worsens before prescribing antibiotics. However, antibiotics are sometimes needed to treat sinusitis when a bacterial infection is suspected. Acute bacterial sinusitis is suspected when:

• symptoms are getting worse after initial improvement;
• you have a high fever, symptoms are severe and have lasted for more than 3 days; or
• symptoms of rhinosinusitis have lasted for longer than 7 days.

If your doctor prescribes an antibiotic, be sure to take the whole course, even after your symptoms get better. If you stop taking them early, your symptoms may recur.

Antibiotics for the treatment of acute bacterial rhinosinusitis are outlined in Table 3. Most guidelines recommend amoxicillin with or without clavulanate as a first-line antibiotic for adults because of its safety, effectiveness, low cost, and narrow microbiologic spectrum ⁶. Amoxicillin/clavulanate (Augmentin) should be used in patients who are at high risk of bacterial resistance or who have comorbid conditions, as well as in those with moderate to severe infection ⁶. No significant differences in acute bacterial rhinosinusitis cure rates are noted between different antibiotic classes ⁶.

Table 3. Oral Antibiotics for the Treatment of Acute Bacterial Sinusitis

Footnotes:

†—May be available at discounted prices at one or more national retail chains.

‡—Fluoroquinolones should be reserved for those who do not have alternative treatment options.

Respiratory fluoroquinolones are not recommended as first-line antibiotics because they conferred no benefit over beta-lactam antibiotics and are associated with a variety of adverse effects ⁶. According to a recent U.S. Food and Drug Administration safety alert, fluoroquinolones should be reserved for patients who do not have other treatment options ³². Macrolides, including azithromycin (Zithromax), trimethoprim/sulfamethoxazole, and second- or third-generation cephalosporins, are no longer recommended as initial therapy for acute bacterial rhinosinusitis because of high rates of resistance in S. pneumoniae and H. influenzae ⁶.

The recommended duration of therapy for uncomplicated acute bacterial rhinosinusitis is five to 10 days for most adults ⁶. This recommendation is based primarily on findings from a meta-analysis of 12 randomized controlled trials ³³. A shorter treatment course (median of five days) may be just as effective as a longer course of treatment (median of 10 days) and is associated with fewer adverse effects ³³. Regardless, clinicians should assess disease and symptom response before stopping antibiotic therapy prematurely, especially in older adults and in patients with underlying disease.

Treatment failure occurs when a patient’s symptoms do not improve by seven days after diagnosis or when they worsen at any time, with or without antibiotic therapy ⁶. If treatment failure occurs following initial antibiotic therapy, an alternative antibiotic with a broader spectrum is required. High-dose amoxicillin/clavulanate, a respiratory fluoroquinolone, or the combination of clindamycin plus a third-generation oral cephalosporin may be considered ⁶.

Adjunctive symptomatic treatment

Current guidelines consider analgesics, intranasal corticosteroids, and saline nasal irrigation to be options for the management of rhinosinusitis symptoms ⁶. They are recommended for use within the first 10 days but may be continued if antibiotics are initiated. Selection of interventions should be based on shared decision making. Decongestants, antihistamines, and guaifenesin are not recommended for patients with acute bacterial rhinosinusitis because of their unproven effectiveness, potential adverse effects, and cost ¹. Table 2 summarizes adjunctive therapies for acute rhinosinusitis ³⁴, ³⁵, ³⁶.

Table 4. Adjunctive Therapies for Acute Rhinosinusitis

Intranasal Corticosteroids

Intranasal corticosteroids may be helpful in reducing mucosal swelling of inflamed tissue and facilitating sinus drainage because of an anti-inflammatory effect ⁶. However, data on intranasal corticosteroids as monotherapy for symptomatic relief in patients with acute sinusitis are limited ²⁹. Several studies suggest that they provide additional benefit in symptom improvement when used with antibiotics in patients with acute sinusitis ³⁹. A meta-analysis of six trials ³⁶ concluded that intranasal corticosteroids offered a modest therapeutic benefit in patients with acute sinusitis (number needed to treat = 13).

Similarly, a 2013 Cochrane review found that patients receiving intranasal corticosteroids were more likely to experience symptom improvement after 15 to 21 days compared with those receiving placebo (73% vs. 66.4%; number needed to treat = 15) ³⁵. Higher doses of intranasal corticosteroids had a greater effect on symptom relief than lower doses. Even though their benefits are only marginal,3 intranasal corticosteroids are often used as an adjunct to antibiotic therapy in the symptomatic treatment of acute bacterial sinusitis. They are likely most beneficial in patients with concurrent allergic rhinitis ¹.

Saline Nasal Irrigation

Intranasal irrigations with either physiologic or hypertonic saline have been shown to improve mucociliary clearance and may be beneficial for the treatment of acute rhinosinusitis ³⁸. One randomized controlled trial of 76 patients with frequent sinusitis found that daily hypertonic saline nasal irrigation decreases nasal symptoms and medication use ⁴⁰. A Cochrane review concluded that saline nasal irrigation may relieve symptoms of upper respiratory infection ⁴¹. Despite limited evidence regarding effectiveness, saline nasal irrigation can be a safe and inexpensive adjunctive therapy for symptom relief in acute rhinosinusitis. It is important to inform patients to prepare irrigations using distilled, boiled, or filtered water because there have been reports of amebic encephalitis due to contaminated tap water rinses ⁴².

Decongestants

Oral decongestants have been shown to be modestly effective for short-term relief of symptoms in adults with the common cold by reducing nasal airway resistance ⁴³. However, the effect of decongestants in the nasal cavity does not extend to the paranasal sinuses ⁴⁴. There are currently no randomized controlled trials evaluating the effectiveness of decongestants in patients with sinusitis. Oral decongestants should be used with caution in patients with hypertension or cardiovascular disease. Topical decongestants should not be used for longer than 72 hours, owing to the potential for rebound congestion (rhinitis medicamentosa).

Antihistamines

Antihistamines are often used to relieve symptoms of excessive secretions and sneezing. However, there are no studies to support the effectiveness of antihistamine in acute rhinosinusitis ⁶. Antihistamines may also worsen congestion by overdrying the nasal mucosa. Current guidelines do not recommend antihistamines as an adjunctive therapy for acute bacterial rhinosinusitis, except in patients with a history of allergy ¹.

Immunotherapy

If allergies are contributing to your sinusitis, allergy shots (immunotherapy) that help reduce the body’s reaction to specific allergens may help treat your symptoms.

How to treat acute sinusitis at home yourself

If you are looking after yourself, the tips below may help relieve the symptoms:

• Decongestant medicines – available as tablets, nasal sprays or drops – may be helpful, but do not take them for longer than instructed. Always follow the manufacturer’s instructions when taking or giving someone else any medicines. Decongestants work by narrowing blood vessels to help reduce inflammation and swelling that cause sinus congestion.
  • Most people can use decongestants safely, but they’re not suitable for everyone.
    • Decongestants should not be used by the following groups of people without getting advice from a pharmacist or doctor first:
    • Children under 6 (children aged 6 to 12 should take them for no longer than 5 days. Ask a pharmacist for advice about this).
    • Pregnant and breastfeeding women (it’s not clear whether it’s safe to take any type of decongestant if you’re pregnant, so you should only use them if told to by a healthcare professional). Decongestants that come as tablets, liquids or powders that you swallow are not recommended if you’re breastfeeding. Some decongestants that come as nose sprays or drops are safe to use if you’re breastfeeding, but check with a pharmacist or doctor first before using them.
    • People taking other medicines
    • People with diabetes
    • People with high blood pressure
    • People with an overactive thyroid gland (hyperthyroidism)
    • Men with an enlarged prostate
    • People with liver, kidney, heart or circulation problems
    • People with increased pressure in the eye glaucoma
• It is important to stay well hydrated so drink plenty of water. Consuming additional fluids helps dilute mucous secretions and promotes drainage. If you have an existing medical condition check with your doctor about how much water is right for you.
• Gently blow your nose one nostril at a time.
• Apply warm compresses. Place a warm or cool cloth, whichever helps, over the aching area (your nose, cheeks and eyes) to ease facial pain.
• Use a saline nasal spray. Saline washes or sprays can remove thick secretions and allow the sinuses to drain.
• Use a neti pot. A neti pot is a container designed to rinse debris or mucus from your nasal cavity. Neti pots are often available in pharmacies and health food stores, as well as online. Talk to your doctor to see if nasal rinsing is right for you.
• Rinse your nasal passages. Use a specially designed squeeze bottle (Sinus Rinse, others) or neti pot. This home remedy, called nasal lavage, can help clear your sinuses. If you make your own rinse, use water that’s contaminant-free — distilled, sterile, previously boiled and cooled, or filtered using a filter with an absolute pore size of 1 micron or smaller — to make up the irrigation solution. Also be sure to rinse the irrigation device after each use with contaminant-free water and leave open to air-dry.
• Moisten your sinus cavities by inhaling warm water vapor. Drape a towel over your head as you breathe in the vapor from a bowl of warm or moderately hot water. Keep the vapor directed toward your face. Or take a hot shower, breathing in the warm, moist air. This will help ease pain and help mucus drain.
• Sleep with your head elevated. This will help your sinuses drain, reducing congestion.
• Rest and avoid heavy activity until symptoms go away.
• Keep the room at a comfortable temperature.
• Smoking or breathing in other people’s smoke can make symptoms worse. Try to avoid being around people who are smoking. If you are a smoker, try to cut down or quit. For advice on quitting smoking, visit our quit smoking article.
• Find advice on suitable medicines for pain. Pain caused by pressure buildup in the sinus cavities may be relieved with acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others). Use caution when giving aspirin to children or teenagers. his is because aspirin has been linked to Reye’s syndrome, a rare but potentially life-threatening condition, in such children.
• Find out more about self-care tips if you have a high temperature (fever).

Most people with acute sinusitis get better without antibiotics. However, if your symptoms are severe or last longer than a few days, talk to your doctor.

Over-the-counter medicines for pain

An over-the-counter analgesic, such as acetaminophen or a nonsteroidal anti-inflammatory drug, is often sufficient to relieve pain or fever in acute rhinosinusitis. Narcotics are not recommended because of potential adverse effects ⁶.

There are a range of pain relief medicines that can be bought without prescription as over-the-counter pain relievers, including paracetamol (Tylenol, others), ibuprofen (Advil, Motrin IB, others) and aspirin. Always use over-the-counter products as directed.

Use caution when giving aspirin to children or teenagers. Children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin. This is because aspirin has been linked to Reye’s syndrome, a rare but potentially life-threatening condition, in such children.

Just because they are available over-the-counter does not mean that they are completely free of side effects and you should always check with your pharmacist or doctor if you are unsure whether these drugs are safe for you or not.

If you have allergies, chronic illness or are on any other medicines always check first before taking these medicines. The pharmacist can help in giving medication advice in these cases. Always if your pain persists or you are concerned see your doctor.

Acetaminophen (paracetamol)

Acetaminophen (paracetamol) is effective for mild to moderate pain, if used correctly. When you take paracetamol, check that none of your other medicines contain the same active ingredient, as it can cause serious liver damage if taken in larger doses than recommended. Arthritis medicines and over-the-counter cold and flu medicines can contain paracetamol.

Acetaminophen (paracetamol) can be given to children from the age of one month for pain and symptoms of fever. Paracetamol for children can only be bought at pharmacies. Make sure you’ve got the right strength for your child’s age and weight as overdosing can be dangerous. Read and follow the directions on the label carefully. If you are not sure, check with your doctor or pharmacist.

Ibuprofen

Non-steroidal anti-inflammatory (NSAIDs) drugs, such as ibuprofen, are effective against mild to moderate pain. Use these at the lowest dose that improves your symptoms and only use them for a short time. These medicines may not be suitable for people with stomach troubles, heart problems, kidney impairment, high blood pressure or asthma. See your doctor if you need to take these drugs for more than one week. The use of oral NSAIDs in older people is not recommended.

Ibuprofen can be given for pain and symptoms of fever in children aged three months and over who weigh more than 5kg. Ibuprofen for children can only be bought at pharmacies. Make sure you’ve got the right strength for your child’s age and weight as overdosing can be dangerous. Read and follow the directions on the label carefully. If you are not sure, check with your doctor or pharmacist. Avoid ibuprofen if your child has asthma, unless advised by your doctor.

If you have a high temperature there are a number of things you can do to help manage the condition:

• it’s important to stay well hydrated so drink plenty of clear non-alcoholic fluids
• ice blocks or iced drinks may be soothing
• wear lightweight clothing and avoid using blankets or quilts in bed as this may make you too hot and increase your temperature
• keep the room at a comfortable temperature
• Rinse your nasal passages. Use a specially designed squeeze bottle (Sinus Rinse, others) or neti pot. This home remedy, called nasal lavage, can help clear your sinuses. If you make your own rinse, use water that’s contaminant-free — distilled, sterile, previously boiled and cooled, or filtered using a filter with an absolute pore size of 1 micron or smaller — to make up the irrigation solution. Also be sure to rinse the irrigation device after each use with contaminant-free water and leave open to air-dry.
• Moisten your sinus cavities. Drape a towel over your head as you breathe in the vapor from a bowl of hot water. Keep the vapor directed toward your face. Or take a hot shower, breathing in the warm, moist air. This will help ease pain and help mucus drain.
• Apply warm compresses to your face. Place warm, damp towels around your nose, cheeks and eyes to ease facial pain.
• rest and avoid heavy activity until your symptoms go away
• sleep with your head elevated. This will help your sinuses drain, reducing congestion.
• avoid cool baths or sponging – this can actually make you or your child feel more uncomfortable
• see your doctor if your fever persists or you are concerned.

Medicines you can take if you have a high temperature

There is no need to take medicines for fever unless you are experiencing discomfort.

If you are experiencing discomfort consider:

• paracetamol (acetaminophen)
• ibuprofen.

Before taking any medicine, you should check that it’s safe to take them:

• with any medical conditions that you may have
• with any other medicines that you are taking
• if you are pregnant or breastfeeding.

You can do this by reading the information leaflet inside the packet or asking a pharmacist.

Endoscopic sinus surgery

If medication does not help, endoscopic sinus surgery could help prevent the sinusitis from coming back. Endoscopic Sinus Surgery is the name given to operations for sinus problems when treatment with tablets or sprays has not helped. Surgery is performed though the nostrils, with no cuts or stitches on the face. Before any operation patients will be treated using drops, tablets or sprays for a period of weeks if not months. You will usually need to have a CT scan to confirm the diagnosis and to help the surgeon plan what type of operation will help you best.

Usually the operation is done with you asleep (general anaesthetic) but it can also be done with just your nose anaesthetised (local anaesthetic). The operation is all done inside your nose. The surgeon will use special telescopes and instruments to unblock your sinuses. Small amounts of bone and swollen lining blocking your sinuses are removed. Once the sinuses are unblocked, the inflammation usually settles and your symptoms should start to get better. Rarely there maybe some bruising around the eye but this is very uncommon. There should be no need for incisions (cuts) unless the operation is a complicated one in which case this will have been discussed with you before the operation.

Immediately after the operation you may feel your nose is blocked. You may be advised to rinse the nose with salt water to help relieve this. Your doctor will inform you if any dressings have been left in the nose, and whether these dissolve by themselves, or if they have to be removed.

You can expect to go home on the day of your surgery or the day after your operation depending on the size of your operation. You will need to rest at home for at least a week. Most people are able to return to work and normal activities between 10 – 14 days after surgery. If you do heavy lifting and carrying at work you should be off work for at least two weeks. You will be given instructions on when to return to the hospital for your follow-up visit.

It is important that you do not blow you nose for the first 48 hours following your operation. Your surgeon will advise you on when you can start to gently blow your nose. Some doctors recommend the use of drops, ointments and salt water sprays after the operation. You will be given specific instructions by the ward staff before your discharge from hospital. Some mucus and blood stained fluid may drain from your nose for the first week or two following the operation and this is normal. Heavy bleeding should be reviewed by a doctor. It is important to stay away from dusty and smoky environments while you are recovering.

Endoscopic sinus surgery risks

All operations carry some element of risk in the form of possible side effects. There are some risks that you must know about before giving consent to this treatment. These potential complications are very uncommon. You should discuss with your surgeon about the likelihood of problems in your case before you decide to go ahead with the operation.

• Bleeding. Bleeding is a risk of any operation. It is very common for small amounts of bleeding to come from the nose in the days following the operation. Major bleeding is extremely uncommon and it is very rare for a transfusion to be required.
• Eye problems. The sinuses are very close to the wall of the eye socket. Sometimes minor bleeding can occur into the eye socket and this is usually noticed as some bruising around the eye. This usually gets better without any special treatment, although it is important that you do not blow your nose. More serious bleeding into the eye socket sometimes can occur, however this is very rare. This can cause severe swelling of the eye and can even cause double vision or in very rare cases loss of sight. If such a serious eye complication did occur you would be seen by an eye specialist and may require further operations.
• Spinal Fluid Leak. The sinuses are very close to the bone at the base of the brain. All sinus operations carry a small risk of damage to this thin bone with leakage of fluid from around the brain (cerebrospinal fluid or CSF) into the nose, or other related injuries. If this rare complication does happen you will have to stay in hospital longer and may require another operation to stop the leak. On very rare occasions infection has spread from the sinuses into the spinal fluid causing meningitis but this is extremely uncommon. You can discuss this complication with your surgeon before the operation.

Do I have to have the operation?

In some patients an operation can be avoided by use of antibiotics and steroid medicines, and surgery is usually only considered when this has failed. If you have little trouble by way of symptoms, or have other conditions that make surgery or anaesthetics high risk, an operation may not be the best way to help you.

Sinus surgery is very effective in about 90% of patients, but sometimes sinus problems can come back in the future, and roughly 1 in 8 patients will need another sinus operation within 5 – 10 years.

Acute sinusitis prognosis

Acute bacterial rhinosinusitis is most commonly viral. The large majority of cases will either resolve spontaneously or can be effectively treated with antibiotics. Invasive fungal rhinosinusitis is a rare, serious form of the infection that can occur in immunocompromised patients. It is associated with a high morbidity and mortality rate ¹⁴.

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