Patient information: Acute sinusitis (sinus infection) (Beyond the Basics)
- Peter H Hwang, MD
Peter H Hwang, MD
- Chief, Division of Rhinology
- Department of Otolaryngology - Head & Neck Surgery
- Stanford University School of Medicine
- Zara M Patel, MD
Zara M Patel, MD
- Assistant Professor
- Division of Rhinology
- Department of Otolaryngology - Head and Neck Surgery
- Stanford University School of Medicine
- Section Editors
- Daniel G Deschler, MD, FACS
Daniel G Deschler, MD, FACS
- Section Editor — Otorhinolaryngology
- Professor of Otology and Laryngology
- Harvard Medical School
- Stephen B Calderwood, MD
Stephen B Calderwood, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine (Microbiology and Immunobiology)
- Harvard Medical School
ACUTE SINUSITIS OVERVIEW
Rhinosinusitis, or more commonly sinusitis, is the medical term for inflammation (swelling) of the lining of the sinuses and nose. The sinuses are the hollow areas within the facial bones that are connected to the nasal openings (figure 1). The sinuses are lined with mucous membranes, similar to the inside of the nose.
There are two main types of sinusitis: acute and chronic. Acute sinusitis is inflammation that lasts for less than four weeks, subacute sinusitis lasts from 4 to 12 weeks, while chronic sinusitis lasts for more than 12 weeks. Acute sinusitis is common.
This article will discuss the causes, symptoms, and treatment of acute sinusitis in adults. Information about the common cold is also available separately. (See "Patient information: The common cold in adults (Beyond the Basics)".)
ACUTE SINUSITIS CAUSES
The most common cause of acute sinusitis is a viral infection associated with the common cold. Bacterial sinusitis occurs much less commonly, in only 0.5 to 2 percent of cases, usually as a complication of viral sinusitis.
Because antibiotics are effective only against bacterial, and not viral, infections, most people with acute sinusitis do not need antibiotics, and would be putting themselves at risk for medication side effects and developing antibiotic resistance by taking them for nonbacterial sinusitis.
ACUTE SINUSITIS SYMPTOMS
Symptoms of acute sinusitis include:
●Thick, yellow to green discharge from the nose
●Nasal congestion or blockage
●Facial pain, pressure, or fullness
Other acute sinusitis symptoms can include fever (temperature greater than 100.4ºF or 38ºC), fatigue, cough, difficulty or inability to smell, ear pressure or fullness, headache, and bad breath. In most cases, these symptoms develop over the course of one day and begin to improve by 7 to 10 days.
DO I HAVE VIRAL OR BACTERIAL SINUSITIS?
It is difficult to know if you have a viral or bacterial sinus infection initially. Studies show that duration of symptoms cannot always be used to distinguish between viral and bacterial sinusitis, even when lasting longer than 7 to 10 days.
If symptoms of sinusitis last more than 10 days, you have these symptoms that initially improve but then worsen again within the first seven days ("double-worsening"), or you have severe symptoms (eg, fever >102°F and thick, yellow to green discharge from your nose for three or four days in a row when your illness starts), you may have bacterial sinusitis.
DO I NEED TO BE EXAMINED?
If you have one or more of the following symptoms, you should seek medical attention immediately (even if symptoms have been present for less than seven days):
●Persistent high fever (>102°F)
●Sudden, severe pain in the face or head
●Double vision or difficulty seeing
●Confusion or difficulty thinking clearly
●Swelling or redness around one or both eyes
You may also want to see a healthcare provider if you have symptoms that last more than 10 days, have severe symptoms (eg, fever >102°F or thick, yellow to green discharge from the nose), or symptoms that initially improve and worsen again.
ACUTE SINUSITIS TREATMENT
Treatment for sinusitis involves symptom relief and may or may not include antibiotic therapy. You should speak with your healthcare provider about whether or not you need antibiotic therapy. Bacterial and viral sinusitis can often improve with nonantibiotic treatment, although bacterial sinusitis can also worsen and require antibiotic treatment.
Symptomatic treatment — Symptomatic treatment of a sinus infection aims to relieve symptoms. These treatments do not shorten the duration of illness.
Pain relief — Nonprescription pain medications, such as acetaminophen (eg, Tylenol) or ibuprofen (eg, Motrin, Advil), are recommended for pain.
Nasal irrigation — Flushing the nose and sinuses with a saline solution several times per day has been proven to decrease pain associated with congestion and shorten the duration of symptoms. Instructions for nasal irrigation are provided in the table (table 1).
Nasal steroids — Nasal steroids (steroids delivered by a nasal spray) can help to reduce swelling inside the nose, usually within two to three days. These drugs have few side effects and relieve symptoms in most people.
There are a number of nasal steroids available by prescription, and one (triamcinolone or Nasacort) is available without a prescription. These drugs are all effective, but differ in how frequently they must be used and how much they cost.
●Oral decongestants – Oral decongestants (most commonly pseudoephedrine and phenylephrine) may be helpful if you have associated symptoms of ear pain or fullness.
●Nasal decongestant sprays – Nasal decongestant sprays, including oxymetazoline (Afrin) and phenylephrine (Neo-synephrine), can be used to temporarily treat congestion. However, these sprays should not be used for more than two to three days due to the risk of rebound congestion (when the nose becomes congested constantly unless the medication is used repeatedly), possible addiction, and long-term consequences of frequent use, including persistent nasal dryness and crusting, which is very difficult to treat once it has developed.
●Oral antihistamines – Oral antihistamines (such as diphenhydramine/Benadryl) are not proven to improve symptoms of sinusitis and can have unwanted side effects.
●Mucolytics – Medications to thin secretions (such as guaifenesin) may help to clear mucus.
Observation — Observation (continuing to watch and wait) is an option for treatment for many patients. You should speak with your healthcare provider about whether or not this is the best option for you.
Watching and waiting is a reasonable option because up to 75 percent of people with bacterial sinusitis improve within one month without antibiotics. During the watch and wait period, treatments to improve symptoms are recommended. If symptoms worsen with observation, treatment with an antibiotic is usually started. (See 'Symptomatic treatment' above.)
Antibiotics — Bacterial sinusitis does not always need to be treated with antibiotics as many patients improve without antibiotics. You should speak with your healthcare provider about whether or not you need antibiotics. Patients who have worsening symptoms after being managed with watchful waiting are usually started on antibiotics. Treatments to relieve symptoms are also recommended during antibiotic treatment. (See 'Observation' above and 'Symptomatic treatment' above.)
One of the least expensive and most effective antibiotics for sinusitis is amoxicillin. An alternate antibiotic will be prescribed if you are allergic to penicillin or if you live in an area where resistance to that particular antibiotic is high. Regardless of which antibiotic is prescribed, it is important to follow the dosing instructions carefully and to finish the entire course of treatment. Taking the medication less often than prescribed or stopping the medication early can lead to complications, such as a recurrent infection.
What if I do not improve with treatment? — If you do not improve or worsen after a course of antibiotics, you should be re-examined. You may need a different antibiotic or further evaluation with imaging or an exam of the inside of the sinuses.
In some cases, symptoms of sinusitis improve but then recur. This is usually because the infection was not completely eliminated by the antibiotic. An alternate antibiotic, extended antibiotic treatment, and/or further testing may be recommended, depending upon your individual situation.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis
Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis
Chronic rhinosinusitis: Management
Microbiology and antibiotic management of chronic rhinosinusitis
Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment
The following organizations also provide reliable health information.
- Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007; 137:S1.
- Piccirillo JF. Clinical practice. Acute bacterial sinusitis. N Engl J Med 2004; 351:902.
- Ah-See KW, Evans AS. Sinusitis and its management. BMJ 2007; 334:358.
- Tan T, Little P, Stokes T, Guideline Development Group. Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance. BMJ 2008; 337:a437.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.