Hopkins C, Surda P, Walker A, Wolf A, Speth M, Jacques T, et al. EPOS 4 patients. Rhinology. 2021 Suppl. 30: 1-57.
What is it?
Acute rhinosinusitis (ARS) is a term that can be used to describe any short-lasting condition that causes inflammation of the lining of the nose and sinuses. However, most often when we use the term ARS it refers to an infection that causes the nose and sinuses to become swamped by cells that fight infection, which trigger inflammation as part of the effort to kill the agent causing infection. It is most often due to a viral infection, but occasionally can also be caused by bacteria.
Symptoms of ARS include a blocked nose or a feeling of congestion, nasal discharge – either when blowing the nose or trickling down the back, green/yellow coloured mucus or even pus, or facial pain or pressure, headache, and reduction/loss of smell. When ARS is caused by an infection, it is often accompanied by the feeling of having a typical cold, with sore throats, cough, and fever being common alongside the problems in the sinuses.
What causes it?
ARS is very common and in fact, is the thirteenth most common reason for patients to need to see a doctor. Adults have 2-5 colds per year, while schoolchildren have about 7-10 colds per year. Viral infections are much more common than bacterial infection and are thought to cause over 98% of all cases of ARS. However, cases that are more severe or long-lasting may indicate a bacterial infection.
The features that commonly help to indicate a bacterial infection include:
How long symptoms have been present.
A viral infection usually lasts less than 10 days, with the worst symptoms reached around 3-5 days. After this point, symptoms gradually get better and subsequently decline until resolution. Bacterial infections are more common when symptoms last longer
This term is used by doctors to describe when a patient initially seems to be recovering from their cold, but then suddenly gets worse again. This is a feature of bacterial infections.
Bacterial ARS infections generally make patients feel more unwell than a typical cold and may result in severe facial pain located around one side, a high fever (>38°), mucus that looks green, yellow, or rusty brown; and signs of infection on blood tests if your doctor thinks these are required.
How is it treated?
Viral infections will virtually always get better with time, rest, and sticking to healthy behaviours such as staying well hydrated.
There are some medications which are available over the counter that can help to relieve the symptoms while you are waiting to recover; these are listed in the table. It is important that you always read the leaflets of any medications you take – even if bought over the counter – and that you tell your doctor about them before any new medicines are prescribed.
Some branded cold remedies contain several drugs, such as paracetamol and decongestants, so check the contents before taking any additional medication to make sure that you don’t exceed daily limits.
Treatments for the “common cold”/acute viral rhinosinusitis/acute bacterial rhinosinusitis
If a doctor feels that a patient is likely to have a bacterial cause of their acute rhinosinusitis then it is likely that antibiotics will be the first line of treatment. Usually, this is a short course of antibiotics targeted at the most common bacterial causes – and is quite different to the use of antibiotics in the longer-lasting form of sinus disease, chronic rhinosinusitis. Antibiotics have a modest effect when used in patients with bacterial rhinosinusitis but are completely ineffective in viral infections. Their use can occasionally have side effects such as rash, nausea, and diarrhoea. Additionally, there are some concerns that using antibiotics without proper consideration of whether a patient is suffering from a viral or bacterial infection may lead to overuse, and in turn, allow bacteria to become resistant to current antibiotic treatments.
As well as antibiotics, bacterial rhinosinusitis symptoms can be made more tolerable by simple medications such as paracetamol.
A 60-year-old female patient presented to an emergency department with headache, fever and purulent anterior nasal discharge. The patient was started on simple analgesia and was given the advice to rest at home and told that if the facial pain would become one-sided and particularly severe, or if she noted a change in vision or eye swelling/reddening, then she would need to see a doctor immediately. However, within the next few days, her fever settled and within a week all other symptoms also regressed without the need for further treatment.
When should I be worried?
Complications of ARS are very uncommon, but when they do occur they may be potentially life-threatening and patients who are concerned they may have a complication must seek medical attention immediately. Complications that may arise in ARS are illustrated in the table below. They may occur regardless of whether or not antibiotics have already been prescribed by your doctor.
Warning symptoms of complicated ARS requiring immediate medical care
Swelling/redness surrounding the eyes
Eye pushed down or out
Double vision, new or suddenly worse visual impairment
Reduced conscious level, or inability to respond when roused
A tender lump/swelling on the forehead
Recurrent acute rhinosinusitis refers to when an individual experiences four or more episodes in a single 12-month period. It is not quite as common as you might expect, and there are many conditions that can mimic rhinosinusitis such as migraine and tension-type headaches. Additionally, recurrent ARS may actually be a sign of chronic rhinosinusitis and represent a flare-up in symptoms on a background of chronic inflammation. If you think you are suffering from recurrent ARS that is interfering with your quality of life significantly, you should discuss your symptoms with your doctor.
Frequently asked questions
Why won’t my GP give me antibiotics for my sinusitis as I need to get back to work quickly?
Antibiotics are powerful instruments to fight diseases caused by bacterial infections. Most cases of rhinosinusitis are caused by viral infections. Randomized, controlled trials did not show any benefits from the use of antibiotics in patients suffering from viral rhinosinusitis (‘common cold’). On the other hand, antibiotics can
cause several side effects that have to be considered. Only in the few cases of diagnosed, severe, acute bacterial rhinosinusitis or chronic rhinosinusitis, is the use of antibiotics can be indicated.
Is there anything I can do to help my acute sinusitis except take antibiotics?
Yes, several medications apart from antibiotics are available for the (symptomatic) treatment of acute rhinosinusitis. Treatment options comprise nasal saline irrigations, NSAIDS, paracetamol, decongestants, local steroids, etc. If you have any concerns they should be discussed with your doctor or pharmacist.
Is there anything I can do to reduce the risk of side effects from antibiotics?
The best way to avoid the risks of antibiotics is to avoid unnecessary usage.
For the treatment of acute and chronic rhinosinusitis, a broad range of medications apart from antibiotics are available. Treatment options comprise nasal saline irrigations, NSAIDS, paracetamol, decongestants, steroids, etc.. Treatment strategies should be optimized by consultation with your doctor or pharmacist.
Always follow the written instructions provided on how to take your medicines – some antibiotics should be taken with water (and no food or dairy products), while others should be taken with meals
to reduce the risk of tummy upset and some react with alcohol. Take them at regular intervals if possible and complete the course prescribed. Some antibiotics react strongly with alcohol (especially metronidazole). There is some evidence that taking a probiotic can reduce the risk of antibiotic-associated diarrhoea.
If you develop a rash, severe diarrhoea, vaginal itching or white spots on the tongue, please contact your doctor. If you develop any swelling of the lips or tongue, or difficulty breathing please seek emergency medical care.
When should I be worried about a sinus infection not settling down?
A viral sinus infection may be transitioning to bacterial sinus infection when the sinus symptoms have lasted for longer than 10 days, there is severe local facial pain (usually one-sided), and/or a so-called “double sickening” (when symptoms are improving and then suddenly worsen again) occurs.
Signs that a bacterial sinus infection may be becoming severe and require urgent medical attention include swelling/redness surrounding the eyes, change in vision (for example decreased, blurry or double vision), severe headache, sensitivity to light or sound, neck stiffness, confusion or change in consciousness. In these cases, one should consult a physician immediately.
I needed surgery for an abscess in my eye – could this have been prevented if I had antibiotics earlier?
No. Studies suggest early oral antibiotics do not prevent the development of complications. Although complications of sinusitis are rare, they often occur quickly, both in people who have and have not been given antibiotics