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Key Features

Essentials of Diagnosis

  • Upper respiratory infection symptoms are present 10 or more days beyond onset, or symptoms worsen within 10 days after an initial period of improvement

  • Symptoms may include nasal congestion, nasal drainage, postnasal drainage, facial pain, headache, and fever

  • Symptoms resolve completely within 30 days

General Considerations

  • Almost always preceded by a cold

  • Other predisposing conditions include allergies and trauma

  • Maxillary and ethmoid sinuses are most commonly involved

  • Viral upper respiratory infections may cause sinus mucosal injury and swelling, resulting in sinus outflow obstruction, loss of ciliary activity, and mucous hypersecretion

  • Common causative bacterial pathogens

    • Steptococcus pneumoniae

    • Haemophilus influenzae (nontypeable)

    • Moraxella catarrhalis

    • β-hemolytic streptococci

Clinical Findings

  • Onset may be gradual or sudden

  • Nasal drainage, nasal congestion

  • Facial pressure or pain

  • Postnasal drainage

  • Hyposmia or anosmia

  • Fever, cough, fatigue

  • Maxillary dental pain

  • Ear pressure or fullness


  • In complicated or immunocompromised patients, sinus aspiration and culture by an otolaryngologist should be considered for diagnostic purposes and to facilitate culture-directed antibiotic therapy

  • Gram stain or culture of nasal discharge does not necessarily correlate with cultures of sinus aspirates

  • If the patient is hospitalized because of rhinosinusitis-related complications, blood cultures should also be obtained


  • For children with cold symptoms that are not improving by 10 days, observation for up to 3 more days or antibiotic therapy may be chosen, depending on individual circumstances, such as ability to follow up and treat with antibiotics if needed

  • For children with uncomplicated infection who have worsening or severe symptoms (fever of at least 39°C and purulent nasal drainage for at least 3 consecutive days), antibiotic therapy is recommended

    • First-line antibiotic therapy should be amoxicillin or amoxicillin-clavulanate

    • Cefuroxime, cefpodoxime, and cefdinir are recommended for patients with a non–type I hypersensitivity to penicillin

    • Other agents that may be used, particularly in more severe cases where resistant S pneumoniae and H influenzae are suspected, include clindamycin, linezolid, and quinolone

    • Due to high resistance of S pneumoniae and H influenzae, the use of trimethoprim-sulfamethoxazole and azithromycin is not advised

  • Duration of therapy: 7 days after symptoms have resolved

  • Second-line therapies

    • Should be initiated when there is no improvement after 48–72 hours of antibiotic therapy

    • If the patient is already taking amoxicillin–clavulanate or a cephalosporin, intravenous antibiotic therapy should be considered

  • For patients who have evidence of invasive infection or CNS complications,

    • Intravenous therapy with nafcillin or clindamycin plus a third-generation cephalosporin such as cefotaxime should be initiated until culture results become available



  • Complications occur when infection spreads to adjacent structures, such as the eye and the brain

  • Orbital complications are the most common, arising from the ethmoid sinuses

  • Most common complication of frontal sinusitis ...

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