AKT · ENT/Nose & sinuses

Acute rhinosinusitis

Inflammation of the nasal mucosa and paranasal sinuses (usually viral)

Overview

Symptomatic inflammation of the nose and paranasal sinuses, usually following a viral URTI; only a small minority become bacterial. Nasal blockage/discharge with facial pain/pressure. Mostly self-limiting — antibiotics are rarely needed, and the job is to spot the rare orbital/intracranial complication.

Recognise

Nasal blockage/congestion + discharge (anterior or postnasal) + facial pain/pressure ± reduced smell, <12 weeks
Most are viral (cold) and peak then improve by ~10 days
A "double-sickening" pattern (initial improvement then worsening with fever and purulent discharge) suggests bacterial superinfection

Red flags

Periorbital swelling/erythema, proptosis, painful/restricted eye movements or visual change → ORBITAL CELLULITIS; severe frontal headache, swelling, or neurology → intracranial spread — emergency

Differentials & how to tell them apart

Allergic rhinitisitch, sneezing, clear rhinorrhoea, seasonal/allergen-triggered, no facial pain/fever

Orbital cellulitisthe emergency complication — eye swelling, proptosis, painful eye movements

Dental abscess (maxillary)unilateral upper-tooth pain

Nasal polyps / chronic rhinosinusitissymptoms ≥12 weeks

Investigations

Clinical. No imaging in uncomplicated disease. Complications (orbital/intracranial) → urgent CT + admission.

Management

Symptomatic care; intranasal steroid if ≥10 days; antibiotics rarely

1Reassure and treat symptomatically (analgesia, saline, decongestant) — most resolve within 2–3 weeks. If symptoms persist ≥10 days, consider an intranasal corticosteroid.Gate: Reserve ANTIBIOTICS for the systemically very unwell or clear bacterial deterioration ("double sickening") — most acute rhinosinusitis is viral; and any ORBITAL or intracranial sign is an emergency, not a prescription
2Marked bacterial features → phenoxymethylpenicillin; orbital/intracranial complications → urgent CT, admission, IV antibiotics, ENT/ophthalmology.

Analgesia + saline irrigation/decongestant — symptomatic; most cases

Intranasal corticosteroid — consider if symptoms ≥10 days (modest benefit)

Antibiotics (phenoxymethylpenicillin) — rarely — only if systemically very unwell or marked deterioration ("double sickening")

Key points

Mostly viral and self-limiting. The exam pivot is the orbital complication: eye swelling, proptosis or painful eye movements = orbital cellulitis → emergency.

Monitor & prognosis

Resolution by ~3 weeks; watch for complications.

Self-limiting; complications are rare but serious.

Source: NICE NG79 (sinusitis - acute); NICE CKS