SPECIAL TOPICS IN OTOLARYNGOLOGY

Acute rhinosinusitis: New guidelines for

diagnosis and treatment
Jennifer Teeters, ATC; Michelle Boles; Julie Ethier; Ambria Jenkins;
L. Gail Curtis, PA-C, MPAS

ABSTRACT
New treatment guidelines for acute rhinosinusitis outline
when antibiotic therapy is appropriate, as well as describe
evidence-based treatment to relieve symptoms, prevent
complications, and prevent chronic disease.
Keywords: acute rhinosinusitis, inflammation, IDSA, antibiotics, bacterial

cute rhinosinusitis continues to be one of the most

common conditions treated by primary care providers. In adults 18 years or older, almost 13% were
given a diagnosis of rhinosinusitis within 12 months.1 More
than one in five antibiotics prescribed in adults are for acute
rhinosinusitis.2 This condition can have many causes, from
allergens and environmental irritants to bacteria, fungi,
and viral infection, with the latter being the most common
cause of acute rhinosinusitis.3 Most cases are preceded by a
viral upper respiratory infection (URI). The prevalence in
young children is two to seven episodes per year and two
to three episodes per year in adults.3-5 Viral causes account
for 90% to 98% of cases; bacterial infection accounts
for 2% to 10%.3 Secondary bacterial infection occurs in
0.5% to 2.0% of adult cases and about 5% of cases in
children.2-5 Lack of sensitive and specific diagnostic testing
means that clinicians must be able to accurately diagnose
acute rhinosinusitis and, if bacterial infection is suspected,
initiate appropriate antimicrobial therapy.
PATHOGENESIS
Acute rhinosinusitis is defined as inflammation of the lining
of the nasal mucosa and paranasal sinuses. The paranasal
sinuses include the paired maxillary, frontal, ethmoid, and
Jennifer Teeters, Michelle Boles, Julie Ethier, and Ambria Jenkins
are graduates of the PA program at Wake Forest School of Medicine,
Winston-Salem, North Carolina. L. Gail Curtis is an associate professor
and vice chair of the department of physician assistant studies at Wake
Forest School of Medicine. The authors have indicated no relationships
to disclose relating to the content of this article.
Roy A. Borchardt, PA-C, PhD, department editor.
DOI: 10.1097/01.JAA.0000431519.28443.5e
Copyright 2013 American Academy of Physician Assistants

JAAPA Journal of the American Academy of Physician Assistants

Key points
Clinical diagnosis is the most commonly used and costeffective approach to distinguish between viral and
bacterial rhinosinusitis.
2012 guidelines from the IDSA provide current evidencebased recommendations for treatment of rhinosinusitis.
Empiric antibiotic therapy should be reserved for patients
with symptoms of acute bacterial rhinosinusitis that have
persisted for more than 10 days or been severe for more
than 3 days.
The IDSA guidelines are based on data showing increased
resistance to previously accepted antimicrobial therapy
as well as an increase in the incidence of Haemophilus
influenzae and Moraxella catarrhalis as causative
pathogens of acute bacterial rhinosinusitis.

the sphenoid sinuses. These sinuses are lined with ciliated

epithelium that contain mucus-producing goblet cells.6 A
viral infection causes inflammation of this epithelium and
increased mucus production, which results in impaired
mucociliary clearance.6 The cessation of mucus clearance
causes obstruction of the sinuses, making it a suitable
environment for the growth of bacteria. This entire process
typically takes 7 to 10 days.
CLINICAL PRESENTATION AND DIAGNOSIS
The healthcare provider should know not only the signs
and symptoms of acute rhinosinusitis but also how to
distinguish a viral from a bacterial cause. According to
2012 guidelines from the Infectious Diseases Society of
America (IDSA), clinical presentation criteria include duration of symptoms, typical clinical course, nasal discharge
quality and additional symptoms.3 Typical clinical course
of a viral infection includes symptoms of nasal discharge,
congestion with cough, and often a sore throat.3 The nasal
discharge is most often clear at first and becomes thicker
and purulent after a few days. A distinguishing sign of
an uncomplicated viral URI is the return of the nasal
discharge to a clear watery consistency without the use of
antimicrobial therapy. Additional symptoms characteristic
of a viral URI include headaches and myalgias. Patients
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SPECIAL TOPICS IN OTOLARYNGOLOGY

may also develop fever early in the illness.3 Respiratory

symptoms of an uncomplicated viral URI will usually last
between 5 and 10 days.3
One way to distinguish an uncomplicated viral upper
respiratory infection from acute bacterial rhinosinusitis
is by noting the typical clinical pattern of acute bacterial
rhinosinusitis3:
persistent symptoms lasting more than 10 days with no
evidence of improvement
onset with severe symptoms, including fever of 39 C
(102 F) or higher or purulent nasal discharge at onset
a double-sickening pattern, which includes new-onset
fever, headache or increase in rhinorrhea that worsen or
return after a 5- to 6-day viral presentation which was
initially improving.

Because of high rates

of resistance among
Streptococcus pneumoniae,
macrolides, trimethoprimsulfamethoxazole, or
third-generation cephalosporins
are not recommended for
empiric therapy.
The classic presentation of acute bacterial rhinosinusitis
in adults is characterized by a triad of symptoms including headache, facial pain, and fever. The most commonly
reported symptoms include nasal congestion, purulent rhinorrhea, and facial pain or pressure.5 In children, the most
common symptoms include cough with nasal discharge,
fever, and malodorous breath.3
The diagnosis of acute rhinosinusitis is primarily based
on clinical presentation. The conventional criteria for the
clinical diagnosis of acute bacterial rhinosinusitis involves
the presence of at least two major symptoms (such as
purulent discharge and facial pain) or one major and two
minor symptoms (such as headache and dental pain); for
details, see the 2012 IDSA guidelines.3 The most accurate
diagnostic approach is acquiring a quality history of disease
pattern and progression and performing an appropriate
physical examination.3
TREATMENT FOR RHINOSINUSITIS
The clinical picture will dictate the course of treatment.
The primary objectives for acute viral rhinosinusitis are
to relieve symptoms of nasal obstruction and rhinorrhea;
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treatment for acute bacterial rhinosinusitis includes antibiotics to eradicate the infection, prevent complications,
and prevent chronic disease.6
Nonpharmacologic therapy Most healthcare providers
will recommend nonpharmacologic treatments such as
increased fluid intake, rest, and good personal hygiene.
Water is the recommended fluid for avoiding dehydration
and keeping mucous membranes moist, with increased
intake requirements for illness. An adequate amount of rest
provides time to fight off infection and is important for a
prompt recovery. Proper hand washing techniques reduce
the spread of virus and bacteria that cause rhinosinusitis
and other illnesses.7
Ancillary therapy Common ancillary therapies include
saline nasal spray, mucolytic agents, antipyretics/analgesics, decongestants, and antihistamines, but not all are
favored by the IDSA guidelines. Saline spray can be used
to irrigate the nasal cavity to soften secretions and improve
mucociliary clearance.8 The IDSA guidelines recommend
the use of nasal saline spray as an adjunctive treatment for
rhinosinusitis in adults with low to moderate symptoms.3
The most common mucolytic agent is guaifenesin, which is
used to thin mucus secretions and improve drainage.6 No
clinical trials validate the use of guaifenesin, so the IDSA
guidelines do not recommend it as adjunctive therapy for
acute rhinosinusitis.3 Analgesics are used to relieve pain, and
help patients to rest. Acetaminophen or an NSAID may be
used for mild to moderate pain.8 Acetaminophen is also an
effective antipyretic. Oral or topical decongestants and/or
antihistamines are not recommended as adjunctive treatment in patients with acute bacterial rhinosinusitis because
of their adverse effects in adults and children.3 Topical
decongestants may induce inflammation and rebound
congestion.6 Oral antihistamines may cause drowsiness
and xerostomia.6 The FDA recommends that these drugs,
found in OTC products, not be given to children younger
than 2 years because of their potentially serious adverse
reactions.3
Antibacterial therapy According to the IDSA guidelines, antibacterial therapy should be initiated as soon as
the diagnosis of acute bacterial rhinosinusitis has been
established. The recommended first-line drug for both
children and adults is amoxicillin-clavulanate.3 Acute
bacterial rhinosinusitis caused by Haemophilus influenzae and Moraxella catarrhalis has increased in children;
and amoxicillin-clavulanate offers greater coverage of
ampicillin-resistant strains of these bacteria. Doxycycline
may be used as an alternative for empiric therapy for
patients who cannot tolerate amoxicillin-clavulanate. In
patients with a penicillin allergy, the recommendations
include doxycycline or a respiratory fluoroquinolone such
as levofloxacin or moxifloxacin. Because of high rates of
resistance among Streptococcus pneumoniae, macrolides,
trimethoprim-sulfamethoxazole, or third-generation
cephalosporins are not recommended for empiric therapy.
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Acute rhinosinusitis: New guidelines for diagnosis and treatment

Acute bacterial rhinosinusitis

is a common complication
of acute viral rhinosinusitis,
so differentiating between
viral and bacterial causes is
imperative to determining
proper management.
The IDSA guidelines list potential causative agents for
acute bacterial rhinosinusitis in Table 6; first-line and
second-line antimicrobial therapies are listed in Table
10.3 Treatment duration recommendations include 5 to
7 days for adults and 10 to 14 days for children, based
on symptomatic improvement. Figure 1 in the IDSA
guidelines is an algorithm for management.
CONCLUSION
Clinicians must treat acute bacterial rhinosinusitis with
the appropriate antimicrobial therapy and understand
how to manage patients who fail to respond to this therapy. Consider an alternate plan if the patients symptoms
worsen after a 2- to 3-day trial of antibiotics or if there
is no response after 3 to 5 days. The antimicrobial agent
needs to be reevaluated and consideration must be given to
noninfectious causes. Further workup should be initiated,

such as endoscopic evaluation of the sinuses with direct

sinus aspiration for culture.
Acute bacterial rhinosinusitis is a common complication
of acute viral rhinosinusitis, so differentiating between
viral and bacterial causes is imperative to determining
proper management. The IDSAs minor and major clinical
symptoms serve as strong indicators to assist clinicians with
diagnosis. When the clinical picture suggests a bacterial
cause, current evidence-based recommendations are for use
of amoxicillin-clavulanate as first-line empiric treatment.
Healthcare providers should familiarize themselves with
the 2012 IDSA guidelines and use appropriate prescribing
criteria to prevent antimicrobial resistance and further
complications. JAAPA
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for U.S. adults: national health interview survey, 2010. National
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suppl):S1-S31.
3. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice
guideline for acute bacterial rhinosinusitis in children and adults.
Clin Infect Dis. 2012;54(8):e72-e112.
4. Revai K, Dobbs LA, Nair S, et al. Incidence of acute otitis media
and sinusitis complicating upper respiratory tract infection: the
effect of age. Pediatrics. 2007;119(6):e1408-e1412.
5. Meltzer E, Hamilos D. Rhinosinusitis Diagnosis and management for the clinician: a synopsis of recent consensus guidelines.
Mayo Clin Proc. 2011;86(5):427-443.
6. Masood A, Moumoulidis I, Panesar J. Acute rhinosinusitis in
adults: an update on current management. Postgrad Med J.
2007;83(980):402-408.
7. Fashner J, Ericson K, Werner S. Treatment of the common cold
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Physician. 2011;83(9):1057-1063.

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