Background

Rhinosinusitis is an inflammatory process of the mucosal lining of nasal cavity and paranasal sinuses. The natural pathogenesis involves inflammation of sinus mucous membranes which disrupts mucociliary function, resulting in sinus obstruction. It is typically caused by viruses, bacterial infections, noninfectious allergies, and fungi.¹ It can be subdivided by chronicity with an acute phase lasting <4 weeks, subacute 4–12 weeks, chronic >12 weeks, and recurrent disease defined as >4 episodes in a given year.² Rhinosinusitis is one of the most common complaints in primary care and emergency medicine affecting ~1 in 7 adults, or about 31 million people per year. Rhinosinusitis is a common diagnosis, often leading to an antibiotic prescription in the United States.³ The overwhelming majorities of cases of rhinosinusitis are viral, and account for > 90% of acute infections. The most common viruses include rhinoviruses, adenoviruses, coronaviruses, influenza viruses, and parainfluenza viruses.⁴ Bacterial infections are much less common. The most common bacteria include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus.⁵ Clinical adjuncts such as blood work and imaging are not routinely advised on initial presentation and add little to the diagnostic work up.⁶ Differentiating viral from bacterial rhinosinusitis can be difficult, and the treatment decision continues to be made on clinical grounds.

Clinical question

Which clinical features are associated with acute bacterial rhinosinusitis in ambulatory ED patients?

A diagnosis of viral versus bacterial acute rhinosinusitis is typically made clinically. Rhinosinusitis is present when there is inflammation of the nose/paranasal sinuses with a combination of purulent nasal discharge, nasal obstruction, and/or facial pain or fullness.¹ Additional complaints are variable, and can include maxillary dental pain, headache, postnasal drip, cough (particularly in children), fever, sore throat, and halitosis. Unfortunately, there are no validated clinical decision rules to guide the diagnosis, and laboratory studies and imaging do not have sufficient specificity to justify routine usage. Clinicians should rely upon a combination of signs and symptoms to make the diagnosis.

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