Sinusitis

Inflammation of paranasal sinus mucosa, acute (<4 weeks, usually viral, occasionally secondary bacterial), subacute (4-12 weeks), chronic (>12 weeks, often multifactorial; allergy, structural, biofilm, polyps).

Nasal congestion/obstruction, purulent nasal discharge/postnasal drip, facial pain/pressure (worse bending forward), hyposmia/anosmia, headache. Viral (most acute cases): improves within 7-10 days.

Bacterial superinfection suggestive features: symptoms >10 days without improvement, or biphasic worsening after initial improvement ("double sickening"), high fever with purulent discharge/facial pain for ≥3-4 consecutive days at onset.

Red flags (orbital/intracranial complication; urgent): periorbital swelling/erythema, visual disturbance/reduced acuity, ophthalmoplegia, severe frontal headache with meningism, altered consciousness, frontal swelling ("Pott's puffy tumor").

Clinical for acute uncomplicated. Nasal endoscopy: chronic sinusitis assessment.

CT sinuses: chronic/recurrent disease, pre-surgical planning, or complication suspected. Allergy testing: chronic sinusitis with suspected allergic component.

Urgent CT/MRI + ophthalmology/ENT if orbital/intracranial complication suspected.

Differentials: allergic rhinitis, dental infection (referred), migraine/tension headache, temporal arteritis (older patients), nasal polyps, malignancy (unilateral symptoms, bleeding; red flag).

Acute (mostly viral):

• Symptomatic: analgesia, saline irrigation, intranasal corticosteroid (reduces symptom duration/severity even in viral disease), short-course topical decongestant (≤5-7 days, rebound congestion risk beyond this)

• Antibiotics NOT routinely indicated; most acute sinusitis is viral; consider if bacterial features (above) present and symptoms severe/persistent beyond 10 days: amoxicillin 500mg tds × 5-7 days, or co-amoxiclav if recent antibiotic failure

Chronic (>12 weeks):

• Intranasal corticosteroid, mainstay, long-term

• Saline irrigation, high-volume, regular use, good evidence

• Address underlying allergy if contributing

• Short course oral corticosteroid: severe symptoms/polyps, short courses only

• Chronic sinusitis with nasal polyps: consider biologics (dupilumab) for severe refractory disease with type 2 inflammation

• Endoscopic sinus surgery: refractory to medical management, anatomical obstruction, recurrent acute episodes

Orbital/intracranial complications (EMERGENCY): admission, IV antibiotics, urgent ENT/ophthalmology, imaging, surgical drainage if abscess

Referral: ENT for chronic/recurrent sinusitis refractory to medical therapy, nasal polyps, suspected complications (emergency), diagnostic uncertainty.