Clinical Presentation
Targeted history and physical exam are both beneficial and cost-effective during initial diagnosis. Acute viral, non-infectious, and allergic rhinosinusitis must be ruled out to prevent inappropriate antibiotic treatment. Most guidelines diagnose acute bacterial rhinosinusitis based on clinical presentation. The gold standard for acute bacterial rhinosinusitis diagnosis is ≥10⁴ CFU/mL of bacteria from the paranasal sinus cavity.
Signs and symptoms of acute bacterial rhinosinusitis may be non-specific and typically difficult to differentiate from viral URTI. There may be nasal obstruction or congestion, anterior and/or posterior purulent drainage, facial pressure/pain/fullness, and reduction or loss of smell. Other signs and symptoms include fever, fatigue, headache, ear pressure or discomfort, throat pain, halitosis, maxillary dental pain, facial swelling or periorbital edema, and cough. Eustachian tube dysfunction (eg ear pain, fullness or pressure, hearing loss, tinnitus) may also be present.
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Persistent symptoms are moderately sensitive but non-specific predictors of acute bacterial rhinosinusitis. Pay particular attention to speech, which may indicate fullness of the sinuses. It is also important to include questions on allergic symptoms.
Rhinosinusitis - Acute, Bacterial_Initial Assesment
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Examine the face for periorbital edema, other facial swelling, and erythema. Percussion or direct pressure over the frontal and maxillary sinuses may produce unilateral pain. Anterior rhinoscopy can be used for patients with suspected acute rhinosinusitis in the primary care setting. This may reveal inflammation, mucosal edema, purulent discharge, and incidental findings of polyps, tumors, foreign bodies, and other anatomical abnormalities (eg deviated septum). Examination of the oropharynx should be done for postnasal discharge. Tapping of the maxillary teeth with a tongue depressor can be used to test for tenderness. Patients with symptoms involving the ears should undergo an ear examination to evaluate for associated eustachian tube dysfunction and/or middle ear pathology (eg otitis media).
Diagnosis or Diagnostic Criteria
According to the 2020 European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), diagnosis should be made based on at least three of five criteria:
- Fever (>38°C)
- Presence of severe local pain
- With discolored discharge and purulent nasal secretion (nasal cavity)
- Increased erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP)
- Patients become worse after initial recovery or deterioration of signs and symptoms ("double-worsening")
A presumptive diagnosis of acute bacterial rhinosinusitis can also be made if the patient presents with any of the following: Persistent illness, if there is the presence of >10 days nasal discharge or daytime cough not relieved by medications; worsening course, if there is worsening of previously resolved or new-onset nasal discharge, daytime cough, headache or pyrexia; and severe onset of the disease, if there is fever ≥39°C with purulent nasal discharge or facial pain of ≥3 days duration.