Initial assessment
When a patient presents to the consultation with symptoms such as nasal obstruction, rhinorrhoea, facial pain or reduced sense of smell, this is one of the most frequent conditions in clinical practice. Acute rhinosinusitis is, in most cases, a self-limiting disease of viral aetiology, frequently associated with upper respiratory tract infections. Despite its usually benign nature, its high prevalence and the frequent inappropriate use of antibiotic therapy make its approach particularly relevant.
The first step is to ensure clinical safety by identifying signs of complication. The presence of proptosis, diplopia, pain on eye movement, reduced visual acuity, severe headache, meningeal signs, neurological deficits or altered level of consciousness should raise suspicion of extension of infection to orbital or intracranial structures. These situations constitute medical emergencies and require urgent hospital assessment, appropriate imaging and intravenous antibiotic therapy.
Viral rhinosinusitis
In the absence of severity signs, the next distinction is mainly based on the pattern of symptom evolution. Most episodes correspond to viral rhinosinusitis, characterised by a duration of less than ten days and spontaneous progressive improvement. In these cases, the approach should be essentially symptomatic.
Treatment includes nasal irrigation with saline solution, control of pain and fever with analgesics or antipyretics, limited use of topical nasal decongestants for short periods and, in selected situations, intranasal corticosteroids. Antibiotic therapy is not indicated, as it does not alter the natural course of the disease and contributes to antimicrobial resistance.
Probable bacterial rhinosinusitis
Suspicion of bacterial aetiology arises when the clinical pattern deviates from the typical viral course. Three scenarios are particularly suggestive: persistence of symptoms for more than ten days without improvement, worsening after an initial phase of recovery — the so-called “double sickening” phenomenon — and severe presentations characterised by high fever associated with intense facial pain for several consecutive days.
It is important to emphasise that the colour of nasal secretions alone does not distinguish between viral and bacterial infection, and clinical decision-making should be based on the temporal pattern and severity of symptoms.
Therapeutic decision
Even when criteria suggestive of probable bacterial rhinosinusitis are present, the approach should be individualised. In patients without severity signs and with the possibility of clinical follow-up, watchful waiting for 48 to 72 hours may be chosen, starting antibiotic therapy only if there is no improvement or if worsening occurs. This strategy reduces unnecessary antibiotic use without compromising patient safety.
When antibiotic therapy is indicated, first-line regimens appropriate to the clinical context should be used, generally for short courses of five to seven days. The addition of intranasal anti-inflammatory therapy may contribute to symptom control and faster resolution.
Clinical reassessment
Reassessment plays a central role throughout the entire process. Worsening at any time should prompt immediate reassessment. Lack of improvement after appropriate treatment should lead to reconsideration of the diagnosis, verification of treatment adherence and exclusion of complications or alternative diagnoses, such as dental disease, primary headache disorders or chronic inflammatory disease.
Clinical integration
In summary, the clinical approach to acute rhinosinusitis is based on a logical and progressive sequence: ensuring safety by excluding complications, distinguishing a self-limiting viral course from patterns suggestive of bacterial infection, instituting appropriate symptomatic treatment and using antibiotic therapy judiciously and individually. This strategy helps optimise symptom control, reduce unnecessary interventions and promote rational use of therapeutic resources.
