Management of acute sinusitis in primary care

People presenting with symptoms for around 10 days or less

• do not offer an antibiotic prescription.
• give advice about:
  • the usual course of acute sinusitis (2 to 3 weeks)
  • an antibiotic not being needed
  • managing symptoms, including fever, with self-care
  • seeking medical help if symptoms worsen rapidly or significantly, do not improve after 3 weeks, or they become systemically very unwell
• reassess if symptoms worsen rapidly or significantly, taking account of:
  • alternative diagnoses such as a dental infection
  • any symptoms or signs suggesting a more serious illness or condition (1)

People presenting with symptoms for around 10 days or more with no improvement

• consider prescribing a high-dose nasal corticosteroid for 14 days for adults and children aged 12 years and over, being aware that nasal corticosteroids:
  • may improve symptoms but are not likely to affect how long they last
  • could cause systemic effects, particularly in people already taking another corticosteroid
  • may be difficult for people to use correctly
• consider no antibiotic prescription or a back-up antibiotic prescription, taking account of:
  • evidence that antibiotics make little difference to how long symptoms last, or the proportion of people with improved symptoms
  • withholding antibiotics is unlikely to lead to complications
  • possible adverse effects, particularly diarrhoea and nausea
  • factors that might make a bacterial cause more likely
• when a back-up antibiotic prescription is given, give verbal and written advice about:
  • managing symptoms, including fever, with self-care
  • an antibiotic not being needed immediately
  • using the back-up prescription if symptoms do not improve within 7 days or if they worsen rapidly or significantly at any time
  • seeking medical help if symptoms worsen rapidly or significantly despite taking the antibiotic, or the antibiotic has been stopped because it was not tolerated.
• reassess if symptoms worsen rapidly or significantly despite taking treatment, taking account of:
  • alternative diagnoses such as a dental infection
  • any signs or symptoms suggesting a more serious illness or condition
  • previous antibiotic use, which may lead to resistant organisms (1)

People presenting at any time who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high risk of complications

• offer an immediate antibiotic prescription or further appropriate investigation and management
• if the patient is at high risk of serious complications because of pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or
  neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely (2)
  • if the patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria:
    • hospitalisation in previous year
    • type 1 or type 2 diabetes
    • history of congestive heart failure
    • current use of oral glucocorticoids
      
      
• refer people to hospital if they have symptoms and signs of acute sinusitis associated with any of the following:
  • a severe systemic infection
  • intraorbital or periorbital complications, including periorbital oedema or cellulitis, a displaced eyeball, double vision, ophthalmoplegia, or newly reduced visual acuity
  • intracranial complications, including swelling over the frontal bone, symptoms or signs of meningitis, severe frontal headache, or focal neurological signs.

Self-care

• consider paracetamol or ibuprofen for pain or fever
• explain that some people may wish to try nasal saline or nasal decongestants, although there is not enough evidence to show that they help to relieve nasal congestion.
• explain that no evidence was found for using oral decongestants, antihistamines, mucolytics, steam inhalation, or warm face packs

Reference:

1. National Institute for Health and Care Excellence (NICE) 2017. Sinusitis (acute): antimicrobial prescribing
2. NICE (July 2008). Respiratory tract infections (selflimiting): prescribing antibiotics