Acute Sinusitis Guidelines

Updated: Aug 14, 2023
  • Author: Itzhak Brook, MD, MSc; Chief Editor: Michael Stuart Bronze, MD  more...
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Guidelines Summary

The guidelines by the American Academy of Otolaryngology--Head and Neck Surgery Foundation recommend watchful waiting for initial management of all patients with uncomplicated acute bacterial rhinosinusitis, regardless of severity, [34] and not just for those with "mild" illness. [33]  The preferred agent when antibiotics are prescribed is amoxicillin with or without clavulanate, [34]  whereas the previous guideline called for amoxicillin alone. [33]

Other recommendations include the following [34] :

  • Clinicians should not obtain radiographic imaging in patients who meet diagnostic criteria for acute rhinosinusitis, unless a complication or alternative diagnosis is suspected.
  • Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis or acute bacterial rhinosinusitis (ABRS).
  • If the patient fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management, the clinician should reassess the patient to confirm ABRS, to exclude other causes of illness, and to detect complications. If ABRS is confirmed in a patient who was initially managed with observation, the clinician should begin antibiotic therapy. If the patient was initially managed with an antibiotic, the clinician should change the antibiotic.

The United Kingdom National Institute for Health and Care Excellence (NICE) issued guidance on acute sinusitis that recommends: 

  • A high-dose nasal corticosteroid could be considered for adults and children aged 12 years and over presenting with prolonged symptoms of acute sinusitis.
  • An antibiotic prescription should not be offered to people presenting with acute sinusitis symptoms for around 10 days or less. Back-up antibiotic prescription could be used if symptoms worsen rapidly or significantly, or do not improve within the next 7 days.
  • A narrow-spectrum antibiotic phenoxymethylpenicillin as the first choice.
  • Co-amoxiclav as the first-choice antibiotic for 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.
  • Doxycycline or clarithromycin (or erythromycin in pregnancy), can be used as an lternative first-choice antibiotics for use in penicillin allergy or phenoxymethylpenicillin intolerance.