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Acute Sinusitis

(For adults and children aged 12 years and over)
Exclude: immunosuppressed, chronic sinusitis (>12 weeks), pregnant individuals under 16 years.
Acute sinusitis is usually caused by a virus and is only complicated by bacterial infection in about 2 in 100 cases.

Consider the risk of deterioration, red flags or serious illness:
  • Intraorbital/periorbital complications: orbital cellulitis, displaced eyeball, reduced vision
  • Intracranial complications: swelling over the frontal bone
  • Signs of meningitis: severe frontal headache, or focal neurological signs
Gateway Point
Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999.
Diagnose acute sinusitis by the presence of ONE or more of:
  • Nasal blockage (obstruction/congestion) OR nasal discharge
WITH ONE or more of:
  • Facial pain/pressure (or headache) OR
  • Reduction (or loss) of the sense of smell (in adults) OR
  • Cough during the day or at night (in children)
Acute sinusitis less likely.

Consider alternative diagnosis and proceed appropriately.
Gateway Point
Has the patient had symptoms for ≤ 10 days?
Self-care and regular pain relief
• Antibiotic is not needed
• Sinusitis usually lasts 2-3 weeks
• Manage symptoms with self-care
• Safety netting advice
Has the patient had symptoms for > 10 days with no improvement?
Does the patient have 2 or more of the following symptoms to suggest acute bacterial sinusitis?
  • Marked deterioration after an initial milder phase
  • Fever (>38°C)
  • Unremitting purulent nasal discharge
  • Severe localised unilateral pain, particularly over teeth/jaw
Self care and pain relief
• Acute sinusitis is usually viral.
• Antibiotics make little difference.

Ask patient to return to Pharmacy if symptoms do not improve in 7 days.
Shared decision making approach based on severity of symptoms.
Offer high dose nasal corticosteroid (off-label) for 14 days (subject to inclusion/exclusion criteria in PGD) plus self care and pain relief instead of antibiotics first line.
or if unsuitable/ineffective
Offer phenoxymethylpenicillin (if no allergy) for 5 days plus self care.
Reported penicillin allergy?
Offer clarithromycin OR doxycycline for 5 days plus self care.
If pregnant
Offer erythromycin for 5 days plus self care.
FOR ALL PATIENTS: If symptoms worsen rapidly or significantly at any time, OR do not improve after completion of treatment course -> Onward referral.
FOR ALL PATIENTS: share self-care and safety-netting advice using TARGET Respiratory Tract Infection leaflets.