Step 1 of 8
Presentation & Emergency Triage
The rhinosinusitis symptom picture, then the orbital / intracranial / bony / fungal red-flag screen that diverts to the complicated and invasive-fungal pathways
Rhinosinusitis presents with nasal symptoms (obstruction and congestion, anterior rhinorrhoea, postnasal drip and purulent discharge), facial symptoms (pain, pressure, fullness and dental pain) and associated symptoms (headache, cough, halitosis, fever, hyposmia or anosmia and fatigue). In children the picture skews to persistent daytime cough, nocturnal cough, halitosis, periorbital oedema and irritability.
Before any duration-based reasoning, the patient is screened for the complication red flags that define complicated rhinosinusitis. The orbital flags are proptosis, diplopia, ophthalmoplegia, visual loss, painful eye movement and marked periorbital oedema; the intracranial flags are severe headache, altered sensorium, meningism, a focal neurologic deficit, seizures and a toxic appearance; the bony flags are forehead swelling, frontal tenderness and a Pott's puffy tumour; and the fungal flags are diabetes, an immunocompromised state, a black nasal eschar, a cranial neuropathy and rapid progression. Any red flag diverts immediately to the complicated rhinosinusitis pathway — contrast CT, MRI where intracranial disease is suspected, admission, intravenous antibiotics and ENT consultation — with the fungal flags routing to the invasive fungal pathway. Only when the screen is negative does the patient proceed to routine evaluation. This triage is the chapter's principal safety step.
- Nasal — obstruction, anterior rhinorrhoea, postnasal drip, purulent discharge; facial — pain, pressure, fullness, dental pain
- Associated — headache, cough, halitosis, fever, hyposmia, fatigue; paediatric — daytime/nocturnal cough, halitosis, periorbital oedema, irritability
- Red flags — orbital (proptosis, ophthalmoplegia, visual loss), intracranial (altered sensorium, meningism, deficit, seizures), bony (Pott's puffy tumour), fungal (diabetes/immunocompromise, black eschar, cranial neuropathy)
- Any red flag → complicated pathway (contrast CT, admission, IV antibiotics); fungal flags → invasive fungal pathway
★ High-yield pearls (chapter-wide)
- The ten-day rule, double-worsening and severe-presentation criteria separate acute bacterial rhinosinusitis from the far commoner viral rhinosinusitis — under ten days and improving needs no antibiotic.
- Routine imaging is not recommended for uncomplicated ABRS — image only for complications, recurrent or unilateral disease, suspected neoplasm or suspected fungal disease.
- Orbital, intracranial, bony and fungal red flags define complicated rhinosinusitis — proptosis, ophthalmoplegia or visual loss, altered sensorium or meningism, a Pott's puffy tumour, or a black eschar in the immunocompromised patient warrants contrast CT, admission and intravenous therapy.
- Amoxicillin is first-line for standard-risk ABRS, with amoxicillin-clavulanate reserved for high-risk patients and the penicillin-allergic patient given doxycycline or a respiratory fluoroquinolone.
- Unilateral maxillary disease is odontogenic until proven otherwise — ask about recent extraction, root-canal treatment, implants and a foul odour, and assess the teeth and a CT.
- Persistent unilateral disease with epistaxis, facial numbness or orbital symptoms is a sinonasal neoplasm until endoscopy, imaging and biopsy prove otherwise.
- Invasive fungal rhinosinusitis is a debridement emergency — a diabetic or immunocompromised patient with a black eschar, facial numbness or ophthalmoplegia needs urgent biopsy, intravenous antifungal therapy and surgical debridement.
- Mild adult ABRS may be managed with seven days of watchful waiting and symptomatic care before any antibiotic, and routine systemic steroids are avoided.
- Reassess adults at seven days and children at seventy-two hours — treatment failure escalates to a change of antibiotic, then endoscopic middle-meatal culture or maxillary aspiration with culture-directed therapy.
- Symptoms beyond twelve weeks with two or more cardinal symptoms and objective endoscopic or CT inflammation define chronic rhinosinusitis — transition the patient to the CRS algorithm rather than re-treating as acute disease.
Evidence base
2 sources- HIGH
Rosenfeld RM, Piccirillo JF, Chandrasekhar SS · Otolaryngol Head Neck Surg · 2015Practice guidelinePMID 25832968
AAO-HNS clinical practice guideline on adult sinusitis, covering presentation, diagnosis and the viral-versus-bacterial distinction.
- MOD
Butler FM & Hernandez DR · Am Fam Physician · 2025ReviewPMID 39823615
Evidence review of acute rhinosinusitis covering the symptom picture and the complication warning signs.
Decision tree
A complication red flag exits to the complicated or invasive-fungal arm. The stable patient is classified by duration — under ten days and improving is viral and gets no antibiotic — and ABRS is managed by stewardship-led antibiotics, with unilateral, recurrent and failing disease branching to the special pathways and the chronic-rhinosinusitis transition.