Point-of-Care Guides

Clinical Diagnosis of Acute Bacterial Rhinosinusitis


Am Fam Physician. 2020 Jun 15;101(12):758-759.

Author disclosure: No relevant financial affiliations.

Clinical Question

Which patients presenting with symptoms of acute rhinosinusitis have acute bacterial rhinosinusitis?

Evidence Summary

Acute rhinosinusitis in adults is defined as sinonasal inflammation that lasts less than four weeks and is associated with the sudden onset of symptoms.1 In the 2012 National Health Interview Survey, 12% of respondents reported being diagnosed with rhinosinusitis in the previous 12 months.2 In 2016, there were 8 million U.S. ambulatory visits for acute sinusitis.3 Acute bacterial rhinosinusitis develops in only 0.5% to 2% of all upper respiratory tract infections.4

A 2018 Cochrane review demonstrated that the potential benefit of antibiotics for the treatment of acute rhinosinusitis, diagnosed clinically or confirmed with imaging, is marginal.5 Without antibiotics, rhinosinusitis resolved in 46% of patients after one week and in 64% of patients after 14 days.5 Antibiotics can shorten time to resolution but in only five to 11 more people per 100 compared with placebo or no treatment.5 Despite this, approximately 86% of U.S. ambulatory visits for acute rhinosinusitis result in oral antibiotic prescriptions.1 In Europe, antibiotic prescription rates for acute rhinosinusitis in primary care range from 72% to 92%.6

There is no consensus on the diagnostic criteria for acute bacterial rhinosinusitis. A 2007 European position paper states that acute bacterial rhinosinusitis should be suspected with the presence of at least three of the following symptoms or signs: discolored discharge with unilateral predominance and purulent secretion in the nasal cavity, severe local pain with unilateral predominance, fever greater than 100.4°F (38°C), elevated erythrocyte sedimentation rate or C-reactive protein (CRP) level, and double sickening (i.e., deterioration after an initial milder phase of illness).7

The American Academy of Otolaryngology–Head and Neck Surgery recommends diagnosing acute bacterial rhinosinusitis when symptoms or signs of acute rhinosinusitis (purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both) persist without evidence of improvement for at least 10 days after the onset of symptoms, or when symptoms or signs of acute rhinosinusitis worsen within 10 days of initial improvement or milder phase of illness (double sickening).8 However, a 2016 international consensus statement on rhinosinusitis concluded that symptoms such as purulent nasal discharge, fever, or facial pain alone cannot distinguish between viral and bacterial infection and that further studies are needed.1

In 2017, a clinical prediction rule (Table 1) was created for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis using 175 adult Danish patients in whom acute maxillary sinusitis was clinically suspected.9 CRP and erythrocyte sedimentation rate were measured and computed tomography of the sinuses was performed; antral puncture was also performed if computed tomography showed mucosal thickening or fluid. If a culture of antral fluid was positive for bacteria, the patient was deemed to have acute bacterial rhinosinusitis (about one-third of all patients). Of those with a low risk based on the clinical prediction rule (score of −1 to 3 points), 16% had acute bacterial rhinosinusitis, whereas of those with moderate risk (4 to 6 points) or high risk (7 to 8 points), 49% and 73% had acute bacterial rhinosinusitis, respectively.9 About one-third of patients with acute rhinosinusitis have a bacterial cause.10

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Clinical Prediction Rule for the Diagnosis of Acute Bacterial Rhinosinusitis

Clinical findingPoints

C-reactive protein > 1.5 mg per dL (15 mg per L)


Maxillary toothache


Tender maxillary sinus (unilateral)


Purulent nasal discharge


Preceding respiratory tract infection


History of

Address correspondence to Alan Barry, MB, BCh, BAO, at alanbarry@rcsi.com. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Orlandi RR, Kingdom TT, Hwang PH. International consensus statement on allergy and rhinology: rhinosinusitis executive summary. Int Forum Allergy Rhinol. 2016;(6 suppl 1):S3–S21....

2. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. Vital Health Stat. 2014;(260):1–161.

3. National Center for Health Statistics. National Ambulatory Medical Care Survey: 2016 national summary tables. Accessed October 17, 2019. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf

4. Desrosiers M, Evans GA, Keith PK, et al. Canadian clinical practice guidelines for acute and chronic rhinosinusitis. Allergy Asthma Clin Immunol. 2011;7(1):1–38.

5. Lemiengre MB, van Driel ML, Merenstein D, et al. Antibiotics for acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2018;(9):CD006089.

6. Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis. Lancet. 2008;371(9616):908–914.

7. Fokkens WJ, Lund V, Mullol J. European position paper on rhinosinusitis and nasal polyps 2007. Rhinol Suppl. 2007;20:1–136.

8. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update). Otolaryngol Head Neck Surg. 2015;152(2 suppl):S1–S39.

9. Ebell MH, Hansen JG. Proposed clinical decision rules to diagnose acute rhinosinusitis among adults in primary care. Ann Fam Med. 2017;15(4):347–354. Accessed May 5, 2020. https://www.annfammed.org/content/15/4/347.full

10. Dale AP, Marchello C, Ebell MH. Clinical gestalt to diagnose pneumonia, sinusitis, and pharyngitis. Br J Gen Pract. 2019;69(684):e444–e453.

11. Ebell MH, McKay B, Dale A, et al. Accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis. Ann Fam Med. 2019;17(2):164–172. Accessed May 5, 2020. https://www.annfammed.org/content/17/2/164.full

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision-making at the point of care.

This series is coordinated by Mark H. Ebell, MD, MS, deputy editor for evidence-based medicine.

A collection of Point-of-Care Guides published in AFP is available at https://www.aafp.org/afp/poc.



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