Do I need antibiotics for sinusitis?

Usually not. The great majority of acute sinusitis is viral and settles on its own within two to three weeks. Reviews of the trial evidence show antibiotics shorten symptoms only marginally — around 15 to 18 people must be treated for one additional cure, while roughly one in eight suffers a side effect such as diarrhoea, rash or thrush. First-line treatment is an intranasal corticosteroid spray, saline nasal irrigation, simple analgesia and time. Antibiotics should be reserved for the specific patterns that suggest bacterial infection: symptoms persisting beyond ten days without any improvement; severe symptoms with a fever above 38-39°C and purulent discharge or facial pain for three to four days from the outset; or "double sickening", where the illness clearly improves and then distinctly worsens again.

Does green or yellow mucus mean I need antibiotics?

No — and this is one of the most persistent and consequential misconceptions in primary care. The green or yellow colour comes from myeloperoxidase, an enzyme released by neutrophils, and appears in ordinary viral colds just as readily as in bacterial infection. Coloured discharge on its own tells you nothing about whether bacteria are present or whether antibiotics will help. What matters is the pattern and duration of illness: persistence beyond ten days without improvement, severe illness with high fever from the start, or improvement followed by clear deterioration. Being told this explicitly, with an explanation of why, is one of the more effective ways of reducing unnecessary antibiotic prescribing.

When is sinusitis dangerous?

When infection spreads beyond the sinuses into the orbit or the cranial cavity — uncommon, but potentially blinding or fatal, and disproportionately affecting children and young adults. Warning signs around the eye: swelling of the eyelids that is progressing, redness, the eye being pushed forward (proptosis), pain on moving the eye, double vision, or any reduction in vision or colour perception. Warning signs of intracranial spread: severe or rapidly worsening headache, drowsiness or confusion, neck stiffness, vomiting, seizures, or any weakness or focal neurological sign. A soft, boggy swelling over the forehead (Pott's puffy tumour) indicates frontal bone osteomyelitis and underlying intracranial infection. All of these require immediate hospital assessment with contrast imaging and intravenous antibiotics — not another oral antibiotic prescription.

What is chronic sinusitis and how is it different?

Chronic rhinosinusitis means symptoms lasting more than twelve weeks — nasal blockage or discharge, plus facial pressure or loss of smell — with objective changes on nasal endoscopy or CT. Crucially, it is an inflammatory disease of the sinus lining rather than a persistent infection, which is why repeated antibiotic courses do not work and why the treatment is quite different. The mainstays are long-term daily intranasal corticosteroids and high-volume saline irrigation, which together control the great majority of cases. Patients with nasal polyps may need short courses of oral steroids. Those who fail optimised medical treatment are considered for endoscopic sinus surgery, which opens the natural drainage pathways and — importantly — improves the delivery of topical treatment afterwards, rather than replacing it. Severe recurrent polyp disease may now be treated with biologics such as dupilumab.

Why do I keep getting nasal polyps back after surgery?

Because polyps are the visible manifestation of an underlying type 2 inflammatory process, and surgery removes the polyps without switching off the inflammation. Recurrence is therefore expected unless topical corticosteroid therapy and saline irrigation are continued indefinitely after surgery — stopping them is the single commonest reason for early recurrence. Certain groups recur particularly aggressively: patients with coexisting asthma, and especially those with NSAID-exacerbated respiratory disease, the triad of nasal polyps, asthma and aspirin sensitivity. For these patients, options beyond repeated surgery include leukotriene receptor antagonists, aspirin desensitisation in selected cases, and the type 2 biologics — dupilumab, omalizumab and mepolizumab — which have substantially reduced both polyp burden and the need for further surgery in trials.

How does GMJ News cover sinusitis?

GMJ News covers EPOS 2020 definitions, the viral nature of most acute rhinosinusitis and antimicrobial stewardship implications, the double-sickening pattern versus the discharge-colour myth, orbital and intracranial complications requiring emergency imaging, chronic rhinosinusitis as inflammatory disease, phenotyping by polyp status, biologics for severe CRSwNP, NSAID-exacerbated respiratory disease, fungal rhinosinusitis including acute invasive disease in the immunocompromised, functional endoscopic sinus surgery, facial pain misattribution and migraine, and intranasal corticosteroid technique. Directly relevant to PHIG's antimicrobial stewardship and ENT programmes.

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Sinusitis

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Rhinosinusitis — symptomatic inflammation of the nasal cavity and paranasal sinuses — is among the most common reasons for antibiotic prescription worldwide, yet the overwhelming majority of acute cases are viral and self-limiting, with the European Position Paper on Rhinosinusitis (EPOS 2020) making clear that antibiotics offer minimal benefit in acute rhinosinusitis and that intranasal corticosteroids, saline irrigation and analgesia are the appropriate first-line management, making this one of the single largest opportunities for antimicrobial stewardship in primary care (WHO). Chronic rhinosinusitis (symptoms beyond 12 weeks) is a distinct inflammatory disease rather than a persistent infection, subdivided by the presence or absence of nasal polyps, and its management has been transformed by type 2 inflammation-targeted biologics — dupilumab, omalizumab and mepolizumab — for severe polyp disease; while the clinician's critical task in acute presentations remains recognising the rare but devastating orbital and intracranial complications, where periorbital swelling, proptosis, diplopia, visual change, severe headache or altered consciousness demand emergency imaging rather than another antibiotic prescription.

Key messages

Most acute rhinosinusitis is viral — antibiotics offer minimal benefit

Acute rhinosinusitis is overwhelmingly viral and self-limiting. EPOS 2020 and Cochrane evidence are clear: antibiotics produce only a marginal improvement in symptom resolution, with a number needed to treat of around 15-18 for cure at 7-14 days, against a number needed to harm of around 8 for adverse effects. Given the sheer volume of sinusitis consultations globally, this is one of the largest single opportunities for antimicrobial stewardship in primary care. First-line management: intranasal corticosteroids, saline irrigation, analgesia and time.

Suspect bacterial infection using the double-worsening pattern, not colour of discharge

Purulent or coloured nasal discharge does NOT indicate bacterial infection — it reflects neutrophil myeloperoxidase and occurs routinely in viral illness. This misconception drives an enormous volume of unnecessary prescribing and must be corrected explicitly with patients. Features suggesting acute BACTERIAL rhinosinusitis (EPOS): symptoms persisting beyond 10 days without improvement; OR severe symptoms with fever above 38-39°C and purulent discharge or facial pain for 3-4 consecutive days at the start; OR — most specific — "double sickening": initial improvement followed by clear deterioration.

Orbital and intracranial complications are the emergency — image, do not re-prescribe

Rare but potentially devastating, and disproportionately affecting children and young adults. Orbital: periorbital or orbital cellulitis, subperiosteal abscess, orbital abscess, cavernous sinus thrombosis — signalled by periorbital swelling, proptosis, restricted or painful eye movements, diplopia, reduced visual acuity or colour vision, or a relative afferent pupillary defect. Intracranial: meningitis, epidural or subdural empyema, brain abscess, superior sagittal sinus thrombosis — signalled by severe headache, altered consciousness, focal neurology, seizures, or a swelling over the frontal bone (Pott's puffy tumour). These require emergency contrast CT or MRI, IV antibiotics and urgent ENT and ophthalmology or neurosurgical involvement — not another course of oral antibiotics.

Chronic rhinosinusitis is inflammatory disease, not persistent infection

CRS is defined by symptoms persisting beyond 12 weeks (nasal blockage or discharge, plus facial pain/pressure or reduction of smell) with objective evidence on endoscopy or CT. It is fundamentally an inflammatory disorder of the sinonasal mucosa, not a chronic infection — which is why repeated antibiotic courses are ineffective and inappropriate. Phenotyped by polyp status: CRS with nasal polyps (CRSwNP — typically type 2 inflammation, eosinophilic, associated with asthma and NSAID-exacerbated respiratory disease) and CRS without nasal polyps (CRSsNP). Mainstay treatment: long-term intranasal corticosteroids plus high-volume saline irrigation, with short courses of oral corticosteroids for polyp disease and endoscopic sinus surgery for treatment-refractory cases.

Biologics transformed severe nasal polyp disease

Type 2 inflammation-targeted biologics have changed the management of severe recurrent CRSwNP, particularly in patients with coexisting asthma who previously faced repeated surgery and recurrent oral steroid courses. Dupilumab (anti-IL-4Rα, blocking IL-4 and IL-13 signalling; the SINUS-24 and SINUS-52 trials showed large reductions in polyp score, congestion and need for surgery and systemic steroids), omalizumab (anti-IgE) and mepolizumab (anti-IL-5) all have licensed indications in severe CRSwNP. These are adjuncts to, not replacements for, optimised topical therapy and appropriate surgery, and require specialist assessment and defined response criteria.

Recognise NSAID-exacerbated respiratory disease (Samter's triad)

The triad of nasal polyps, asthma and hypersensitivity to aspirin and other COX-1 inhibiting NSAIDs — driven by dysregulated arachidonic acid metabolism with cysteinyl leukotriene overproduction. Clinically vital because these patients: have particularly aggressive, rapidly recurring polyp disease with high revision surgery rates; may suffer severe bronchospasm from a single dose of aspirin or ibuprofen and must be explicitly warned; and benefit from specific interventions — leukotriene receptor antagonists, aspirin desensitisation followed by daily aspirin therapy in selected patients, and biologics. Always ask directly about aspirin and NSAID reactions in any patient with nasal polyps.

Key statistics

Viral

the great majority of acute rhinosinusitis — antibiotics give minimal benefit (EPOS 2020)

EPOS 2020/Cochrane

>10 days

without improvement, or "double sickening" — the pattern suggesting bacterial infection

EPOS 2020

Not colour

purulent discharge does NOT indicate bacterial infection — a major driver of overprescribing

EPOS/NICE

12 weeks

symptom duration defining chronic rhinosinusitis — an inflammatory, not infective, disease

EPOS 2020

Dupilumab

large reductions in polyp burden and need for surgery in severe CRSwNP (SINUS-24/52)

Lancet 2019

Eye signs

proptosis, diplopia or reduced vision = orbital complication = emergency imaging, not antibiotics

EPOS/AAO-HNS

Rhinosinusitis management — evidence for common interventions (EPOS 2020)

Source: EPOS 2020/Cochrane. Intranasal corticosteroids and saline irrigation are first-line; antibiotics have marginal benefit in acute disease.

Glossary of key terms

EPOS 2020 definitions
ENT/RhinologyThe European Position Paper on Rhinosinusitis and Nasal Polyps is the international reference. Acute rhinosinusitis: sudden onset of two or more symptoms — one of which must be nasal blockage/obstruction/congestion or nasal discharge (anterior or posterior drip) — plus/minus facial pain or pressure, plus/minus reduction or loss of smell; lasting less than 12 weeks. Recurrent acute rhinosinusitis: four or more episodes per year with complete resolution between. Chronic rhinosinusitis: the same symptom criteria persisting beyond 12 weeks, PLUS objective evidence — endoscopic signs (polyps, mucopurulent discharge from the middle meatus, mucosal oedema/obstruction) or CT changes (mucosal changes within the ostiomeatal complex or sinuses). The requirement for objective evidence matters: symptom criteria alone substantially over-diagnose CRS, and much "chronic sinusitis" is actually migraine or non-allergic rhinitis.

Facial pain — sinusitis is over-diagnosed
Differential diagnosisIsolated facial pain or "sinus headache" without nasal obstruction, discharge or smell disturbance is very unlikely to be sinusitis, and this is one of the commonest diagnostic errors in primary care. The great majority of such patients have MIGRAINE — which characteristically produces mid-facial pain, nasal congestion and rhinorrhoea through trigeminal-autonomic activation, closely mimicking sinus disease, and which responds to triptans rather than antibiotics. Other mimics: tension-type headache; midfacial segment pain; trigeminal neuralgia; temporomandibular disorder; dental pathology; and cluster headache. A normal sinus CT in a patient with facial pain effectively excludes sinusitis as the cause, and a CT that is normal during an episode of pain is particularly informative.

Functional endoscopic sinus surgery (FESS)
ENT surgeryEndoscopic surgery aims to restore ventilation and mucociliary drainage by opening the natural sinus ostia — principally the ostiomeatal complex — rather than stripping mucosa, and to create access for topical therapy to reach the sinus mucosa. Indicated for CRS failing optimised medical therapy (adequate-duration intranasal corticosteroids and saline irrigation), complications of sinusitis, mucoceles, fungal disease, and to obtain tissue where neoplasm is suspected. Key principles: surgery is an adjunct that enables ongoing medical therapy, not a cure — patients who stop topical steroids after surgery relapse; and image-guided navigation is used for revision surgery and where anatomy is distorted. Major complications are rare but serious: orbital injury including blindness, CSF leak, and major haemorrhage.

Fungal rhinosinusitis
ENT/Infectious diseaseA spectrum that must be distinguished because management diverges sharply. Non-invasive forms: fungal ball (usually maxillary, in immunocompetent patients — surgical removal is curative); allergic fungal rhinosinusitis (type 1 hypersensitivity to fungi, thick eosinophilic mucin with fungal hyphae, expansile disease often with bone remodelling in young atopic patients — treated by surgery plus corticosteroids, not antifungals). Invasive forms: chronic invasive; and acute invasive fungal rhinosinusitis — a rapidly fatal emergency in the immunocompromised, particularly diabetic ketoacidosis, haematological malignancy, neutropenia and transplant patients. Warning signs of acute invasive disease: facial or palatal numbness, black necrotic eschar on the turbinate or palate, orbital or cranial nerve involvement, disproportionate pain. It requires immediate imaging, urgent surgical debridement and systemic antifungals — delay is measured in hours.

Antibiotic choice when genuinely indicated
Antimicrobial stewardshipWhen acute bacterial rhinosinusitis is genuinely indicated by the EPOS criteria, the usual pathogens are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. First-line in most guidelines is amoxicillin, or amoxicillin-clavulanate where beta-lactamase-producing organisms are prevalent or the patient has recent antibiotic exposure, comorbidity or severe illness. Doxycycline is the usual alternative in penicillin allergy. Macrolides are avoided as first-line in many settings because of high pneumococcal resistance. Duration should be short — typically 5 days in adults where guidelines permit. Importantly, antibiotics have NO established role in uncomplicated chronic rhinosinusitis, where the disease process is inflammatory; long-term low-dose macrolide therapy is used in some specialist settings for CRSsNP with neutrophilic inflammation, but the evidence is inconsistent.

Intranasal corticosteroid technique
Practical therapeuticsThe most common reason intranasal corticosteroids "fail" is technique, not drug choice — and correcting it is a high-value two-minute consultation. Key points: use the opposite hand to the nostril (right hand for left nostril), directing the spray outward toward the ipsilateral ear rather than straight back at the septum, which causes irritation, crusting, epistaxis and rarely septal perforation; do not sniff hard after spraying, as this deposits the drug in the nasopharynx where it is swallowed rather than on the nasal mucosa; and continue daily rather than as-needed, since maximal effect takes around two weeks of regular use. For chronic rhinosinusitis, high-volume saline irrigation with corticosteroid added to the irrigation solution delivers drug far more effectively to the sinus mucosa than sprays, particularly after sinus surgery has opened the ostia.