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Acute Rhinosinusitis Care Pathway Overview

This pathway has been published with the aim of streamlining services and supporting GPs in providing best practice care to patients with acute rhinosinusitis. It includes updated information on antibiotic prescribing based on October 2017 NICE guidance Sinusitis (acute): antimicrobial prescribing. The aim of the pathway is to ensure that only appropriate patients are referred into the Ear, Nose and Throat (ENT) service, and that all primary care options, including self-care, have been exhausted.


Please click the relevant flowchart box to be taken directly to textual information.


Red Flags
Immediate referral:
  • Periorbital odema/erythema
  • Displaced globe
  • Double vision
  • Ophthalmoplegia
  • Reduced vision acuity
  • Severe unilateral/bilateral frontal headache
  • Frontal swelling
  • Signs of meningitis
  • Neurological signs

Acute rhinosinusitis (ARS) refers to symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than 4 weeks. Symptoms include nasal congestion and or obstruction and coloured discharge, along with frontal pain, headache and smell disturbance.

The vast majority of cases of acute rhinosinusitis are due to viral infection. The most common viruses that cause acute viral rhinosinusitis (AVRS) are rhinovirus, influenza virus, and parainfluenza virus. Acute bacterial infection occurs in only 0.5 to 2.0 percent of episodes of ARS. Acute bacterial rhinosinusitis (ABRS) occurs when bacteria secondarily infect inflamed sinus cavity. The most common bacteria associated with ABRS are Streptococcus pneumoniae, Heamophilus infleunzae, and Moraxella catarrhalis.

Initial Primary Care Assessment
  • Assess the patient for any Red Flag symptoms and refer accordingly - see pathway above
  • Nasal examination- swelling, redness, pus
  • Oral examination - posterior discharge
  • Exclude dental infection
  • X-ray - not recommended
  • Computed tomography (CT) scan - Not recommended
Initial Primary Care Management

Symptoms lasting less than 10 days are more likely to be caused by the common cold rather than viral or bacterial rhinosinusitis and may be suitable for self-care with medicines purchased over the counter.

Prolonged symptoms (for around 10 days or more with no improvement) could be due to either viral or bacterial acute sinusitis. Viral acute sinusitis is far more likely  (approximately 98% of cases will be viral). Acute rhinosinusitis has an average duration of 2.5 weeks. There are no treatments to shorten the course of viral rhinosinusitis, however symptomatic management includes analgesics, nasal saline irrigation, decongestants, and topic nasal steroids. All these options are available to purchase over the counter, but some age restrictions apply to topical nasal steroids (See OTC resources). Prolonged symptoms may be due to bacterial rhinosinusitis but even bacterial rhinosinusitis is usually self-limiting (and appropriate for symptomatic management) and does not routinely need antibiotics.

Please see Prescribing section for guidance

For people with frequent recurrent episodes of rhinosinusitis (more than three episodes requiring antibiotics a year) consider routine referral to an Ear, Nose and Throat (ENT) specialist.

When to Refer

Refer Red Flags immediately.

Consider referral where significant symptoms persist despite primary care management (including appropriate use of antibiotics as indicated). Specialist Advice can be sought via the ENT eRS Advice and Guidance service as an alternative to referral.

Consider referral for people with frequent recurrent episodes of rhinosinusitis. Specialist Advice can be sought via the ENT eRS Advice and Guidance as an alternative to referral.

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