Bacterial Sinusitis

Bacterial sinusitis is a bacterial infection that causes inflammation in the hollow spaces around your nose, often developing after a cold or viral infection that won’t go away. While most sinus infections are caused by viruses and clear up on their own, bacterial sinusitis may require different treatment to help you feel better.

Table of contents

• What is bacterial sinusitis?
• The sinuses and how they work
• What causes bacterial sinusitis?
• Signs and symptoms
• Symptoms in children
• How long does it last?
• How is it diagnosed?
• Treatment options
• Self-care and home remedies
• Prevention
• When to see a healthcare provider

What is bacterial sinusitis?

Bacterial sinusitis is an infection of the paranasal sinuses—the hollow spaces in the bones of your face around your nose—caused by bacteria. This condition involves inflammation of the mucous membrane that lines these spaces^[1]. Sinusitis is a very common problem, affecting approximately one in every eight American adults each year. Almost 30 million people seek medical help for sinusitis in the United States every year^[2].

Because sinusitis often occurs along with rhinitis (inflammation of the mucous membrane in the nose), healthcare providers sometimes call it rhinosinusitis^[1][2]. This more accurately describes what’s happening, since the sinus passages are connected to the nasal passages.

Bacterial sinusitis often follows a viral infection, such as a cold or the flu. Viral infections can cause the mucosal lining of the sinuses to swell. In healthy sinuses, mucus drains into the nasal cavity through small holes called ostia. When swelling blocks these holes, mucus cannot drain out of the sinuses. Bacteria then colonize the undrained mucus, which can lead to bacterial sinusitis^[2].

The sinuses and how they work

Your sinuses are four paired cavities (spaces) in your head. Narrow passages connect them. There are four pairs of paranasal sinuses located below, above, between and behind the eye sockets: the maxillary sinuses, frontal sinuses, ethmoid sinuses, and sphenoidal sinuses^[2].

The maxillary sinuses are the largest of these and are most often affected by sinusitis. However, sinusitis can affect any or all of the paranasal sinuses^[2].

Sinuses make mucus that drains out of the passages in your nose. This drainage helps keep your nose clean and free of bacteria, allergens, and other germs^[1]. The sinuses are normally lined with a thin membrane that produces mucus, which is swept along by tiny hair-like projections called cilia. These cilia move the mucus (and whatever is trapped in it) toward openings that lead to the back of the throat, where it slides down to the stomach^[6].

What causes bacterial sinusitis?

Bacterial sinusitis is caused by bacteria that infect the lining of your nasal cavity and sinuses. It’s most often caused by the bacteria Streptococcus pneumoniae. Another bacteria called Haemophilus influenzae may also cause bacterial sinusitis^[3].

Other types of bacteria that commonly cause bacterial sinusitis include Staphylococcus aureus and Moraxella catarrhalis^[2].

The bacterial infection happens after the lining is already inflamed. This inflammation is often caused by a virus, but other factors can also cause inflammation and make a bacterial infection more likely, such as allergies, blockage in the nose, swimming in contaminated water, tooth infection, cocaine use in the nose, or air pollutants^[3].

People with certain conditions are at greater risk of developing bacterial sinusitis. These include those who have allergies, asthma, structural blockages in the nose or sinuses, or people with weak immune systems^[6].

Signs and symptoms

Common symptoms of bacterial sinusitis include pressure or pain around the nose, in the forehead, in the cheeks, or around the eyes. The pain often gets worse if the affected person bends forward^[2].

Other typical symptoms include^[1][2]:

• Discolored, thick nasal discharge (often yellow or greenish)
• Decreased sense of smell and ability to taste
• Stuffy nose
• Bad breath
• Postnasal drip (mucus dripping down the back of the throat)
• Ear pain or a feeling of fullness in the ears
• Fever
• Fatigue
• Facial pain
• Painful teeth
• Painful chewing
• Cough or sore throat
• Headache

Bacterial sinusitis can follow a cold or the flu, and often the symptoms occur just when it seems as if the initial infection is clearing up. In this situation, it is common to start to feel better, and then to feel worse as the subsequent bacterial sinusitis develops^[2].

Symptoms in children

In children, the symptoms of sinusitis may differ from those in adults. Children may experience^[2]:

• Irritability
• Ear discomfort
• Lethargy
• Snoring
• Mouth breathing
• Difficulty feeding
• Nasal speech

Bacterial sinusitis can affect children of any age, even though the paranasal sinuses are not visible on X-ray before the age of about nine^[2].

How long does it last?

Bacterial sinusitis can be grouped into different subtypes based on how long symptoms last^[1][2][4]:

• Acute bacterial sinusitis: symptoms last less than four weeks
• Subacute bacterial sinusitis: symptoms last between four and 12 weeks
• Chronic bacterial sinusitis: symptoms last more than 12 weeks
• Recurrent acute bacterial sinusitis: four or more episodes occur in a year, each lasting more than seven days, with symptoms resolving completely between episodes

Most cases of bacterial sinusitis resolve within two weeks and have no further symptoms^[2].

How is it diagnosed?

Your healthcare provider will determine if you have a sinus infection by asking about symptoms and examining you^[5]. They will ask about your health history and how long you’ve had symptoms. You may have a physical exam to look for signs of a respiratory infection^[3].

It’s hard to tell the difference between viral and bacterial rhinosinusitis because both have similar symptoms^[3]. Viruses, like the ones that cause the common cold, cause most cases of sinusitis. Bacteria can cause sinusitis, or they can infect you after a case of viral sinusitis^[1].

You may be more likely to have bacterial sinusitis if you’ve had symptoms for more than 10 days with no improvement; a fever of 100.4°F (38°C) or higher; yellow or greenish nasal discharge; pain in the areas around your nose; or symptoms that suddenly get much worse after they seemed to be getting better^[3].

If the condition lasts longer than 10 days, or there is a worsening of symptoms after 5 to 7 days, the sinusitis is more likely caused by bacteria than a virus^[2].

In most cases, you won’t need more tests. Radiographic imaging is not recommended in patients with acute rhinosinusitis unless a complication or an alternative diagnosis is suspected^[4].

Treatment options

You do not need antibiotics for many sinus infections. Most sinus infections usually get better on their own without antibiotics. When antibiotics aren’t needed, they won’t help you, and their side effects could still cause harm^[5].

However, in some cases, you may need antibiotics. Antibiotic therapy is recommended for patients with rhinosinusitis symptoms that do not improve within seven days or that worsen at any time; those with moderate illness (moderate to severe pain or temperature of 101°F [38.3°C] or higher); or those who are immunocompromised^[4].

Amoxicillin is considered the first-line antibiotic for most patients with acute bacterial rhinosinusitis. Trimethoprim/sulfamethoxazole and macrolide antibiotics are reasonable alternatives to amoxicillin for treating bacterial sinusitis in patients who are allergic to penicillin^[4]. Antibiotics and decongestants usually work well on bacterial sinusitis^[1].

For some sinus infections, your healthcare provider might recommend watchful waiting or delayed antibiotic prescribing. With watchful waiting, your healthcare provider may suggest watching and waiting for 2 to 3 days to see if you need antibiotics. This gives the immune system time to fight off the infection. If your symptoms don’t improve, the healthcare provider may prescribe an antibiotic. With delayed prescribing, your healthcare provider may prescribe an antibiotic but suggest that you wait 2 to 3 days before filling the prescription. You may recover on your own and may not need the antibiotic^[5].

In cases where symptoms persist or progress after maximal medical therapy, and if imaging shows evidence of sinus disease, referral to an otolaryngologist (ear, nose, and throat specialist) may be warranted^[4].

Self-care and home remedies

There are several strategies you can use at home to help manage your symptoms and feel better^[5]:

• Put a warm compress over the nose and forehead to help relieve sinus pressure
• Use a decongestant or saline nasal spray
• Breathe in steam from a bowl of hot water or shower
• Drink plenty of fluids to keep your mucus thin
• Sleep with your head propped up

Nasal irrigation, or using a neti pot or sinus rinse, can be an effective way to flush out mucus, bacteria, and allergens from your nasal passages. This can help reduce inflammation and improve airflow. Always use distilled or sterile water when performing nasal irrigation to avoid introducing harmful bacteria into your sinuses^[2].

Running a humidifier in your bedroom or living space can add moisture to the air, keeping your sinuses from drying out, especially in the winter months when indoor air is often dry. Saline nasal sprays help keep the inside of your nose moist and can be used multiple times a day^[2].

Ask your healthcare provider about over-the-counter medicines that can help you feel better. Always use over-the-counter medicines as directed^[5]. Acetaminophen or ibuprofen can help with head and face pain. Decongestant nasal sprays can open up your stuffy nose, but don’t use them for more than a few days. Over time they could make your symptoms worse^[1].

Prevention

You can help prevent sinus infections by doing your best to stay healthy and keep others healthy^[5]:

• Clean your hands frequently
• Receive recommended vaccines, such as the flu vaccine and pneumococcal vaccine
• Avoid close contact with people who have colds or other upper respiratory infections
• Don’t smoke and avoid secondhand smoke
• Use a clean humidifier to moisten the air at home
• Avoid nasal irritants such as pollution and smoke
• Keep your allergies managed well
• Irrigate your sinuses on a regular basis (from once a day to once a week) with a saline sinus wash

You should also avoid drinking alcohol when you have sinusitis. Even though booze is a liquid, it makes you dehydrated. It also can cause your sinuses and the lining of your nose to swell, which makes your symptoms worse^[1].

When to see a healthcare provider

See a healthcare provider if you have^[5]:

• Severe symptoms, such as severe headache or facial pain
• Symptoms that get worse after improving
• Symptoms lasting more than 10 days without getting better
• Fever longer than 3 to 4 days
• Multiple sinus infections in the past year

This list is not all-inclusive. Please see a healthcare provider for any symptom that is severe or concerning.

• Paranasal sinuses (maxillary, frontal, ethmoid, sphenoidal sinuses)
• Nasal cavity
• Nose