Differential diagnoses

Use the clinical pathway for acute sinusitis to guide your further actions. If acute sinusitis is unlikely, consider differential diagnoses and proceed appropriately. 

Other conditions presenting with similar signs and symptoms to sinusitis include:

• Upper respiratory tract infection — in most common colds symptoms peak by three days
• Allergic rhinitis — usually restricted to nasal symptoms. Consider especially if there is a prior history of allergy
• Nasal foreign body — typically causes a unilateral mucopurulent discharge or blockage (more common in children)
• Adenoiditis and tonsillitis (particularly in children) — adenoiditis can be difficult to differentiate from sinusitis in children as symptoms are similar
• Sinonasal tumour — suspect particularly if there are persistent unilateral symptoms, such as nasal obstruction, nasal discharge or nosebleeds, crusting, or facial swelling
• Turbinate hypertrophy — nasal obstruction is the predominant symptom.

Other causes of facial pain or headache include:

• Migraine
• Giant cell arteritis (temporal arteritis)
• Temporomandibular joint dysfunction
• Neuropathic or atypical facial pain
• Dental pain.

If the patient has had symptoms for less than 10 days, advise an antibiotic is not needed and provide self-care advice and OTC medicines for symptom relief.

GP referral

These criteria are for guidance only. Pharmacists should use their professional judgement on urgency (see Clinical Pathway and PGDs for more detail).

Same day

• Individual is severely immunosuppressed or immunosuppressed (this may include patients on chemotherapy or high dose systemic corticosteroids)
• Individual is systemically unwell but not showing signs or symptoms of sepsis
• Possible cancer suspected: unilateral (one-sided) polyp or mass, or bloody nasal discharge present
• Foreign body inserted into nasal passages
• Significant/active epistaxis (nosebleeds)
• Persistent unilateral symptoms, such as nasal obstruction, nasal discharge or nosebleeds, crusting or facial swelling 
• Individual where treatment is not indicated/not permitted under a PGD but upper respiratory symptoms are present and require further assessment.

Less urgent referral

• Individual with untreated localised infection involving the nasal mucosa, such as herpes simplex
• Recurrent sinusitis (four or more annual episodes of sinusitis without persistent symptoms in the intervening periods)
• Chronic sinusitis (sinusitis that causes symptoms that last for more than 12 weeks)
• Anatomic defect(s) causing nasal obstruction
• Co-morbidities complicating management, such as nasal polyps
• Concurrent use of any interacting medicine as listed in Drug Interactions section of the PGD.