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Rhinosinusitis may be classified by duration of symptoms. Rhinosinusitis is called acute rhinosinusitis if less than 4 weeks’ duration or as chronic rhinosinusitis if lasting more than 12 weeks, with or without acute exacerbations. Acute rhinosinusitis may also be classified by presumed etiology, such as viral rhinosinusitis or acute bacterial rhinosinusitis.

1. VIRAL RHINOSINUSITIS (COMMON COLD)

ESSENTIALS OF DIAGNOSIS

  • Associated malaise, headache, and cough.

  • Nasal congestion, facial pressure, rhinorrhea, and hyposmia.

  • Erythematous, engorged nasal mucosa without intranasal purulence.

  • Symptoms are self-limited, lasting typically less than 10 days.

Clinical Findings

Due to the numerous serologic types of rhinoviruses, adenoviruses, and other viruses, patients remain susceptible to the common cold throughout life. These infections, while generally quite benign and self-limited, have been implicated in the development or exacerbation of more serious conditions, such as acute bacterial sinusitis and acute otitis media, asthma, cystic fibrosis, and bronchitis. Nasal congestion, decreased sense of smell, rhinorrhea, and sneezing accompanied by general malaise, throat discomfort and, occasionally, headache, are typical in viral infections. Nasal examination usually shows erythematous, edematous mucosa and a watery discharge. The presence of purulent nasal discharge suggests bacterial rhinosinusitis. The SARS-CoV-2 has a propensity to cause hyposmia and anosmia. While this altered olfaction was thought to be temporary, the loss of the sense of smell could be permanent (see also Part 34). There are ongoing studies on its prevalence and there is no consensus statement on treatment beyond addressing the underlying COVID infection.

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Najafloo  R  et al. Mechanism of anosmia caused by symptoms of COVID-19 and emerging treatments. ACS Chem Neurosci. 2021;12:3795.
[PubMed: 34609841]  
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Vance  H  et al. Addressing post-COVID symptoms: a guide for primary care physicians. J Am Board Fam Med. 2021;34:1229.
[PubMed: 34772779]  

Treatment

The main treatment for viral rhinitis is supportive care, including rest, hydration, and use of over-the-counter analgesics and decongestants. There are no effective antiviral therapies for either the prevention or treatment of most viral rhinitis despite a common misperception among patients that antibiotics are helpful. Buffered hypertonic saline (3–5%) nasal irrigation has been shown to improve symptoms and reduce the need for NSAIDs. Other supportive measures, such as oral decongestants (pseudoephedrine, 30–60 mg every 4–6 hours or 120 mg twice daily), may provide some relief of rhinorrhea and nasal obstruction.

Nasal sprays, such as oxymetazoline or phenylephrine, are rapidly effective but should not be used for more than a few days to prevent rebound congestion. Withdrawal of the medication after prolonged use leads to rhinitis medicamentosa, an almost addictive need for continuous usage. Treatment of rhinitis medicamentosa requires mandatory cessation of the sprays, and this is often extremely frustrating for patients. Topical intranasal corticosteroids (eg, flunisolide, 2 sprays in each nostril twice daily), intranasal anticholinergic (ipratropium 0.06% nasal spray, 2–3 sprays every 8 ...

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