Sinusitis: When a Blocked Nose Needs More Than a Decongestant
A blocked nose with facial pressure sends a great many people to the pharmacy for antibiotics they do not need, and keeps others on decongestant sprays that are quietly making the problem worse. The distinction that matters is between viral, bacterial and chronic sinusitis.
What the sinuses do
The sinuses are air-filled spaces in the bones of the face that drain into the nose through narrow openings. When the lining swells, those openings block, mucus collects, and pressure builds. That is sinusitis.
Acute sinusitis
Viral, the overwhelming majority. Follows a cold. Nasal blockage, thick discharge, facial pressure, reduced smell, cough. It peaks around days three to five and improves within about ten days.
Bacterial, a small minority. Suspected when:
- Symptoms last more than 10 days without improvement
- Symptoms are severe from the start with fever above 39 degrees and purulent discharge for three or more days
- Double worsening: the person improves, then clearly gets worse again around day five to six
Coloured mucus by itself does not mean bacterial infection. Green and yellow discharge is normal in ordinary viral colds and comes from immune cells, not bacteria. This single misconception drives an enormous amount of unnecessary antibiotic use.
Treatment of acute sinusitis
What helps:
- Saline nasal irrigation, which is the most useful single measure. Use a neti pot or squeeze bottle with sterile, distilled or previously boiled and cooled water, never untreated tap water
- Intranasal corticosteroid spray, which reduces swelling at the sinus openings. Use correctly: aim away from the septum using the opposite hand
- Steam inhalation for symptomatic relief
- Paracetamol or ibuprofen for pain
- Plenty of fluids and rest
- Warm compresses over the face
Decongestant sprays such as oxymetazoline for a maximum of three to five days. Beyond that they cause rebound congestion, rhinitis medicamentosa, which is a common and entirely avoidable cause of permanent-feeling blockage.
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Antibiotics only when bacterial infection is genuinely suspected, by the criteria above.
Antihistamines help only when allergy is also present; otherwise they thicken secretions.
Chronic sinusitis
Symptoms lasting 12 weeks or more: nasal blockage, discharge or post-nasal drip, facial pain or pressure, and reduced or lost sense of smell.
Causes and contributors include allergic rhinitis, nasal polyps, a deviated septum, dental infection in the upper teeth, fungal sinusitis, cystic fibrosis, immune deficiency, aspirin-exacerbated respiratory disease, and smoking.
Treatment: daily saline irrigation and intranasal steroids as the foundation, allergy treatment, a longer course of antibiotics in selected cases, oral steroids for polyps, and functional endoscopic sinus surgery when medical treatment fails. Surgery widens the drainage pathways; it does not remove the need for ongoing medical treatment afterwards.
Investigation usually means nasal endoscopy and a CT scan of the sinuses. Plain X-rays are of limited value.
Loss of smell
Reduced smell is common in sinusitis and usually recovers with treatment. Sudden complete loss of smell without blockage has other causes, including viral infection, and deserves separate assessment. Smell training, deliberately sniffing a set of strong scents twice daily for months, has reasonable evidence for post-viral loss.
Red flags needing urgent care
Sinus infections sit close to the eye and the brain, and complications, although uncommon, are serious:
- Swelling, redness or pain around the eye
- Double vision, reduced vision, or an eye that will not move normally
- Severe headache with neck stiffness
- Confusion, drowsiness or seizure
- Swelling over the forehead
- High fever with severe illness
- Symptoms in someone immunocompromised or with diabetes, where invasive fungal sinusitis is a risk and progresses very quickly
Any of these needs emergency assessment, not another course of tablets.
Prevention
Treat allergic rhinitis properly, stop smoking, use saline rinses during cold season, manage reflux if present, humidify dry indoor air, and get the influenza vaccine. Attend to dental health, since upper molar infections cause a recognised subset of sinusitis.
This is general information. Persistent facial pain, visual symptoms or fever with sinus symptoms should be seen by a doctor rather than self-treated.