This patient, who has acute sinusitis, should be managed with supportive care. Acute sinusitis is most commonly caused by viral infections associated with the common cold, and it has a bacterial etiology in only a small percentage of cases. Acute sinusitis is characterized by symptoms of nasal congestion and obstruction; facial pain, pressure, and fullness that generally worsen when bending forward; headache; purulent nasal discharge; and maxillary tooth pain. When caused by viral infection, fever may be present within the first 24 to 48 hours of symptom onset, often associated with other symptoms such as myalgia and fatigue, but temperature normalizes after this time period. Bacterial sinusitis is more likely if there are severe symptoms associated with a high fever for at least 3 or 4 consecutive days following the onset of illness or if symptoms are persistent (lasting more than 10 days). Initial treatment of acute sinusitis is focused on symptom relief with analgesics, decongestants (systemic or topical), antihistamines, intranasal glucocorticoids, and nasal saline irrigation, and these treatment options would be the most appropriate therapy in this patient who does not have findings concerning for a possible bacterial etiology.

Antibiotics are not indicated in this patient at this time. Although more than 90% of cases of acute sinusitis are viral in origin, antibiotics are regularly prescribed for patients presenting with acute sinusitis symptoms. Antibiotics should be reserved for patients with persistent and severe symptoms (such as high fever and marked facial pain), progressively worsening symptoms, or failure to improve after 10 days of supportive care. If antibiotics are indicated, both amoxicillin-clavulanate and doxycycline would be appropriate first-line agents. Although this patient has purulent nasal discharge, the acute nature of the symptoms makes antibiotics inappropriate at this time.

Imaging with plain radiographs or CT is rarely needed in acute sinusitis and does not help in distinguishing a bacterial from viral cause.