Rhinosinusitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]


Rhinosinusitis must be differentiated from other diseases that may present with a headache and/or respiratory symptoms.

Differential Diagnosis

Acute rhinosinusitis

Acute rhinosinusitis must be differentiated from [1][2]:

  • Allergic rhinitis
  • Headaches and midfacial pain syndromes: migraine, tension-type headache, cluster headache, paroxysmal hemicrania, atypical facial pain and midfacial segment pain [3][4][5]
  • Orofacial pain syndromes (e.g. temporomandibular disorders)[6]
  • Ocular pain syndromes: glaucoma [7][8]
  • Dental disease
  • Chronic fatigue syndrome

Chronic rhinosinusitis

Chronic rhinosinusitis must be differentiated from:[1][9][10][11]

Disease History Physical examination Laboratory or radiological findings
Acute viral nasopharyngitis[12]
  • Diagnosis is usually clinical and lab tests are rarely needed
  • The virus can be cultured on human lung cells but results take time
  • PCR is rapid and accurate test but done only in immunocompromised patients when the virus strain needs to be known
Allergic rhinitis[13]
  • Characterized by repeated paroxysms of rhinorrhea, sneezing and cough.
  • Symptoms may be related to a specific season of the year, hence the name “seasonal allergies”.
  • Rhinorrhea fluid is usually clear and watery.
  • Examination of the nose reveals a crease below the nasal bridge from repeated pulling of the nose secondary to irritation.
  • Edema in the area below the eye if associated conjunctivitis is present.[14]
Acute sinusitis[15]
Infectious mononucleosis[17]


  1. 1.0 1.1 Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM; et al. (2016). "International Consensus Statement on Allergy and Rhinology: Rhinosinusitis". Int Forum Allergy Rhinol. 6 Suppl 1: S22–209. doi:10.1002/alr.21695. PMID 26889651.
  2. Wittkopf ML, Beddow PA, Russell PT, Duncavage JA, Becker SS (2009). "Revisiting the interpretation of positive sinus CT findings: a radiological and symptom-based review". Otolaryngol Head Neck Surg. 140 (3): 306–11. doi:10.1016/j.otohns.2008.12.007. PMID 19248933.
  3. Lal D, Rounds A, Dodick DW (2015). "Comprehensive management of patients presenting to the otolaryngologist for sinus pressure, pain, or headache". Laryngoscope. 125 (2): 303–10. doi:10.1002/lary.24926. PMID 25216102.
  4. Jones NS (2009). "The prevalence of facial pain and purulent sinusitis". Curr Opin Otolaryngol Head Neck Surg. 17 (1): 38–42. doi:10.1097/MOO.0b013e32831b9e45. PMID 19225304.
  5. Jones NS, Cooney TR (2003). "Facial pain and sinonasal surgery". Rhinology. 41 (4): 193–200. PMID 14750345.
  6. Shephard MK, Macgregor EA, Zakrzewska JM (2014). "Orofacial pain: a guide for the headache physician". Headache. 54 (1): 22–39. doi:10.1111/head.12272. PMID 24261452.
  7. Lee AG, Al-Zubidi N, Beaver HA, Brazis PW (2014). "An update on eye pain for the neurologist". Neurol Clin. 32 (2): 489–505. doi:10.1016/j.ncl.2013.11.007. PMID 24703541.
  8. Zakrzewska JM (2013). "Differential diagnosis of facial pain and guidelines for management". Br J Anaesth. 111 (1): 95–104. doi:10.1093/bja/aet125. PMID 23794651.
  9. Slavin RG, Spector SL, Bernstein IL, Kaliner MA, Kennedy DW, Virant FS; et al. (2005). "The diagnosis and management of sinusitis: a practice parameter update". J Allergy Clin Immunol. 116 (6 Suppl): S13–47. PMID 16416688.
  10. Fagnan LJ (1998). "Acute sinusitis: a cost-effective approach to diagnosis and treatment". Am Fam Physician. 58 (8): 1795–802, 805–6. PMID 9835855.
  11. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M; et al. (2015). "Clinical practice guideline (update): adult sinusitis". Otolaryngol Head Neck Surg. 152 (2 Suppl): S1–S39. doi:10.1177/0194599815572097. PMID 25832968.
  12. Heikkinen T, Järvinen A (2003). "The common cold". Lancet. 361 (9351): 51–9. doi:10.1016/S0140-6736(03)12162-9. PMID 12517470.
  13. Pawankar R, Bunnag C, Chen Y, Fukuda T, Kim YY, Le LT, Huong le TT, O'Hehir RE, Ohta K, Vichyanond P, Wang DY, Zhong N, Khaltaev N, Bousquet J (2009). "Allergic rhinitis and its impact on asthma update (ARIA 2008)--western and Asian-Pacific perspective". Asian Pac. J. Allergy Immunol. 27 (4): 237–43. PMID 20232579.
  14. Skoner DP (2001). "Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis". J. Allergy Clin. Immunol. 108 (1 Suppl): S2–8. PMID 11449200.
  15. Low DE, Desrosiers M, McSherry J, Garber G, Williams JW, Remy H, Fenton RS, Forte V, Balter M, Rotstein C, Craft C, Dubois J, Harding G, Schloss M, Miller M, McIvor RA, Davidson RJ (1997). "A practical guide for the diagnosis and treatment of acute sinusitis". CMAJ. 156 Suppl 6: S1–14. PMID 9347786.
  16. "Acute maxillary sinusitis". N. Engl. J. Med. 305 (4): 226–7. 1981. doi:10.1056/NEJM198107233050419. PMID 7242607.
  17. Niederman JC, McCollum RW, Henle G, Henle W (1968). "Infectious mononucleosis. Clinical manifestations in relation to EB virus antibodies". JAMA. 203 (3): 205–9. PMID 4864269.

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