Name: URI / sinusitis — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Almost all upper-respiratory infection and rhinosinusitis is viral and self-limited — so the defensible chart is about two things: documenting that the orbital and intracranial complications were screened (the eye exam), and recording the stewardship rationale that kept (or justified) the antibiotic.

01What's at stake

The danger of sinusitis isn't the sinusitis — it's the complication: orbital cellulitis and subperiosteal abscess threatening the eye, Pott puffy tumor, and intracranial extension (epidural/subdural empyema, meningitis, cavernous sinus thrombosis). The other failure is reflexive antibiotics for viral illness; nasal-discharge color does not distinguish viral from bacterial, and most bacterial sinusitis can be observed.

02Can't-miss complications

Orbital cellulitis / subperiosteal abscess — pain with eye movement, restricted extraocular movements, proptosis, vision change, chemosis → CT, IV antibiotics, ophthalmology. → eye exam
Intracranial extension — severe/intractable headache, meningismus, confusion, seizure, cranial-nerve deficit (epidural/subdural empyema, meningitis, cavernous sinus thrombosis). → neuro screen
Pott puffy tumor — frontal-bone osteomyelitis with forehead swelling.
Influenza in the high-risk patient — consider antivirals.

03Viral vs bacterial (and stewardship)

Acute bacterial rhinosinusitis needs one of: symptoms persistent ≥10 days without improvement; severe onset (high fever ≥39 °C + purulent discharge/facial pain ≥3 consecutive days); or "double-sickening" (worsening after initial improvement). → which pattern?
Discharge color does not distinguish viral from bacterial — trajectory, severity, and duration do.
No imaging for uncomplicated sinusitis — sinus changes appear in ordinary viral URIs and most healthy controls.
Watchful waiting (no antibiotics) is appropriate for the persistent pattern with reassessment in 48–72 h; treat the severe and double-sickening patterns. → stewardship

Skip the typing

Work the case in the URI / Sinusitis Workup — it records the orbital/intracranial complication screen (the eye exam) and the antibiotic-stewardship decision, and assembles an MDM that documents the complications were excluded and the viral-vs-bacterial reasoning.

04Management

Viral URI / uncomplicated sinusitis: supportive care; analgesia; symptomatic measures (saline irrigation, intranasal steroids) for relief; no routine labs or imaging.
Bacterial sinusitis (when criteria met): amoxicillin-clavulanate first-line (high-dose with risk factors); avoid macrolides/TMP-SMX (high resistance); shorter 5–7 day courses for uncomplicated disease.
Complicated sinusitis: IV antibiotics (e.g., vancomycin + ceftriaxone/ampicillin-sulbactam) without delay, contrast CT (MRI if intracranial concern persists), and ophthalmology/ENT/neurosurgery; anticoagulation for venous sinus thrombosis.
Mild periorbital cellulitis with a reliable exam → oral antibiotics and close follow-up; escalate if the orbit can't be cleared.

05What to document

▼ weak

"Congestion and green discharge. Sinusitis. Azithromycin, discharged."

▲ defensible

"5 days of nasal congestion/discharge and facial pressure, improving. Orbital/intracranial screen negative — no pain with or restriction of eye movement, no proptosis/chemosis, vision intact, no severe headache/meningismus/focal deficit, no forehead swelling. Does not meet bacterial-sinusitis criteria (not ≥10 days, not severe, no double-sickening); discharge color not used to decide. Viral rhinosinusitis — antibiotics not indicated; supportive care and saline irrigation, with watchful waiting and reassessment in 48–72 h. Return precautions for eye pain/swelling/vision change, severe headache, neck stiffness, high fever, or worsening after initial improvement."

06Where charts fail

Antibiotics for a viral URI / discharge color used to justify them.
Missing orbital cellulitis (no documented eye-movement/proptosis/vision exam) or an unreliable eye exam not escalated.
Missing intracranial extension (severe headache, meningismus, neuro signs).
Imaging uncomplicated sinusitis, or routine labs with no diagnostic value.
Treating complicated sinusitis with oral antibiotics/discharge instead of IV antibiotics, imaging, and consultation; using a macrolide/"Z-pack."

07Sources

Zummer J, Luedke A. Pediatric sinusitis: complications and management in the emergency department. Pediatric Emergency Medicine Practice (EB Medicine). 2024;21(8).
Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.
Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72-e112.
Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1-S39.

URI & sinusitis: documentation that holds up