Purulent rhinitis: causes in adults and children, treatment

The term "purulent rhinitis" is commonly used to describe a runny nose with thick, yellow-green discharge. In clinical practice, this term most often refers to forms of acute rhinosinusitis: viral (the most common), post-viral, and bacterial. The color of the mucus reflects excess leukocytes and dehydration of the secretion, but does not in itself prove a bacterial infection and is not an indication for antibiotics. It is crucial to avoid treating viral infections with antibacterial agents. [1]

The European EPOS-2020 position paper and national guidelines emphasize that acute rhinosinusitis lasting 2-3 weeks is most often a self-limited viral illness; antibiotics are needed only if there are signs of a bacterial process or a risk of complications. Judging the condition solely by mucus color is a medical myth. Viral, post-viral, and bacterial variants are differentiated by duration, symptom dynamics, pain/fever severity, and clinical "red flags." [2]

In children, "purulent rhinitis" is also more often viral. Bacterial sinusitis in children is diagnosed using the American Academy of Pediatrics triad of criteria: persistent symptoms for more than 10 days without improvement, a "second worsening" after initial improvement, or a severe onset with fever ≥39°C (102°F) and purulent discharge for ≥3 consecutive days. Sinus imaging is not required for confirmation unless there are signs of complications. [3]

Proper tactics conserve antibiotics, reduce the risk of bacterial resistance, and reduce the risk of adverse drug reactions. At the same time, we remain vigilant: although serious complications are rare, they are possible (orbital and intracranial), and their signs require urgent specialist examination. [4]

Code according to ICD-10 and ICD-11

In ICD-10, "acute rhinitis/nasopharyngitis (common cold)" is coded as J00; acute sinusitis - J01 with specification of the sinuses (J01.0-J01.4), including "recurrent acute" with the fifth character "1". If the pathogen is identified, codes B95-B97 can be added for its clarification. Chronic forms - J32.x, nasal polyps - J33.0. [5]

In ICD-11, acute nasopharyngitis is designated CA00, acute sinusitis is designated CA01, and the chronic rhinosinusitis block is designated CA0A (with phenotypes). This helps to correctly classify "purulent rhinitis" as acute rhinosinusitis, specifying the cause and course, rather than using terminology not accepted in the classifier. [6]

Table 1. Codes for conditions commonly referred to as "purulent rhinitis"

System	Code	Name/clarification
ICD-10	J00	Acute nasopharyngitis (acute rhinitis, "cold")
ICD-10	J01.x / J01.x1	Acute sinusitis/acute recurrent sinusitis (by sinuses)
ICD-10	B95-B97	Additional pathogen code (if known)
ICD-11	CA00	Acute nasopharyngitis
ICD-11	CA01	Acute sinusitis
ICD-11	CA0A	Chronic rhinosinusitis (phenotypes)

Epidemiology

Acute rhinosinusitis is one of the most common conditions, with a one-time annual prevalence of 6-15% in the general population. The vast majority of cases are viral episodes, occurring during a "cold"; a bacterial process develops in a minority and is more common after the 5th to 10th day of illness or during a "second worsening." [7]

Postviral rhinosinusitis occurs in approximately 3 cases per 100 people per year; it is the cause of the majority of visits and the temptation to prescribe antibiotics. However, some of these cases remain non-bacterial. [8]

Chronic rhinosinusitis (by contrast) affects 5-12% of adults according to EPOS-2020 and about 9% in global meta-analyses; the proportion of the polypous phenotype in adults is approximately 1-2%. These figures are important to distinguish acute self-limited episodes from long-term inflammatory conditions. [9]

Severe complications of the acute bacterial process are rare, but have been described: orbital complications account for 60-80% of all complications, intracranial complications - 15-20%, bone complications (including Pott's tumor) - about 5%. In children, the risk of complications is somewhat higher than in adults, especially with frontal sinusitis. [10]

Table 2. Frequency and phenotypes (landmarks)

State	Prevalence assessment
Acute rhinosinusitis (in general)	6-15% per year
Postviral acute rhinosinusitis	≈3 cases per 100 people/year
Chronic rhinosinusitis (adults)	5-12% (≈9% according to meta-analysis)
Polyposis phenotype (adults)	1-2%

Reasons

The main cause is a viral infection of the upper respiratory tract (rhino-, coronavirus-, parainfluenza, etc.). This causes swelling of the mucous membrane, closure of the sinus openings, and secretion stagnation. The change in discharge color is caused by neutrophils and inflammatory enzymes and is not consistent with a bacterial process. [11]

Acute bacterial rhinosinusitis develops with secondary colonization of stagnant secretions by typical pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), most often after 10 days of progression or a "second deterioration." These cases cause more pronounced local pain in the face/teeth and may be accompanied by fever. [12]

In children, adenoiditis and anatomically narrow sinus openings often play a role, while in adolescents, frontal sinusitis due to active growth of the frontal sinus often plays a role. Odontogenic sinusitis is possible with pathology of the upper molars. [13]

"Purulent rhinitis" in allergic rhinitis is, as a rule, a secondary thickening of the secretion against the background of inflammation; treatment of the causative agent is not required here; anti-inflammatory basic therapy of the nose is needed. [14]

Risk factors

Key factors: viral exposure in the fall and winter, attending children's groups, smoking/passive smoking, and dry air. In children, this includes attending kindergarten and being young; in adults, this includes concomitant rhinitis, gastroesophageal reflux disease, and immunodeficiency. [15]

Anatomical: deviated septum, turbinate hypertrophy, narrow anastomoses, adenoid vegetation (in children), dental and maxillary pathology (odontogenic sinusitis). These factors increase the likelihood of stagnant secretion and secondary bacterial contamination. [16]

Allergic rhinitis and asthma maintain chronic mucosal inflammation and increase the risk of both acute episodes and the development of chronic inflammation. Allergy control reduces the frequency of "suppurative" exacerbations. [17]

Medications and lifestyle: Overuse of decongestant sprays, sedatives, and sleeping on your back with your mouth open can increase congestion and drainage. Correcting these factors can reduce the severity of symptoms. [18]

Table 3. Risk factors for "purulent rhinitis" (acute rhinosinusitis)

Category	Examples	What to do
Infectious	Seasonal acute respiratory viral infections, children's groups	Hand hygiene, vaccination according to the calendar
Anatomical	Deviated septum, adenoids	Assessment by an ENT doctor
Inflammatory	Allergic rhinitis, asthma	Monitoring of basic therapy
Behavioral	Smoking, dry air, vasoconstrictors	Avoidance/limitation, moisturizing, "3-5 day rule" for decongestants

Pathogenesis

The virus causes mucosal edema, thickening of the mucus, and blockage of the osteomeatal complex. Mucus drainage is impaired, negative pressure develops in the sinuses, and facial pain/pressure increases. This is the stage of the viral or post-viral process, which resolves spontaneously in most cases. [19]

If obstruction persists, secondary bacterial colonization occurs, with a shift in microbiota, increased neutrophilic inflammation, and the appearance of thicker, "purulent" mucus. However, even at this stage, color is only an indirect indicator; the overall criteria of duration and severity are decisive. [20]

With severe swelling and infection, inflammation may spread through the thin orbital bones or along the venous pathways to the meninges, resulting in orbital and intracranial complications including subperiosteal abscesses and Pott's tumor (frontal bone osteomyelitis).[21]

In children, the anatomy and rich venous network increase the risk of frontal sinusitis and orbital complications, so the threshold of concern is lower. [22]

Symptoms

Viral/post-viral rhinosinusitis: congestion, discharge (from clear to yellow-green), facial discomfort/pressure, decreased sense of smell, cough due to post-nasal drip. Symptoms usually peak on days 3-5, then gradually improve by days 10-14. [23]

Bacterial rhinosinusitis is more likely if symptoms persist for more than 10 days without improvement, a "second worsening" after mild improvement, or a severe onset: high temperature ≥39 °C and severe purulent discharge for at least 3 consecutive days. In adults, localized facial/toothache is typical. [24]

In children, the same criteria are present, plus a daytime cough, especially at night; young children do not always describe facial pain, so parental observation is important. With adenoiditis, snoring and mouth breathing are also present. [25]

Red flags: eyelid/orbital edema, diplopia, decreased vision, severe localized headache, stiff neck, neurologic symptoms, forehead edema/swelling - require urgent evaluation and imaging.[26]

Table 4. Viral vs. bacterial acute rhinosinusitis (landmarks)

Sign	Viral/post-viral	Bacterial
Duration	Up to 10 days with improvement by 14-21 days	>10 days without improvement, “second worsening” or severe onset ≥3 days
Fever	Often low-grade fever	Often ≥39 °C with severe onset
Pain/Locality	Discomfort, diffuse	Severe localized facial/dental
Tactics	Symptomatic, observation	Consider antibiotics if criteria are met

Classification, forms and stages

The EPOS-2020 classification was adopted: acute viral (up to 10 days), post-viral (worsening/persistence after the 5th day), acute bacterial (clinical criteria are higher). By duration - acute (up to 12 weeks), subacute (4-12 weeks), chronic (≥12 weeks). [27]

Anatomically, by the involved sinus: maxillary, frontal, ethmoid, sphenoid, poly- or pansinusitis. For ICD-10 coding, this is reflected by the selection of subheadings J01.0-J01.4 and "recurrent" (J01.x1). [28]

In children, frontal sinusitis is common in adolescents, with a risk of Pott's tumor. In adults, odontogenic sinusitis is common due to diseases of the upper molars and after dental procedures. [29]

It is practical to stage the acute process based on time and dynamics: early viral phase (up to 5 days), post-viral (5-10 days), and possible bacterial infection (>10 days or severe onset). This helps to explain tactics that avoid unnecessary antibiotics. [30]

Complications and consequences

Most episodes are harmless and self-limiting. However, the bacterial process may be complicated by orbital (preseptal/orbital cellulitis, subperiosteal abscess) and intracranial (meningitis, venous thrombosis, brain abscess) complications. Approximate distribution: orbital 60-80%, intracranial 15-20%, bone ≈5%. [31]

Pott's tumor - osteomyelitis of the frontal bone with subperiosteal abscess - is a rare but dangerous condition, most often in adolescents and young adults; it requires immediate treatment with antibiotics and surgical drainage when indicated. [32]

Delaying unnecessary antibacterial therapy carries its own risks: diarrhea, candidiasis, drug reactions, and increased antibiotic resistance. Therefore, a "prudent waiting" strategy is advocated for viral and post-viral forms. [33]

In young children, complications may develop more rapidly; the threshold for in-person examination and escalation is lower, particularly with periorbital symptoms or significant fever.[34]

Table 5. Complications of acute bacterial rhinosinusitis

Complications group	Examples	What's alarming
Orbital (60-80%)	Preseptal/orbital cellulitis, subperiosteal abscess	Swelling of the eyelids, pain when moving the eyes, double vision, decreased vision
Intracranial (15-20%)	Meningitis, brain abscess, cavernous sinus thrombosis	Severe headache, neck stiffness, focal neurological symptoms
Bone (≈5%)	Osteomyelitis of the frontal bone (Pott's tumor)	Forehead swelling/pain, fever

When to see a doctor

If a runny nose with discharge and congestion persists for more than 10 days without improvement, if a "second worsening" occurs after a "cold," or if the onset was severe (fever ≥39 °C and thick purulent discharge for ≥3 days), an in-person assessment is indicated. These are criteria for a probable bacterial process. [35]

Immediately - if "red flags" occur: severe facial pain, eyelid swelling, double vision, decreased vision, forehead asymmetry/swelling, meningeal signs, vomiting, confusion, severe unilateral toothache with cheek swelling. [36]

In children, high fever, lethargy, refusal to eat/drink, increasing swelling around the eye or at the base of the nose, and forehead pain are considered. The threshold for referral is lower due to the risk of orbital complications. [37]

In case of recurring episodes, dental problems, allergic rhinitis and asthma, it is worth discussing prevention with an ENT doctor and (in case of allergies) with an allergist. [38]

Diagnostics

Step 1: Clinical assessment. The diagnosis of acute rhinosinusitis is clinical: duration and dynamics of symptoms, nature of pain, temperature, and the effects of self-medication. Mucus color does not determine the etiology. Assess red flags and risk factors for complications. [39]

Step 2 – decision on antibiotics. If symptoms persist for ≤10 days, antibiotics are not indicated. If there is no improvement for ≥10 days or a “second worsening,” a “reserve prescription” or observation is discussed; in case of severe onset/systemic severity, immediate administration according to national guidelines. [40]

Step 3: Instrumental methods. In routine cases, visualization is not necessary. Computed tomography with contrast is only recommended if orbital/intracranial complications or an odontogenic lesion are suspected. Nasal endoscopy is useful with an ENT specialist in cases of severe, atypical, or recurrent disease. [41]

Step 4 - Laboratory. Nasal/pharyngeal cultures are not informative for initial diagnosis. General clinical tests are based on severity and comorbidity; in children, the AAP emphasizes clinical criteria without mandatory tests. [42]

Table 6. Primary solution algorithm

Situation	What to do	Justification
≤10 days from onset, no severity	Symptomatic care, without antibiotics	Viral nature, self-limiting
≥10 days without improvement or "second deterioration"	Observation/"backup prescription", intranasal steroids	Antibiotics offer little benefit, selection is important
Severe onset ≥3 days or systemic severity/risk of complications	Immediate antibiotics, assessment for complications	Reducing the risk of adverse outcomes
Red flags	Urgent visualization and hospitalization as indicated	Risk of orbital/CNS complications

Differential diagnosis

Allergic rhinitis: itching, sneezing, watery discharge, seasonality or obvious triggers; "pusiness" is possible at the peak of inflammation, but without fever and facial pain. Response to intranasal steroids is helpful. [43]

Odontogenic sinusitis: unilateral foul-smelling discharge, history of toothache/treatment of upper molars. Treatment: sanitation of the lesion and ENT management. [44]

A foreign body in the nose of a child: unilateral foul-smelling discharge, bleeding, no fever – requires an ENT examination and removal. The diagnosis is often clinical. (General ENT practices.)

COVID-19/other viruses: systemic symptoms, loss of smell without congestion, epidemiological situation. The decision on testing is based on the clinic and local protocols. (General recommendations.)

Table 7. What distinguishes the main causes of "purulent rhinitis"

Cause	Key Features	Confirmation
Viral/postviral ARS	Up to 10-14 days, improvement, no severe symptoms	Clinically
Bacterial ARS	>10 days without improvement, “second deterioration”, severe onset	Clinical criteria, sometimes endoscopy
Allergic rhinitis	Itching, sneezing, seasonal, watery discharge	Anamnesis, response to INS
Odontogenic sinusitis	Unilateral discharge with odor, dental complaints	Dental examination/CT scan if indicated

Treatment

First, explain the nature of the illness. It's important for the patient to know that mucus color doesn't determine bacterial contamination, and most episodes resolve without antibiotics within 2-3 weeks. This "antibiotic-sparing" approach is standard according to NICE/EPOS. It reduces side effects and bacterial resistance. [45]

Symptomatic therapy includes irrigation with isotonic saline solution and pain relief (paracetamol/ibuprofen, depending on age). Sprays and irrigation cans are suitable for irrigation; evidence for symptom relief is modest, but this method is safe and widely recommended as an adjunct. Ensure proper technique and clean water (boiled/sterile). In young children, use sprays with a limiter. [46]

Intranasal corticosteroids in adults and adolescents may slightly speed recovery from post-viral symptoms and reduce congestion. NICE recommends a short course of "high doses" (e.g., mometasone 200 mcg twice daily for up to 14 days) in individuals aged 12 years or older if symptoms have not improved for 10 days or longer. In children under 12 years of age, use as indicated and under close supervision. Side effects are usually local (dryness, irritation). [47]

Nasal decongestants can provide short-term relief of congestion, but they should be used for no more than 3-5 days to avoid rhinitis medicamentosa. Oral decongestants, antihistamines, and mucolytics have no proven benefit for acute rhinosinusitis; steam inhalation and "warm compresses" have also not shown convincing effectiveness. Focus on products with real benefits. [48]

Antibiotics are not indicated for uncomplicated cases in the first 10 days. Consider them if there is evidence of a bacterial process or in systemically severe patients and risk groups (immunocompromised, etc.). NICE recommends phenoxymethylpenicillin for 5 days as first-line therapy, and in severe cases or those at risk of complications, co-amoxiclav for 5 days; in case of allergy, doxycycline/clarithromycin (taking into account age and pregnancy). Local lists may vary; refer to national guidelines. [49]

In children, the AAP recommends amoxicillin (with or without clavulanate) as a first-line treatment for severe onset or "second worsening"; a "delayed" strategy is acceptable for persistent, non-severe cases. Reframing for parents is important: the goals are to alleviate symptoms, prevent complications, and avoid unnecessary antibiotic use. If there is no improvement within 72 hours, reassess and possibly change therapy. [50]

For severe pain and swelling, a short course of intranasal steroids in combination with analgesics is recommended; antibacterial solutions are used only when indicated. If odontogenic sinusitis is suspected, dental sanitation is recommended, and antibiotics are selected taking into account the anaerobic flora. If episodes recur, an ENT examination and endoscopy are indicated. [51]

Hospitalization and parenteral antibiotics are required for orbital/intracranial complications, severe systemic reactions, failure to respond to oral therapy, or severe comorbidity. Imaging (CT with contrast) and team management (ENT, ophthalmologist, neurosurgeon, infectious disease specialist) are mandatory. Early drainage of subperiosteal/intracranial collections improves outcomes. [52]

Recurrent episodes: Review allergic rhinitis and irrigation technique, review household factors (dry air, smoking), and evaluate the nasal septum/turbinates and adenoids in children. For chronic rhinosinusitis, the basis is daily irrigation and intranasal steroids; further steps (including biologics for polyposis) are discussed in separate guidelines. [53]

After recovery, discuss a "future plan": early initiation of symptomatic therapy at the first signs of a cold, rules for "when to see a doctor," an individual "backup prescription" for frequent post-viral episodes, and clear criteria for its activation. This reduces anxiety and the overuse of antibiotics. [54]

Table 8. Antibiotics for acute sinusitis (according to NICE NG79, 5-day course)

Group	Drug (adults)	Alternative for allergies	Special cases
Base	Phenoxymethylpenicillin 500 mg 4 times a day	Doxycycline or clarithromycin	Pregnancy: Erythromycin
In case of severe/risk of complications	Co-amoxiclav 500/125 mg 3 times a day	Consultation on site	For children, doses according to age/weight

Prevention

Hand washing, cough etiquette, and staying in groups during virus season are simple measures that reduce the frequency of acute respiratory viral infections and, consequently, "purulent" episodes. Air humidity of 40-60% and ventilation reduce mucus drying and discomfort. [55]

Control of allergic rhinitis (regular intranasal steroids, avoidance of triggers) reduces exacerbations and the need for emergency care. The regimen is selected individually. [56]

Limit decongestant sprays to 3-5 days to avoid falling into a rhinitis medicamentosa cycle. Smoking and secondhand smoke increase the frequency of episodes; quitting smoking is important for prevention. [57]

Regular dental prophylaxis reduces the risk of odontogenic sinusitis. For frequently recurring episodes, children should undergo an assessment of the adenoids; in adults, an examination of the septum and turbinates. [58]

Forecast

Viral and post-viral acute rhinosinusitis usually resolves within 2-3 weeks, leaving only short-term fatigue and cough due to drainage. Supportive therapy can improve the condition. [59]

With timely treatment, bacterial infections have a favorable prognosis; the risk of serious complications is low, but requires vigilance and clear patient instructions. Recurrent episodes are a reason to adjust risk factors and consider an ENT evaluation. [60]

In children, the prognosis is good, but the threshold for referral is lower due to orbital complications. Adequate parental education and an "action plan" reduce anxiety and improve adherence. [61]

The long-term strategy is patient education, proper self-care for acute respiratory viral infections, and the judicious use of antibiotics. This benefits both the individual and society. [62]

FAQ

Is green mucus a sign of bacteria and does it require antibiotics?
No. The color reflects neutrophilic inflammation and dehydration of the mucus. The decision to prescribe an antibiotic is based on the duration, dynamics, and severity of symptoms, not on the color. [63]

How long should it take to consider a bacterial process?
If there is no improvement for more than 10 days, a "second worsening" has occurred, or there was a severe onset with fever ≥39°C and purulent discharge for ≥3 days, antibacterial treatment should be discussed. For children, we use the same criteria (AAP). [64]

What antibiotics are prescribed for adults? And for how many days?
According to NICE NG79: phenoxymethylpenicillin for 5 days; in severe cases or at risk of complications, co-amoxiclav for 5 days; in case of allergies, doxycycline or clarithromycin (for pregnant women, erythromycin). For children, dosages are selected based on age and weight. [65]

Are sinus imaging studies necessary for "purulent rhinitis"?
No, imaging is not required for uncomplicated cases. CT with contrast is indicated only if orbital or intracranial complications, an odontogenic lesion, or an atypical course are suspected. [66]

What over-the-counter remedies are helpful?
Saline rinses and age-appropriate pain relievers. A short course of intranasal steroids may help with symptoms lasting 10 days or longer without improvement (from age 12). Decongestants should be used for no longer than 3-5 days. [67]

Table 9. Self-help step by step

Day of illness	What to do	When to revise the plan
1-5	Rest, fluids, saline sprays/irrigation, analgesics	If severe pain/fever does not subside
6-10	Continue symptomatic treatment, evaluate the dynamics	No improvement by day 10
11-14	Consider INS (≥12 years), "reserve prescription" according to indications	Worsening/Red Flags - See a Doctor Immediately
15-21	Most cases improve.	Persistent severe symptoms - in-person examination

Table 10. "Red flags" - urgently see a doctor/go to the hospital

Symptom	Possible complication
Eyelid swelling/pain, double vision, decreased vision	Orbital cellulitis/abscess
Severe forehead pain, swelling of the forehead	Osteomyelitis of the frontal bone (Pott's tumor)
Neck stiffness, focal neurological symptoms	Meningitis/brain abscess
Severe one-sided toothache, swelling of the cheek	Odontogenic sinusitis