Management of Upper Airway Symptoms

Diagnosis and Initial Treatment

The American Academy of Otolaryngology-Head and Neck Surgery recommends that acute bacterial rhinosinusitis (ABRS) be diagnosed based on the presence of purulent nasal drainage accompanied by nasal obstruction and/or facial pain-pressure-fullness lasting up to 4 weeks 3
The American College of Chest Physicians suggests that upper airway cough syndrome (UACS) from allergic rhinitis or chronic rhinosinusitis does not benefit from antibiotics, and first-generation antihistamine-decongestant combinations are recommended as initial treatment 1, 2
The American Academy of Otolaryngology-Head and Neck Surgery recommends verifying the absence of purulent nasal discharge, worsening symptoms after initial improvement, and severe symptoms for at least 3-4 consecutive days to confirm that the condition is not ABRS 3

The American College of Chest Physicians recommends initiating a first-generation antihistamine-decongestant preparation, such as dexbrompheniramine maleate 6 mg twice daily PLUS pseudoephedrine sulfate 120 mg sustained-release twice daily, or azatadine maleate 1 mg twice daily PLUS pseudoephedrine sulfate 120 mg sustained-release twice daily, for UACS-induced cough 1
The American Academy of Allergy, Asthma, and Immunology suggests that intranasal corticosteroids are highly effective for both allergic rhinitis and chronic rhinosinusitis, and should be started simultaneously with antihistamine-decongestant combinations 1, 8, 9

The American College of Chest Physicians recommends that if symptoms improve but don't fully resolve after 1-2 weeks of antihistamine-decongestant therapy, ipratropium bromide nasal spray should be added for additional anticholinergic effect, particularly when antihistamine-decongestant preparations are contraindicated 1
The American College of Chest Physicians suggests that if UACS symptoms resolve but cough persists, asthma should be evaluated as a second cause, and bronchoprovocation challenge or empiric asthma treatment should be considered 2

The American College of Chest Physicians recommends that sinus imaging (CT preferred over plain films) should be obtained if symptoms persist despite 2-3 weeks of appropriate medical therapy, to evaluate for chronic sinusitis 2, 8
The American Academy of Otolaryngology-Head and Neck Surgery recommends that antibiotics should only be prescribed if imaging confirms sinusitis AND symptoms persist despite optimal medical management, and first-line treatment should be amoxicillin or high-dose amoxicillin-clavulanate 3, 8