Is It Possible to Have Sinusitis Without Symptoms of a Cold?

Dr. Franklyn Gergits, ENT

Short answer: Yes — and it is more common than most patients realize. Sinusitis does not require a viral cold to develop. Allergy, laryngopharyngeal reflux, anatomical obstruction, and immune dysregulation can all drive chronic sinus inflammation silently — without fever, facial pain, or any symptom the patient would recognize as a sinus problem. Many patients with chronic sinusitis have been living with their symptoms so long they have become their baseline. A nasal endoscopy and CT scan often reveal what years of unrecognized symptoms could not.

We see this in our clinic regularly. A patient comes in after having an imaging study of the head done for a completely unrelated reason — a headache evaluation, a dental issue, something that had nothing to do with their sinuses. And right there on the scan, clear as day, is evidence of sinusitis. The patient had no idea. No cold. No facial pain. No congestion they were aware of. Nothing they would have called a sinus problem.

An important note before we go further: not every incidental sinus finding on imaging represents disease that needs treatment. Mucosal changes on CT or MRI are common even in people without sinus symptoms — studies show that 12 to 15 percent of genuinely asymptomatic individuals have significant sinus findings on imaging. The key is whether those findings correlate with your symptoms and what nasal endoscopy shows. Imaging alone cannot confirm a diagnosis of chronic sinusitis. That is exactly why a complete evaluation matters.

So how does sinusitis develop without a cold?

A Viral Cold Is Just One of Many Triggers

The most common assumption patients make is that sinusitis starts with a cold — a viral upper respiratory infection that spreads into the sinuses. And that does happen. But a virus is just one of many upstream triggers that can drive sinus inflammation. It is not even close to the only one.

Allergy is one of the most common drivers of chronic sinusitis — present in 40 to 84 percent of CRS patients — and many patients with significant allergic sensitization have never been properly tested. Allergy skin prick testing is the preferred confirmatory method. In Scottsdale, Phoenix, and the greater Maricopa County area, the allergen burden is significant and year-round, with desert broom, olive, mulberry, Bermuda grass, and dust mite exposures extending across more months than most patients realize.

Environmental exposures are a driver that research now quantifies with precision. Every microgram per cubic meter increase in PM2.5 air pollution is associated with a ten percent increase in CRS-related medical visits. A large UK Biobank study of 367,298 participants found that long-term PM2.5 exposure increased CRS risk by 59 percent. Arizona’s air quality — particularly in the Phoenix metro area during high-wind and pre-monsoon periods — makes this a clinically relevant consideration for patients in our area.

Laryngopharyngeal reflux — pepsin from the stomach reaching the posterior nasal cavity — is a driver that most patients have never heard of and that most physicians outside our specialty rarely evaluate. Growing evidence suggests that pepsin triggers an inflammatory response in the posterior nasal mucosa that looks and feels like sinusitis. Importantly, research shows that LPR alone can produce significant sinus symptoms without any endoscopic evidence of sinusitis — meaning some patients with “silent sinusitis” do not have sinus disease at all. The problem is upstream.

Dental infections are another common non-viral cause of sinusitis that is frequently overlooked. Studies estimate that dental sources account for 10 to 40 percent of maxillary sinusitis cases. An infected tooth, a failed root canal, or a dental implant near the floor of the maxillary sinus can drive sinus inflammation directly and persistently — without any cold, any allergy, and any other sinus trigger. If your sinus symptoms are primarily one-sided and you have had recent dental work or dental pain, this connection should be evaluated.

Immune dysregulation is a driver seen in a meaningful subset of patients. In some patients the immune system is underactive — failing to clear pathogens adequately — due to immunoglobulin deficiency. Studies show that 13 to 23 percent of patients with refractory chronic rhinosinusitis have a measurable immunoglobulin deficiency. In others the immune system is overactive, driving mucosal inflammation without any infectious trigger. Either pattern can sustain chronic sinus inflammation silently.

Anatomical problems — a deviated septum, narrowed drainage pathways, or structural variants — can create the conditions for chronic mucosal inflammation that builds silently over months or years. None of these require a cold to get started.

A note on migraine: Some patients who believe they have chronic sinusitis without cold symptoms actually have migraine. Migraine activates the trigeminal system, producing genuine nasal congestion, drainage, and facial pressure through parasympathetic pathways. If nasal endoscopy and CT are both normal but symptoms persist — migraine belongs in the evaluation before any further sinus-directed treatment is pursued.

Why Some Patients Have No Symptoms — and Why Some Truly Do Not

This is the part that surprises patients most. When I sit down with someone who has just been handed a CT scan showing sinusitis they knew nothing about, they almost always ask the same question: if my sinuses are inflamed, why don’t I feel it?

For many patients, the honest answer is that they probably do feel it — they just do not recognize it as a sinus problem. The congestion they write off as normal. The post-nasal drainage they have learned to clear without thinking about it. The slight reduction in their sense of smell they attribute to getting older. The morning fatigue they blame on poor sleep. The mild facial pressure they dismiss as tension. These patients have been living with their symptoms so long that the symptoms have become their baseline. They have no reference point for what normal actually feels like.

But — and this matters — some patients with incidental imaging findings truly are asymptomatic. Not every sinus finding on imaging means a problem that needs to be fixed. What determines whether treatment is needed is the correlation between the imaging findings, the nasal endoscopy, and the symptom history. If the imaging shows mucosal changes but the endoscopy is normal and the patient has no relevant symptoms, watchful waiting may be entirely appropriate. When I tell a patient “you probably have no idea how much better you could feel,” I mean patients in whom the symptom picture and the objective findings align. Not every incidental scan finding is that patient.

Red Flags That Need Urgent Evaluation

Whether or not a cold preceded your symptoms, certain findings always warrant prompt evaluation: one-sided sinus symptoms only, bloody or rust-colored nasal discharge, progressive facial pain or swelling, vision changes, or new neurological symptoms. These can indicate something other than chronic inflammatory sinusitis — including dental pathology, neoplasm, or vascular causes — and require specialist assessment without delay.

What This Means for Your Care

If you have been told incidentally that your sinuses show inflammation on imaging — or if you suspect that what you have been calling your normal is actually chronic sinus disease that has never been properly evaluated — a nasal endoscopy and a complete review of your history is the right next step.

The goal is to identify which upstream driver is active in your case. Treatment matched to the actual cause gets results. Treating the sinuses while the upstream driver continues unaddressed is why so many patients cycle through repeated courses of antibiotics or have sinus procedures with incomplete long-term relief. The sinuses are often the victim. The driver is upstream — and finding it changes everything.

Want to Understand More?

This post is part of the Understanding Your Symptoms series on the Airway & Sinus Wellness Review.

→ Why Antibiotics Keep Failing Your Sinus Infection

→ Can Sinusitis Cause Daily Headaches?

→ The Final Chapter: What the Field Still Cannot See — Posterior Sinonasal Syndrome

→ Airway & Sinus Wellness Review — Full Publication

This post is part of the Understanding Your Symptoms section of the Airway & Sinus Wellness Review.

References

1. Piccirillo JF, Payne SC, Rosenfeld RM, et al. Clinical Practice Guideline: Adult Sinusitis Update. Otolaryngology–Head and Neck Surgery. 2025. entnet.org

2. Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020. Rhinology. 2020.

3. Aldajani A, Alhussain F, Mesallam T, et al. Association between chronic rhinosinusitis and reflux diseases in adults: a systematic review and meta-analysis. American Journal of Rhinology & Allergy. 2024.

4. Hamilos DL. Chronic rhinosinusitis: epidemiology and medical management. Journal of Allergy and Clinical Immunology. 2011.

5. American Academy of Allergy, Asthma & Immunology. Allergic rhinitis and sinusitis overview. AAAAI.org

6. Razi CH, et al. Systematic review of incidental sinus findings in asymptomatic individuals: mean LM score 2.24; 14.71% with LM ≥4. Otolaryngology–Head and Neck Surgery. 2022.

7. Meiklejohn DA, Tummala N, Lalakea ML. Climate change, allergic rhinitis, and sinusitis. JAMA. 2025. PM2.5 associated with 10% increase in CRS visits per µg/m³.

8. Zhou Q, Ma J, Biswal S, et al. Air pollution, genetic factors, and chronic rhinosinusitis. Science of the Total Environment. 2024. HR 1.59 for long-term PM2.5 exposure in UK Biobank cohort of 367,298.

9. Keating MK, Phillips JC. Chronic Rhinosinusitis. American Family Physician. 2023. Odontogenic sinusitis 10–40% of maxillary cases; migraine in differential. AAFP.org

About the Author

Dr. Franklyn R. Gergits, MBA, DO, FAOCO is a Board-Certified Otolaryngologist and Fellowship-Trained Otolaryngic Allergist with a Clinical Focus in Rhinology and Airway Disorders and over 30 years of clinical experience. He is the founder of the Sinus & Allergy Wellness Center of North Scottsdale, where he performs in-office balloon sinuplasty, turbinate reduction, NEUROMARK® posterior nasal nerve ablation, and Eustachian tube dilation under local anesthesia. He performed the first balloon sinuplasty in Pennsylvania and holds dual Entellus Centers of Excellence certifications. Dr. Gergits is the originator of the Posterior Sinonasal Syndrome (PSS) hypothesis — a clinical framework identifying pepsin-mediated posterior nasal mucosal injury as an upstream driver of chronic rhinosinusitis. Preprint available at Preprints.org (DOI: 10.20944/preprints202603.0858.v1). ORCID: 0009-0000-4893-6332.

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This content is for educational purposes only and does not constitute medical advice. If you have been told you have sinusitis on imaging or suspect you may have undiagnosed sinus disease, consult with a qualified otolaryngologist for a complete evaluation.