Sinusitis RCE


Does This Patient Have Sinusitis?

Original Citation

Williams, John H., M.D., Simel, David L., M.D. Does This Patient Have Sinusitis?: Diagnosing acute sinusitis by history and physical examination. JAMA Sept 8 1993, Vol 270, No 10 (1242-1246).

Bottom Line

The combination, maxillary toothache, poor response to nasal decongestants, abnormal transillumination, and colored nasal discharge are the most useful When all five features are present, the odds of sinusitis are very high (LR=6.4) and when none is present, sinusitis is ruled out.

The accuracy and reproducibility of transillumination is controversial

Overall clinical impression of sinusitis definitely present LR=19; likely present LR=4.7; unlikely or definitely absent LR= 0.14-0.4

Updated Search Findings

Unilateral purulent nasal discharge plus unilateral pain have +LR=4.5 -LR=0.25

SORT Grade of Recommendation: B Lower quality diagnositic cohort studies

Comments/Hints/Suggestions

Prevalence

Prevalence of acute bacterial sinusitis was neither discussed nor estimated in the original study. (The updated study estimated acute bacterial sinusitis develops in only 0.5-2% of upper respiratory infections in adults and only half of patients with a clinical diagnosis of acute bacterial sinusitis have it proven upon aspiration.)

Accuracy of Exam

Symptoms

Positive LR

Negative LR

Sensitivity

Specificity

*Colored nasal discharge

1.5

0.5

72

52

Cough

70

44

Sneezing

70

34

Maxillary Headache

Sore Throat

52

56

Itchy Eyes

52

43

Constitutional Sx

56

47

*Maxillary Toothache

2.5

0.9

83-93

*Poor response to nasal decongestants

2.1

0.7

Preceding Common cold

85

28

Pain bending forward

65

59

Signs

Paranasal Sinus Transillumination (dull)

1.6

0.5

*Paranasal Sinus Transillumination (opaque vs. nl)

0.04

Sinus Tenderness

48-50

62-65

*Purulent secretion

2.1

0.7

62

67

4 or more * signs present vs 0

6.4

0.1

Clinician impression of definite sinusitis

4.7- 19

0.14-0.4

Description of how symptoms elicited or defined

By complete history of fever, malaise, cough, nasal congestion, maxillary toothache, purulent nasal discharge, little improvement with nasal decongestants, and headache or facial pain exacerbated by bending forward. Symptoms varied with studies and included up to 69 different historical symptoms depending on the study.

Description of how exams were done or of prediction rules

A. Transillumination of Maxillary Sinuses:

Welch-Allyn transilluminator- place over infraorbital rim and judging light transmission between sides through the hard palate. Performed in completely dark room with time for complete eye adjustment. Results judged as opaque (no light transmission), dull (reduced light transmission), or normal.

B. Palpation for Sinus Tenderness:

Palpation over maxillary and frontal sinuses. Also, tapping the maxillary teeth with a tongue blade.

C. Examination of nostrils: Using short, wide speculum on handheld otoscope directed posteriolaterally. Inspect for mucosal color, edema, character of nasal secretions, polyps, septum structure.

Precision

111 patients examined by general internist and second examiner (PA, IM resident, IM attending). Agreement high for historical items, but on physical exam, agreement was high only for sinus tenderness (κ= 0.59) and fair for maxillary sinus transillumination (κ= 0.22) This was similar to agreement among otolaryngologists.

Studies description

Inclusion criteria: none discussed

Search Date: none discussed (study printed 1993)

Number Found and Reviewed: 3 adult studies

Quality/Limitations: no descriptions of types or blindedness of studies.

1. 164 patients (self or otolaryngologist suspected sinusitis) evaluated by 64 historical sx and compared with 4 view x-ray. No single finding highly accurate although 6 sx found more common in those with abnormal x-rays.

2. 247 males in VA PCP clinic (rhinorrhea or facial pain suspected sinusitis) compared symptoms and transillumination independently of one another to x-rays. Only maxillary toothache highly specific, but rare. Signs and symptoms only helpful as a grouping and not individual symptoms.

3. 400 general practice patients (intended to be treated for sinusitis) compared symptoms to Ultrasound (only moderate correlation with x-rays or aspiration) and was therefore, less accurate. Found toothache highly specific and other signs and symptoms had poor specificity and sensitivity.

Gold Standards: Sinus Aspiration/Culture

Pragmatic Reference Standard: Four view sinus roentgenogram findings of sinus opacity, air fluid level, or 6mm or more thickening (72-96% as accurate for maxillary sinusitis as aspiration and culture)

Updated SearchDate: May 18, 2005

Article: Clinical Inquiry What findings distinguish acute bacterial sinusitis? The Journal of Family Practice, July 2003: Vol 53, No 7 (563-565).

Description: Review of the two studies comparing clinical findings with sinus puncture ( gold Standard) as well as recommendations from other “expert” organizations.

Findings

History of purulent rhinorrhea (unilateral or bilateral), maxillary tooth pain (predominately unilateral) and pus in the nasal cavity were found to be predictors of aspirate purulence. ¾ positive +LR= 6.75, -LR= .21 with both unilateral purulence and pain (sen 79%, spec 83%, PPV 80%).

Critique

Literature on this subject is limited and inconsistent. Studies are few. Predictive values of clinical findings are quite limited in diagnosis of Acute Bacterial Sinusitis.

Level of Evidence

Strength of recommendation B for use of unilateral pain and purulent discharge as best clinical predictors. Strength of Recommendation C for “expert” based recommendations

Fit

These studies were mostly done in Primary Care settings (offices vs. ED) and found sinusitis to be close to the predicted population prevalence of 50% confirmed out of those predicted.

Reviewed by: Jenny Stone, M.D. M. Lee Chambliss MD Date May 28, 2005


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