Physicians should consider the overall clinical impression instead of focusing on individual signs and symptoms to diagnose acute rhinosinusitis, according to a study published in the Annals of Family Medicine.
“Acute rhinosinusitis is a common outpatient infection, responsible for over 3 million outpatient visits annually in the United States; the symptoms overlap considerably with that of other upper respiratory tract infections, making accurate diagnosis challenging,” Mark H. Ebell, MD, MS, of the department of epidemiology and biostatistics at the College of Public Health, University of Georgia, and colleagues wrote. “While 75% of patients with acute rhinosinusitis receive an antibiotic, only about one-third with sinus symptoms have a confirmed bacterial pathogen when sinus fluid is cultured. Helping physicians more accurately identify which patients with clinically suspected sinusitis actually have acute bacterial rhinosinusitis could reduce harm from inappropriate antibiotic use.”
To determine the benefit of evaluating the signs and symptoms of acute rhinosinusitis and acute bacterial rhinosinusitis in making an accurate diagnosis, researchers performed a meta-analysis of 17 studies that centered on outpatients with clinically suspected acute rhinosinusitis.
They calculated summary estimates of test accuracy based on the prevalence of acute sinusitis among patients presenting with sinus symptoms. The primary measures of diagnostic accuracy were the positive and negative likelihood ratios.
After stratifying patients with clinically suspected acute rhinosinusitis by age group and reference standard, researchers found that the prevalence of acute rhinosinusitis ranged from 19% to 63% for adults and from 57% to 79% for children, with imaging studies having the highest prevalence (confirmed acute rhinosinusitis, 51%; confirmed acute bacterial rhinosinusitis, 31%).
In addition, researchers determined that the clinical findings that best ruled in acute rhinosinusitis were purulent secretions in the middle meatus (positive likelihood ratio, 3.2) and the overall clinical impression (positive likelihood ratio, 3.0). The clinical findings that best ruled out acute rhinosinusitis were the overall clinical impression (negative likelihood ratio, 0.37), normal transillumination (negative likelihood ratio, 0.55), the absence of preceding respiratory tract infection (negative likelihood ratio, 0.48), any nasal discharge (negative likelihood ratio, 0.49) and purulent nasal discharge (negative likelihood ratio, 0.54).
The best predictors of acute bacterial rhinosinusitis that researchers found were the overall clinical impression, cacosmia and pain in the teeth.
Physicians should consider the overall clinical impression instead of focusing on individual signs and symptoms to diagnose acute rhinosinusitis.
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According to the researchers, several clinical decision rules have been proposed for the accurate diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis, but none have been prospectively validated.
“Most individual signs and symptoms have limited accuracy for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis,” the researchers wrote. “While many studies have attempted to identify combinations of signs of symptoms that diagnose acute rhinosinusitis and acute bacterial rhinosinusitis, it is equally important to determine which patients are at a low likelihood of acute bacterial rhinosinusitis (would be unlikely to benefit from an antibiotic), as it is to identify which patients are likely to have an uncomplicated course. Thus, research to determine low risk criterial that help rule out acute bacterial rhinosinusitis is needed.” – by Melissa J. Webb
Disclosures: The authors report no relevant financial disclosures.