ACR Appropriateness Criteria ® Sinonasal Disease

Abstract

Imaging of sinonasal pathology may occur for assessment of rhinosinusitis or mass lesions. Rhinosinusitis is prevalent in up to 16% of the US population with annual economic burdens estimated at 22 billion dollars. Rhinosinusitis is characterized as acute or chronic based on symptom duration; if four or more episodes occur annually, the term recurrent acute rhinosinusitis (RARS) is used. In acute uncomplicated rhinosinusitis when inflammatory change remains in the paranasal sinuses and nasal cavity, imaging may not be required. Distinction between viral or bacterial rhinosinusitis is a clinical diagnosis, and imaging should be interpreted in conjunction with clinical and endoscopic findings. Sinus CT imaging is appropriate per clinical judgment in associated complications including headache, facial pain, swelling, orbital proptosis, or cranial nerve palsies. In maxillary sinusitis, teeth may require assessment because 20% may be odontogenic in origin. MRI may be complementary in aggressive infections with intraocular/intracranial complications, invasive fungal sinusitis, or sinonasal masses. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Utility of Pre-Hematopoietic Cell Transplantation Sinus CT Screening in Children and Adolescents

“…It is possible that the degree of mucosal thickening on sinus CT unduly influenced the decision to treat with antibiotics, which should be based on history and examination. 6,7 Mucosal thickening on CT does not differentiate between bacterial and viral pathogens, and 3 of 5 patients receiving antibiotics in this study had nasal washes positive for viral pathogens. Next, only patients undergoing imaging work-up were considered symptomatic post-HCT.…”

“…The American Academy of Pediatrics and American College of Radiology guidelines dictate that diagnosis and treatment of acute sinusitis should be clinical, with imaging reserved for suspicion of orbital or CNS complications. 6,7 IFRS typically presents with a combination of fever, facial pain, nasal congestion, headache, eye symptoms, and/or facial swelling, which should also prompt imaging, and likely endoscopy. [3][4][5]31 On pretransplantation physical examination, none of the 100 patients in our series had findings suggestive of orbital, CNS, or fungal involvement warranting imaging evaluation.…”

“…However, the clinical utility of screening sinus CT remains unclear, and the practice is not universal. According to the American Academy of Pediatrics and the American College of Radiology, uncomplicated sinusitis should be a clinical diagnosis, 6,7 and several large studies (n $ 100) have failed to identify pre-HCT imaging features predictive of post-HCT sinusitis. [8][9][10] Fewer studies have evaluated the contribution of pretransplantation CT to patient management or prediction of posttransplantation IFRS.…”

Appropriateness Criteria for Surgery in the Management of Adult Recurrent Acute Rhinosinusitis

“…The American College of Radiology publishes regularly updated appropriateness criteria on obtaining imaging tests for RARS, CRS, and invasive fungal sinusitis. 38 A multi-specialty, multi-national group developed appropriateness criteria for ESS as a management option for uncomplicated CRS. 39,40 Validation of the CRS appropriateness criteria demonstrated that these criteria predict outcomes for patients undergoing ESS for this disease in certain practice settings.…”

ACR Appropriateness Criteria® Headache

“…Headache accompanying clinical signs of meningitis should be managed by appropriate clinical guidelines. Please also reference the ACR Appropriateness Criteria Ò topic on "Head Trauma" [5], ACR Appropriateness Criteria Ò topic on "Cranial Neuropathy" [6], the ACR Appropriateness Criteria Ò topic on "Orbits Vision and Vision Loss" [7], the ACR Appropriateness Criteria Ò topic on "Sinonasal Disease" [8], and the ACR Appropriateness Criteria Ò topic on "Neuroendocrine Imaging" [9], in the appropriate clinical context. Headaches can be broadly classified into primary and secondary forms [1].…”