Diagnosis of acute rhinosinusitis in primary care: a systematic review of test accuracy

Abstract

BackgroundAcute rhinosinusitis (ARS) is a common primary care infection, but there have been no recent, comprehensive diagnostic meta-analyses. AimTo determine the accuracy of laboratory and imaging studies for the diagnosis of ARS. Design and settingSystematic review of diagnostic tests in outpatient, primary care, and specialty settings. MethodThe authors included studies of patients presenting with or referred for suspected ARS, and used bivariate meta-analysis to calculate summary estimates of test accuracy and the area under the receiver operating characteristic (ROC) curve. The authors also plotted summary ROC curves to explore heterogeneity, cutoffs, and the impact of different reference standards. ResultsUsing antral puncture as the reference standard, A mode ultrasound (positive likelihood ratio [LR+] 1.71, negative likelihood ratio [LR-] 0.41), B mode ultrasound (LR+ 1.64, LR-0.69), and radiography (LR+ 2.01, LR-0.28) had only modest accuracy. Accuracy was higher using imaging as the reference standard for both ultrasound (LR+ 12.4, LR-0.35) and radiography (LR+ 9.4, LR-0.27), although this likely overestimates accuracy. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) both had clear threshold effects, and modest overall accuracy. The LR+ for ESR >30 and >40 were 4.08 and 7.40, respectively. A dipstick of nasal secretions for leucocyte esterase was highly accurate (LR+ 18.4, LR-0.17) but has not been validated. ConclusionIn general, tests were of limited value in the diagnosis of ARS. Normal radiography helps rule out sinusitis when negative, whereas CRP and ESR help rule in sinusitis when positive, although, given their limited accuracy as individual tests, they cannot be routinely recommended. Prospective studies integrating signs and symptoms with point-of-care CRP, dipstick, and/ or handheld B-mode ultrasound are needed.

Proposed Clinical Decision Rules to Diagnose Acute Rhinosinusitis Among Adults in Primary Care

“…29 The end-user cost is approximately $3.50 per test (excluding control costs, equipment, or labor) and Medicare reimbursement is $7.10 using CPT code 86140. It may also be possible to incorporate hand-held ultrasound examination, which is relatively sensitive for sinus fluid, 12 into a decision algorithm that also includes signs, symptoms, and CRP, perhaps limiting its use to patients with an intermediate risk of acute bacterial rhinosinusitis. Even if CRP testing is not available, however, the CART algorithm (Figure 2) can still be useful, as patients without unilateral maxillary sinus tenderness who also do not have maxillary toothache would be classified as low risk for acute bacterial rhinosinusitis regardless of the CRP test result.…”

“…[7][8][9][10][11] Also, many previous studies of individual tests or clinical decision rules have used radiography or computed tomographic (CT) scans as the ref-erence standard, tests that themselves have limited accuracy. 12 Although a CT scan is highly sensitive for the detection of fluid in the sinuses, this fluid may also be caused by a viral infection, so the test lacks specificity and is, therefore, a suboptimal reference standard. Antral puncture can detect purulent secretions, which are more strongly associated with bacterial infection.…”

Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis

“…org/content/17/2/164/suppl/DC1/, for search strategy). 11 A separate search was performed to identify studies that assessed inter-rater agreement of signs and symptoms of sinusitis. PubMed was searched using the search terms ("inter-rater" OR "interrater" OR "kappa") AND ("sinusitis" OR "sinus").…”

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

“…Patients with RARS who undergo ESS report improved symptoms and QoL and decreased missed work days, with mixed results on decreases in antibiotic and sinus medication utilization postoperatively. 26 Bubbles within sinus 30 Obstruction of the osteomeatal complex 30 Nasal endoscopy findings of ABRS Discolored discharge and purulent secretions within the nasal cavity 24,31 CT findings that predispose to RARS…”