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Guidelines

Acute Sinusitis – Diagnosis

Clinical Presentations

The “gold standard” for the diagnosis of acute sinusitis is antral puncture and cultures. However, this is not clinically practical (Herr, 1991; Gwaltney, 1981; Hamory, 1979). Maxillary antrum aspiration for culture is indicated only when precise microbial identification is required. Therefore, the diagnosis of acute bacterial rhinosinusitis (ABRS) is based primarily on the patient’s presenting symptoms and history, and is supported by the physical exam.

Table 5 summarizes the recommendations for the diagnosis of acute bacterial rhinosinusitis from the following societies and their guidelines:

  • Infectious Disease Society of America (IDSA) Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults (Chow, 2012)
  • American Academy of Otolaryngology (AAO) Clinical Practice Guideline (Update): Adult Sinusitis (Rosenfeld, 2015)
  • American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years (Wald, 2013)

There is consensus among these three organizations and the ICSI work group, that there are two clinical presentations where acute bacterial rhinosinusitis (ABRS) has a higher likelihood of being present:

  • Persistence of symptoms consistent with acute rhinosinusitis lasting 10 days or more without evidence of improvement
  • Symptoms are worsening – new onset of fever, headache or increase in nasal discharge after a viral upper-respiratory infection (VURI) that lasted five to six days and the patient was initially improving (double worsening or double sickening)

Recommendations are mixed for patients with severe symptoms and high fever of 102ºF for at least three to four days from onset of illness. The IDSA (Chow, 2012) and AAP (Wald, 2013)continue to recommend diagnosing these patients with bacterial sinusitis, while the AAO (Rosenfeld, 2015) has removed this indication for diagnosis. The ICSI work group was unable to identify primary literature discussing this clinical presentation in diagnosis of acute bacterial sinusitis. Therefore, the ICSI work group based its recommendation on whether to routinely use this clinical presentation as criteria to diagnose bacterial sinusitis upon the existing practice and the review of IDSA, AAO and AAP recommendations (summarized in Table 5).

Table 5: Summary of Recommendations for Diagnosis of Acute Bacterial Rhinosinusitis by IDSA, AAO and AAP

Imaging

Plain sinus x-rays and other imaging tests are not recommended in making the diagnosis of acute sinusitis.

The IDSA, AAO and AAP do not recommend obtaining imaging of any kind for patients who meet diagnostic for acute rhinosinusitis unless a complication or alternative diagnosis is suspected. If a complication or alternative diagnosis is suspected, then CT of the sinuses should be obtained (Rosenfeld, 2015; Wald, 2013; Chow, 2012). This recommendation is in alignment with the American College of Radiology (ACR) recommendation that most cases of uncomplicated acute and subacute rhinosinusitis are diagnosed clinically and should not require any imaging procedure. The ACR recommends that CT of the sinuses without contrast is the imaging method of choice in patients with recurrent acute sinusitis or chronic sinusitis, or to define sinus anatomy before surgery (Cornelius, 2013).

The ICSI work group conducted a literature search on this topic and did not find any new literature that contradicts the above recommendations.

ICSI

ICSI