University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• A 3 year old male with a temperature of 38.1 C, 3 days of purulent rhinorrhea, and a normal physical examination presents to the emergency room. Does he have sinusitis?

Clinical Bottom Lines

1. Articles focusing on accurately diagnosing children in the primary care setting are lacking.
2. The best predictors of acute sinusitis in children are URI symptoms for 14 days, purulent rhinitis, and pain.¹ This article failed to evaluate prolonged cough, which is thought by expert opinion to be a good predictor of sinusitis.³
3. Using the presence of the above signs and symptoms, the positive likelihood ratio is 3. Assuming 50% pre test probability, which is a number derived from the adult literature,² the post test probability of acute sinusitis is 70%.

Summary of Key Evidence

1. 175 patients (ages 1-15) with suspected sinusitis were surveyed for signs and symptoms of sinusitis, and then underwent 3 view sinus x ray examination. Nasopharyngeal and throat cultures were also obtained.¹
2. When all three "main" symptoms (pain, 14 days of URI, and purulent rhinitis) were present, and compared to X-ray, the sensitivity is 21%; the specificity is 93%. When two main symptoms are present, the sensitivity is 77%; specificity is 67%.
3. Nasopharyngeal and throat cultures do not predict pathology within the maxillary sinuses.
4. This study failed to consider cough as a prominent symptom of acute sinusitis, and only considered the "non-severe" form of sinusitis (no consideration of "severe" acute sinusitis).
5. It is not stated from where the 175 patients were recruited (i.e. primary care office versus ENT's office). It is unclear if the radiologist was blinded to the signs and symptoms questionnaire.
6. The sinus X-rays are used as reference test, when true gold standard for diagnosis is maxillary sinus puncture, or at least CT scan.

Additional Comments

• Acute sinusitis is diagnosed in 9% of all patients presenting to the pediatrician's office, and in 17% of children presenting with cough and cold symptoms.⁴
• Normal paranasal sinuses are dependent upon the patency of the sinus ostia, the functionality of the mucociliary apparatus, and the quality of nasal secretions. The patency of the ostia can be affected by many mechanisms, but most commonly is inflamed by viral or allergic inflammation. Nasopharyngeal bacteria enter the inflamed sinuses during times of altered intranasal pressure (i.e. sneezing), and thickened mucosal secretions and blocked sinus ostia prevent bacterial clearance.⁵
• Appropriate clinical signs and symptoms to diagnose non-severe acute sinusitis include prolonged URI symptoms, cough, purulent rhinorrhea, and pain. Additional studies include sinus x-rays ($204 charge) or screening sinus CT scan ($200 without sedation charge), and sinus puncture with culture.
• A meta-analysis of these different tests to diagnose acute sinusitis was recently published, but focuses primarily on the adult literature. This analysis highlights the lack of well-designed studies examining the issue of accurately diagnosing acute sinusitis, especially in the pediatric population.²

Citation

1. Jannert M, Andreasson L, Helin I, Petterson H. Acute sinusitis in children - symptoms, clinical findings and bacteriology related to initial radiologic appearance. Int J Pediatr Otorhinolaryngol 1982; 4: 139-148.
2. Engels E, Terrin N, Barza M, Lau J. Meta- analysis of diagnostic tests for acute sinusitis. J Clin Epidemiol 2000; 53:852-862.
3. Clement P, Bluestone C, Gordts F, Lusk R, Otten F, Goossens H, Scadding G, Takahashi H, van Buchem F, Van Causenberge P, Wald E. Management of rhinosinusitis in children: consensus meeting, Brussels, Belgium, September 13, 1996. Arch of Otolaryngol Head and Neck Surgery 1998; 124: 31-34.
4. Aitken M, Taylor M. Prevalence of clinical sinusitis in young children followed up by primary care pediatricians. Arch Pediatr Adolesc Med 1998; 152: 244-248.
5. Wald, ER. Sinusitis. Seminars in Pediatric Infectious Diseases 1995; 6: 79-84

CAT Author: Laura Kisloff, MD

CAT Appraisers: Robert Schumacher , MD

Date appraised: November 27, 2000