A patient presents to your office with a “bad cold.” Her symptoms began 5 days ago, when a runny nose, a scratchy throat, generalized malaise, and a nonproductive cough developed. Her symptoms are gradually improving with an over-the-counter cough medicine, but during the past 24 hours a “sinus headache” has developed. The patient is concerned that she may have “sinus.” It is the middle of cold and flu season, and this is the fifth patient you have treated today who has upper respiratory tract symptoms.
Why Is This an Important Question to Answer With a Clinical Examination?
The patient's story is familiar to primary care clinicians. Among the most frequent diagnoses made by primary care practitioners are nasal problems such as allergic and infectious rhinitis, vasomotor rhinitis, and bacterial sinusitis.1 Given the constant assault of allergens, environmental pollutants, respiratory viruses, and rapid temperature changes, it is not surprising that nasal complaints are so common. However, not all “sinus” is sinusitis. Sinusitis can be defined simply as inflammation of one or more paranasal sinuses but usually refers to infection of the sinuses. In recent years, many new medications have become available that allow effective medical treatment of sinus problems so that it is important to diagnose nasal complaints accurately to deliver appropriate treatment.2 When this can be accomplished by the clinical examination, it obviates the need for more expensive testing such as radiography.
The list of differential diagnoses for patients with nasal congestion or discharge is long (Table 45-1), but a handful of conditions encompass the majority of cases.3 These conditions can be divided into those causing inflammation of the nose (rhinitis) and those causing inflammation of the sinuses (sinusitis). Rhinitis is most frequently due to viral infection, allergens (seasonal or perennial), or vasomotor instability (eg, caused by extreme temperature change or excessive use of vasoconstrictive medications). When these conditions are severe, the sinus ostia may become blocked and the sinuses infected secondarily. However, the implications of diagnosing rhinitis are different from diagnosing sinusitis. Rhinitis may respond to antihistamines, nasal decongestants, nasal steroids, or cromolyn sodium, but randomized trials have shown that sinusitis requires antibiotics for rapid resolution.4, 5 Sinusitis also occurs as an occult illness that may be associated with asthmatic exacerbations or chronic headache. This overview will focus on the medical history and physical examination findings that distinguish bacterial sinusitis from rhinitis and other conditions.
Table 45-1Differential Diagnosis of Nasal Congestion/Rhinorrhea |Favorite Table|Download (.pdf) Table 45-1 Differential Diagnosis of Nasal Congestion/Rhinorrhea
|Seasonal allergic rhinitis (pollens)a |
|Perennial allergic rhinitis (dusts, molds)a |
|Idiopathic (vasomotor rhinitis)a |
|Abuse of nose drops (rhinitis medicamentosa)a |
|Drugs (reserpine, guanethidine, prazosin, cocaine abuse) |
|Psychological stimulation (anger, sexual arousal) |
|Deviated septum |
|Crusting (as in atrophic rhinitis) |
|Hypertrophied turbinates (chronic vasomotor rhinitis) |
|Foreign body |
|Central nervous system fluid leak |
|Chronic inflammatory |
|Wegener granulomatosis |
|Midline granuloma |
|Acute viral infectiona |
|Acute or chronic bacterial infection of paranasal sinusesa |
|Atrophic rhinitis (secondary infection) |
Sinusitis Requires Antibiotics for Rapid Cure
Reference Standard for Diagnosing Sinusitis
The reference (or gold) standard for diagnosing infectious sinusitis is sinus aspiration and culture. Its use is particularly appropriate for guiding antibiotic choice in patients with complicated or refractory sinusitis. However, in general practice, sinus radiographs are readily obtained and can be considered a pragmatic reference standard. A 4-view sinus series is highly concordant with a single Waters view,6, 7 and when it reveals sinus opacity, an air-fluid level, or 6 mm or more of mucosal thickening, a 4-view sinus series is 72% to 96% as accurate for maxillary sinusitis as aspiration and culture respectively.8, 9 The chief limitations of sinus radiographs are poor visualization of the ethmoid air cells and difficulty distinguishing between infection, tumor, and polyp in the completely opacified sinus. Other potentially useful diagnostic tests are ultrasonography and computed tomography. Ultrasonography is nonionizing but correlates only moderately well with sinus radiographs or sinus aspiration.10, 11, 12 Computed tomography of the sinuses is superior to sinus radiography for visualizing the ethmoid air cells, for evaluating opacified sinuses or mucoceles, and for differentiating the bony changes of chronic inflammation from osteomyelitis.13 Sinus computed tomography may become the diagnostic test of choice but is not as readily available as radiographs and has not been evaluated against sinus puncture. This caveat is important because computed tomography may be highly sensitive, yet lack specificity.14
Normal Anatomy and Pathophysiology of Sinusitis
The nose humidifies, warms, and filters inspired air as it passes through the nasal vestibule and over the nasal turbinates.15 The nasal turbinates promote turbulent air flow that causes particulate matter to fall on the nasal mucosa, where it is swept by ciliated pseudostratified columnar cells to the nasopharynx. Respiratory epithelium also lines the paranasal sinuses and creates drainage into the nasal cavity via the superior meatus (sphenoid and posterior ethmoid) and middle meatus (maxillary and anterior ethmoids) (Figure 45-1).16 Properly functioning ciliated cells are critical because maxillary sinus drainage is uphill (Figure 45-2). Patients predisposed to infectious sinusitis may have mucosal edema (eg, allergic rhinitis, viral rhinitis), mechanical obstruction of the meatus (eg, polyps, deviated nasal septum), or impaired ciliary activity (eg, Kartagener syndrome).3, 17 Under these conditions, viruses and bacteria proliferate in the poorly draining sinus and provoke acute sinusitis.
Sagittal View of Paranasal Sinuses
Coronal View of Paranasal Sinuses
How to Elicit the Relevant Symptoms and Signs
Although patients may give a simple description, such as “sinus trouble,” the examiner should seek a more complete medical history. Symptoms that may increase the likelihood of sinusitis include fever, malaise, cough, nasal congestion, maxillary toothache, purulent nasal discharge, little improvement with nasal decongestants, and headache or facial pain exacerbated by bending forward.
Examination of the nostrils can be performed with a short, wide speculum mounted on a handheld otoscope. The speculum should be directed posterolaterally, avoiding the sensitive nasal septum. The nasal mucosa should be inspected for color, edema, character of nasal secretions, polyps, and structure of the nasal septum (Figure 45-3). Purulent secretion from the middle meatus is reported to be highly predictive of maxillary sinusitis but may be difficult to see unless the examiner shrinks the nasal mucosa with a topical vasoconstrictive agent (eg, oxymetazoline hydrochloride) and uses a nasal speculum to enhance visualization.18 Septal deviation or nasal polyps are important findings because they may contribute to nasal obstruction and promote recurrent sinusitis.
Examination of the Nose Through an Otoscope With a Disposable Speculum
The middle meatus is usually not visible behind the turbinates.
Palpation for sinus tenderness should be performed over the maxillary and frontal sinuses (Figure 45-4). In addition, checking for tenderness by tapping the maxillary teeth with a tongue blade may be valuable because 5% to 10% of maxillary sinusitis is a result of dental root infection.19 The ethmoid and sphenoid sinuses cannot be adequately evaluated during the routine physical examination.
Surface Landmarks for Palpation of Frontal Sinuses (Left) and Maxillary Sinuses (Right)
Some experts recommend palpating the frontal sinuses by placing the fingers on the orbital roof below the eyebrow.
Transillumination of the maxillary sinuses may be performed by 2 methods. The best-studied method is performed by placing a Welch-Allyn-Finnoff transilluminator (Welch-Allyn Inc, Skaneateles Falls, New York) over the infraorbital rim, shielding the light source from the observer's eyes, and judging light transmission between sides through the hard palate (Figure 45-5). The examination must be performed in a completely darkened room after allowing the observer's vision to adapt fully to darkness. Obviously, the patient's dentures should be removed. Most experts report the transillumination results as opaque (no light transmission), dull (reduced light transmission), or normal (light transmission typical of a normal subject). An alternative method is to place a light source in the patient's mouth and have the patient make a tight seal around the transilluminator; the observer judges light transmitted through the maxillary sinuses. This technique has the advantage of being able to simultaneously compare sides but requires sterilization of the instrument between patient examinations.
Transillumination of the Maxillary Sinus
The light source should be shielded from the examiner's vision with the free hand.
The frontal sinuses can be examined by placing a light source below the supraorbital rim, but interpretation is difficult because the frontal sinuses naturally develop asymmetrically. This normal variation may falsely suggest sinusitis but is resolved by routine radiography.
Precision of Symptoms and Signs
A total of 111 patients with nasal complaints were examined by a general internist and a second examiner who was a physician assistant, internal medicine resident, or attending internist.20 Agreement was high between examiners for 11 of the 15 historical items, including headache (κ, 0.78); subjective fever, chills, or sweats (κ, 0.71); cough (κ, 0.68); colored nasal discharge (κ, 0.68); facial pain (κ, 0.65); and maxillary toothache (κ, 0.60). (Sackett21 gives a further explanation of the κ statistic and the other special terms and ideas used in this overview.) On physical examination, agreement was high only for sinus tenderness (κ, 0.59) and was fair for maxillary sinus transillumination (simple agreement, 61%; κ, 0.22). In the only other study of observer variability for transillumination, otolaryngologists also had modest agreement between examiners for the maxillary sinuses (simple agreement, 62%), but agreement was good for the frontal sinuses (simple agreement, 95%).22
Observer agreement is high for most patient symptoms, but for the physical examination agreement is high only for sinus tenderness.
Accuracy of Symptoms and Signs of Sinusitis
There have been few attempts to systematically evaluate the accuracy of the clinical examination for sinusitis. Three studies assessed the discriminate ability of sinusitis symptoms and signs in adults. One evaluated 69 historical items among 164 consecutive patients with sinusitis suspected by the patient or otolaryngologist.23 These symptoms were compared to a reference standard of 4-view radiography (Caldwell, Waters, lateral, and submental vertex projections). Six symptoms (preceding upper respiratory infection, any nasal discharge or purulent nasal discharge, painful mastication, malaise, cough, and hyposmia) were significantly (P < .01) more common in patients with abnormal radiographs, but no single finding was highly accurate.
We compared symptoms to radiograph in 247 consecutive male patients who had rhinorrhea or facial pain unrelated to trauma or who suspected they might have sinusitis.20 Colored nasal discharge, cough, and sneezing were the most sensitive symptoms (72%, 70%, and 70%, respectively) but were not specific (52%, 44%, and 34%, respectively). One symptom, maxillary toothache, was highly specific (93%), but only 11% of patients reported this symptom. Historical items thought to make sinusitis less likely, such as sore throat (sensitivity, 52%; specificity, 56%), itchy eyes (sensitivity, 52%; specificity, 43%), and constitutional symptoms (sensitivity, 56%; specificity, 47%), were not useful.
A third study compared symptoms to ultrasonographic findings in 400 general practice patients selected for study because their physician intended to test or treat for sinusitis.24 Results from this study should be interpreted with caution because the reference standard (ultrasonography) was not interpreted independent of the clinical findings and is less accurate than radiography.11, 12 In the study by van Duijn et al,24 preceding common cold (sensitivity, 85%; specificity, 28%), pain at bending forward (sensitivity, 65%; specificity, 59%), and purulent rhinorrhea (sensitivity, 62%; specificity, 67%) were the most useful findings. Toothache was found to be highly specific (specificity, 83%).
Table 45-2), but the discriminating power of these findings is not known.25, 26, 27, and 28
Table 45-2Sensitivities (%) for Signs and Symptoms of Acute Sinusitis in Children |Favorite Table|Download (.pdf) Table 45-2 Sensitivities (%) for Signs and Symptoms of Acute Sinusitis in Children
|Sign or Symptom ||Source |
|Swischuk et al25 (n = 63) ||Wald et al26 (n = 30) ||McClean27 (n = 25) ||Kogutt and Swischuk28 (n = 96) |
|Nasal discharge ||76 ||77 ||84 ||77 |
|Cough ||60 ||80 ||60 ||48 |
|Headache ||48 ||33 ||…a ||… |
|Fever ||46b ||63b ||12c ||21c |
|Facial pain or swelling ||… ||30 ||8d ||… |
|Fetor oris ||… ||50 ||… ||… |
The most studied but least understood physical examination maneuver is paranasal sinus transillumination.5, 8, 20, 22, 25, 27, 29, 30, 31, and 32 Since the technique was first described in 1889 by Voltolini,33 its value as a diagnostic test has been hotly debated. Several authors have described transillumination as “highly predictive of disease,” whereas another author has described the use of transillumination as an act of criminal negligence.34 Most studies of transillumination have methodologic limitations, and 2 of the more complete studies had differing results.20, 30
Our own study compared the results of transillumination to paranasal sinus radiographs in 247 consecutive patients with nasal symptoms who were treated in general medicine clinics at a Veterans Affairs medical center.20 Transillumination, using a Welch-Allyn-Finnoff transilluminator or Mini MagLite (Mag Instrument Inc, Ontario, California) placed over the infraorbital rim, did little to change the posttest probability of sinusitis. It generated a likelihood ratio (LR) of only 1.6 if either maxillary sinus was dull or opaque and 0.5 if both maxillary sinuses transilluminated normally. Clearly, as a single finding, transillumination could not be relied on to rule in or rule out sinusitis.
The second study included 113 patients with nasal symptoms and abnormal sinus radiographs and found different results.30 In the subset of these patients who were examined by an otolaryngologist (using the same transillumination technique as our study), transillumination was highly useful when the sinus was either completely opaque (LR, ∞) or completely normal (LR, 0.04) but less useful when the finding was dull transillumination (LR, 0.41). In contrast to the previous study, opaque transillumination ruled in sinusitis and normal transillumination ruled out sinusitis.
Why did these 2 studies yield such disparate results? First, the study populations were different (a primary care walk-in clinic vs an otolaryngology clinic) and may have created different degrees of expectation bias. Second, the examiners’ training was different; otolaryngologists may be better transilluminators than general internists. These 2 studies suggest that transillumination may be more useful for diagnosing sinusitis when performed by otolaryngologists.
Because the paranasal sinuses develop at different rates among children, transillumination may be less reliable than in adult patients. Three studies have examined the value of transillumination in children. In one, the examination could not be performed in 24% of the children because of poor patient cooperation.5 For the remaining children, there was agreement between transillumination and radiographic findings in 53% and disagreement in 27%, and transillumination was nondiagnostic in 20%.5 The other 2 studies reported sensitivities of only 76% (19/25) in one27 and 48% (23/48) in the other, which was performed in children with opaque maxillary sinuses on radiographs who were undergoing sinus drainage for chronic purulent sinusitis.32 The sensitivity of transillumination should have been maximal in this latter patient group with severe disease but nevertheless performed poorly.
Information is limited for other commonly assessed physical examination components. In adults, sinus tenderness was found to have poor sensitivity and specificity (48% to 50% and 62% to 65%, respectively),20, 24 but other findings (temperature, nasal mucosal color, and percussion tenderness of the maxillary teeth) have not been well studied. In children, tympanic membrane changes from otitis media (sensitivity, 68%) is the most common physical examination finding associated with sinusitis, whereas a documented temperature higher than 38.3°C (101°F) (sensitivity, 12% to 21%) is uncommon.27, 28
Accuracy of Combinations of Symptoms and Signs
Despite the poor accuracy of the individual symptoms and signs, these findings used in combination can be diagnostic for sinusitis. We used logistic regression modeling to identify signs and symptoms that best predict sinusitis. This statistical procedure selects findings that independently contribute toward making the diagnosis of sinusitis. Three symptoms (maxillary toothache, poor response to nasal decongestants, and history of colored nasal discharge) and 2 signs (purulent nasal secretion and abnormal transillumination) were the best predictors of sinusitis (Table 45-3).20 When none of these findings were present, sinusitis could be ruled out (LR, 0.1), and when 4 or more were present, the LR was 6.4 (Table 45-4). One study compared 11 clinical findings elicited by experienced otolaryngologists with radiograph and maxillary sinus aspiration in 155 patients presenting to an emergency department with suspected sinusitis.35 With similar statistical techniques, a history of purulent rhinorrhea or unilateral sinus pain and the presence of pus in the nasal cavity on examination were highly predictive of sinusitis. Maxillary toothache, response to decongestants, and transillumination were not studied.
Table 45-3Independent Predictors of Sinusitisa |Favorite Table|Download (.pdf) Table 45-3 Independent Predictors of Sinusitisa
|Symptom or Sign ||LR+ (95% CI) ||LR– (95% CI) |
|Maxillary toothache ||2.5 (1.2-5.0) ||0.9 (0.8-1.0) |
|Purulent secretion ||2.1 (1.5-3.0) ||0.7 (0.5-0.8) |
|Poor response to decongestants ||2.1 (1.4-3.1) ||0.7 (0.6-0.9) |
|Abnormal transillumination ||1.6 (1.3-2.0) ||0.5 (0.4-0.7) |
|History of colored nasal discharge ||1.5 (1.2-1.9) ||0.5 (0.4-0.8) |
Table 45-4Likelihood Ratios by Number of Signs and Symptoms Presenta |Favorite Table|Download (.pdf) Table 45-4 Likelihood Ratios by Number of Signs and Symptoms Presenta
|No. of Symptoms and Signs ||Sinusitis Present ||Sinusitis Absent ||LR |
|≥4 ||16 ||4 ||6.4 |
|3 ||29 ||18 ||2.6 |
|2 ||27 ||39 ||1.1 |
|1 ||14 ||48 ||0.5 |
|0 ||2 ||32 ||0.1 |
|Total ||88 ||141 ||…b |
Physicians appear able to integrate individual signs and symptoms into an overall assessment that accurately diagnoses sinusitis. In our study, an overall impression that sinusitis was “definitely or most likely present” generated an LR of 4.7, and an overall impression that sinusitis was “unlikely or definitely absent” generated a rather low LR of 0.4. When the impression was intermediate, the LR was 1.4.20, 36 These findings are in agreement with a study that investigated otolaryngologists’ ability to diagnose purulent sinusitis in patients with chronic symptoms. In the study by Berg et al,37 the overall clinical evaluation was compared with sinus aspiration, with the following results: definitely sinusitis, LR = 19; probably sinusitis, LR = 4; probably not sinusitis, LR = 0.14; definitely not sinusitis, LR = 0.19. The general internist's overall assessment of the likelihood of sinusitis performs well compared with radiograph or sinus aspiration.
To summarize, primary care practitioners frequently evaluate patients with nasal symptoms, and in many instances, sinusitis can be confidently ruled in or ruled out according to the clinical examination. Further studies are needed to examine clinical findings that have not been studied (such as headache when leaning forward) and to test whether the 5 clinical findings found to be useful for adult men can be exported to other patient populations.
Sinusitis is insidious in children. Concurrent otitis media is common.
Considered in combination, maxillary toothache, poor response to nasal decongestants, abnormal transillumination, and colored nasal discharge by medical history or examination are the most useful clinical findings in primary care populations. When all 5 features are present, the odds of sinusitis increase sharply (LR, 6.4), and when none are present, sinusitis is ruled out.
Transillumination requires a completely darkened room, adequate time for dark adaptation, and practice.
The overall medical history and physical examination in symptomatic adult patients is accurate.
Author Affiliations at the Time of the Original Publication
Division of General Internal Medicine, University of Texas Health Sciences Center at San Antonio, and the Ambulatory Care Service, Audie L. Murphy Memorial Veterans’ Hospital, San Antonio, Texas (Dr Williams); Ambulatory Care Service and the Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, and the Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina (Dr Simel).
This work was supported in part by a grant from the A. W. Mellon Foundation and Veterans Affairs Health Services Research and Development grant 89-065.A.
The authors wish to thank Donald Hitch, MD, for reviewing an early draft of this manuscript.
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