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Make the Diagnosis: Sinusitis

Prior Probability

Among general medical patients with suspected sinusitis, the prevalence of disease as determined by sinus puncture and culture is 50%.

Population for Whom Sinusitis Should Be Considered

Sinusitis may be thought of as “rhinosinusitis” to emphasis the role of nasal symptoms but requires additional clinical research to determine whether the change in terminology requires a change in management approaches. Sinusitis should be considered in patients with nasal stuffiness, nasal discharge, or maxillary facial pain. Many patients will present with a self-suspicion of sinusitis.

Detecting the Likelihood of Sinusitis in Adults

The presence of 4 or more findings (maxillary toothache, purulent nasal secretion, poor response to decongestant, abnormal transillumination request, patient report of colored nasal discharge) makes sinusitis much more likely, whereas the absence of any of the findings makes sinusitis unlikely (Table 45-6).

Table 45-6Likelihood Ratios for Radiographs and the Clinical Findings for Sinusitis

Reference Standard Tests

Sinus puncture with culture serves as the reference standard for research. Clinicians will prefer to use sinus radiographs, although some patients (approximately 20%) will be misclassified. A recent panel of experts accepts an abnormal radiographic result as evidence of acute bacterial rhinosinusitis for patients with appropriate symptoms.5

Original Article: Does This Patient Have Sinusitis?

Clinical Scenario

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 ...

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