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

To the Editor: Thank you for the invitation to comment on this important publication by Ebell & Hansen (1). I enjoyed reading this paper which is an extension of their original study first published in 1995 (2). The most important contribution of this publication is in promoting the methodologies adopted by these authors for establishing clinical decision rules for acute bacterial rhinosinusitis using stepwise logistic regression analyses and CART algorithms. These should be adopted as gold standards for future investigations of acute bacterial rhinosinusitis. Since the identical dataset collected during 1992-1994 was re-analysed, there were few surprises in their conclusions which placed undue emphasis on a history of preceding upper respiratory tract infection, unilateral maxillary sinus tenderness, maxillary toothache, purulent nasal discharge and elevated C-reactive protein in their point scores for predicting bacterial infection. Importantly, the duration of symptoms was not included in their univariate analysis even though this information was collected in their original database (2). Furthermore, important modalities adopted by most modern clinical practice guidelines for predicting bacterial vs. viral acute rhinosinusitis [i.e. persistent illness (>10 days), severe onset (>3 days), or worsening course with "double-sickening" (>3 days)] were not available for analyses (3,4). These serious limitations cast doubt on the applicability and utility of their proposed clinical decision rules for clinical practice in 2017. Sadly, whether such studies that include additional modern-day predictors can be repeated and validated is in question in light of the reluctance for performing sinus punctures by physicians and patients alike.

Anthony W. Chow MD, FRCPC, FACP Professor Emeritus, Division of Infectious Diseases, Department of Medicine University of British Columbia and Vancouver Hospital Health Sciences Center Vancouver, British Columbia, Canada

References

(1) Ebell MH, Hansen JG. Proposed Clinical Decision Rules to Diagnose Acute Rhinosinusitis Among Adults in Primary Care. Ann Fam Med. 2017;15(4):347-354.

(2) Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting acute maxillary sinusitis in a general practice population [see comments]. BMJ. 1995;311(6999):233-236.

(3) Chow AW, Benninger MS, Brook I et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72-e112.

(4) Wald ER, Applegate KE, Bordley C et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.

Competing interests: None declared