Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis

Mark H. Ebell; Brian McKay; Ariella Dale; Ryan Guilbault; Yokabed Ermias

doi:10.1370/afm.2354

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Table 1

Characteristics of Included Studies (N = 17)

Study	Population	Age Data	Reference Standard	Country	Risk of Bias
Referral setting (ENT, respiratory, or allergy clinic)
McNeill,¹³ 1963	Adults and children (n = 150, 242 sinuses) referred to ENT clinic for clinically suspected ARS	Range ≥10 y (10-19 y, n = 22; ≥20 y, n = 128)	Radiography showing mucosal thickening or any opacity	Northern Ireland	High
Axelsson et al,²¹ 1976	Consecutive adults (n = 164) at ENT clinic with clinically suspected acute maxillary sinusitis	Mean 35 y	Radiography (at least 4 views) showing any mucosal thickening, air-fluid levels, or opacification	Sweden	Moderate
Berg et al,¹⁵ 1981	Adults (n = 50) at ENT clinic with clinically suspected ARS of ≥3 weeks duration	Mean 46 y	Antral puncture revealing purulent discharge	Sweden	High
Berg et al,²² 1985	Adults (n = 90) at ENT clinic with clinically suspected ARS of ≥3 weeks duration	Not reported	Antral puncture revealing purulent discharge	Sweden	Moderate
van Buchem et al,⁵ 1995	Adults (n = 113) referred to ENT clinic with clinically suspected acute maxillary sinusitis	42% 18-29 y; 34% 30-44 y; 16% 45-59 y; and 9% ≥60 y	(1) Antral puncture showing fluid or floccules (by patient) and (2) bacterial culture of fluid (by sinus)	Netherlands	Low
Visca et al,²³ 1995	Children (n = 30) at pediatric respiratory clinic with clinically suspected ARS	Range 5-15 y	CT scan abnormal in coronal projection	Italy	High
Huang et al,²⁴ 2008	Consecutive adults and children (n = 217) at allergy clinic with clinically suspected ARS of <3 weeks duration	Range 4-61 y (4-9 y, n = 89; 10-19 y, n = 101; ≥20 y, n = 27)	Sinus radiograph (n = 151) or CT scan (n = 12) with >4 mm mucosal thickening, air-fluid levels, and/or increased opacity or retention cyst	USA	High
Primary care, urgent care, or emergency department setting
Berg et al,²⁵ 1988	Adults (n = 155) presenting to ED with clinically suspected maxillary sinusitis of <3 months duration	Mean 38 y	Antral puncture with return of purulent or cloudy fluid	Sweden	Moderate
Williams et al,²⁶ 1992	Consecutive men (n = 247) presenting to VA general medicine clinic with <3 months of self-described sinusitis or at least 1 sinus symptom–median symptom duration of 11 days	Median 50 y, IQ range 40-63 y	Radiographs (4 views): mucosal thickening ≥6 mm, complete opacity, or air-fluid level	USA	Moderate
van Duijn et al,²⁷ 1992	Adults (n = 400, 441 episodes) presenting to primary care clinic with clinically suspected ARS	Range ≥15 y	Ultrasonography abnormal	Netherlands	Moderate
Hansen et al,⁴ 1995	Consecutive adults (n = 174) at primary care clinic suspected of having acute maxillary sinusitis by their general practitioner	Median 35 y, range 18-65 y	CT scan abnormal and culture of purulent fluid positive for pathogenic bacteria	Denmark	Low
Lindbaek et al,¹² 1996	Adults (n = 201) clinically diagnosed by primary care doctor with ARS requiring antibiotics	Mean 37.8, range 15-83 y	CT scan showing air-fluid level or complete opacification	Norway	High
Laine et al,²⁸ 1998	Consecutive adults (n = 39) presenting to primary care clinic with clinically suspected acute maxillary sinusitis of <30 days duration	Median 37 y, range 16-68 y	Nasal aspirate with purulent or mucopurulent material	Finland	Low
Varonen et al,²⁹ 2003	Consecutive adults (n = 148) presenting to a primary care clinic with clinically suspected ARS of <30 days duration, 72% >5 days	Mean 39.7 y, range 18-75 y	Sinus radiographs (AP and Waters’ views) showing total opacification, air-fluid level, or mucosal thickening ≥6 mm	Finland	High
Thomas et al,³⁰ 2006	Adults (n = 60) presenting to a VA urgent care center with clinically suspected ARS of <4 weeks duration	Mean 51 y, range 25-83 y	CT scan showing air-fluid level or complete opacification (mucosal thickening alone was not considered diagnostic)	USA	Moderate
Shaikh et al,³¹ 2013	Children (n = 258) at a general pediatric clinic with clinically suspected ARS of <30 days durations (mean symptom duration 14 days)	Mean 6.4 y, range 2.0-12.9 y	Radiographs (AP and Water’s views): complete opacification or any mucosal thickening	USA	Moderate
Autio et al,³² 2015	Adults (n = 50) presenting to a military clinic with clinically suspected ARS of <4 days duration (symptoms recorded at 9-10 days after onset)	Mean 20 y, range 18-23 y	CT followed by antral puncture and bacterial culture if positive	Finland	Low

AP = anteroposterior; ARS = acute rhinosinusitis; CT = computed tomography; ED = emergency department; ENT = ear, nose, and throat; IQ = interquartile; USA = United States of America; VA = Veterans Administration.

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Table 2

Prevalence of ARS and ABRS in the Included Study Populations

Study	Reference Standard	No.	Prevalence, %
Studies of adults
Berg et al,¹⁵ 1981	Antral puncture^a	50	50
Berg et al,²² 1985	Antral puncture^a	90	48
Berg et al,²⁵ 1988	Antral puncture^a	155	44
Hansen et al,⁴ 1995	Antral puncture^a	174	53
Van Buchem et al,⁵ 1995	Antral puncture^a	108	49
Laine et al,²⁸ 1998	Antral puncture^a	39	51
Summary for antral puncture, % (95% CI)			49 (45-53)
Hansen et al,⁴ 1995	Bacterial culture^b	174	35
Van Buchem et al,⁵ 1995	Bacterial culture^b	113	34
Autio et al,³² 2015	Bacterial culture^b	43	19
Summary for bacterial culture, % (95% CI)			31 (24-40)
Lindbaek et al,¹² 1996	CT	201	63
Thomas et al,³⁰ 2006	CT	60	45
Van Duijn et al,²⁷ 1992	Ultrasound	423	49
Varonen et al,²⁹ 2003	Radiograph	32	41
Williams et al,²⁶ 1992	Radiograph	247	39
Axelsson et al,²¹ 1976	Radiograph	164	63
Summary for imaging, % (95% CI)			51 (48-54)
Summary for studies with adults only, % (95% CI)			48 (42-54)
Studies of adults and children
McNeill,¹³ 1963	Radiograph	242	56
Huang et al,²⁴ 2008	Radiograph	217	70
Summary for studies with adults and children, % (95% CI)			63 (49-75)
Studies of children
Visca et al,²³ 1995	CT	30	57
Shaikh et al,³¹ 2013	Radiograph	258	79
Summary for studies with children only, % (95% CI)			70 (45-87)

ABRS = acute bacterial rhinosinusitis; ARS = acute rhinosinusitis; CT = computed tomography.
↵a A positive antral puncture required return of purulent fluid.
↵b Bacterial culture of fluid obtained during antral puncture.

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Table 3

Accuracy of Signs and Symptoms of ARS Diagnosed by Any Reference Standard

Sign or Symptom	# of Studies	Sensitivity (95% CI)	Specificity (95% CI)	LR+ (95% CI)^a	LR− (95% CI)^a	DOR (95% CI)^b
Overall clinical impression	4	0.73 (0.66-0.79)	0.75 (0.64-0.84)	3.0 (2.1-4.4)^c	0.37 (0.29-0.46)^c	8.3 (4.9-13.1)^c
Symptoms
Nasal speech	3	0.51 (0.15-0.85)	0.73 (0.35-0.93)	1.9 (1.3-2.7)^c	0.67 (0.37-0.91)^c	2.9 (1.8-4.3)^c
Pain in teeth	8	0.34 (0.21-0.50)	0.80 (0.63-0.90)	1.8 (1.2-2.5)^c	0.83 (0.74-0.90)^c	2.1 (1.4-3.0)^c
Nasal discharge
Purulent	10	0.71 (0.63-0.78)	0.54 (0.48-0.61)	1.6 (1.4-1.7)^c	0.54 (0.44-0.56)^c	2.9 (2.2-3.7)^c
Any	4	0.75 (0.57-0.91)	0.49 (0.35-0.68)	1.5 (1.3-1.8)^c	0.49 (0.24-0.82)^c	3.5 (1.7-6.2)^c
Maxillary or frontal pain	3	0.49 (0.15-0.83)	0.63 (0.14-0.95)	1.50 (0.86-3.50)	0.89 (0.61-1.40)	1.90 (0.61-4.50)
Maxillary pain
Unilateral	5	0.30 (0.14-0.52)	0.80 (0.51-0.94)	1.50 (0.96-2.60)	0.90 (0.79-1.00)^c	1.70 (0.92-3.00)
Location not specified	5	0.70 (0.42-0.88)	0.20 (0.05-0.51)	0.88 (0.73-1.00)^c	1.60 (0.95-2.80)	0.60 (0.30-1.10)
Cacosmia^d	5	0.23 (0.15-0.33)	0.84 (0.58-0.95)	1.50 (0.63-3.70)	0.96 (0.83-1.20)	1.70 (0.53-4.30)
Double sickening	3	0.74 (0.32-0.95)	0.41 (0.13-0.77)	1.30 (0.77-2.40)	0.69 (0.20-1.50)	2.70 (0.49-8.50)
Hyposmia or anosmia	8	0.61 (0.52-0.70)	0.54 (0.46-0.61)	1.3 (1.1-1.5)^c	0.72 (0.59-0.87)^c	1.9 (1.3-2.5)^c
Cough
Nocturnal	3	0.89 (0.80-0.94)	0.11 (0.06-0.19)	0.99 (0.87-1.10)	1.20 (0.43-2.60)	1.10 (0.35-2.60)
Any	7	0.69 (0.57-0.80)	0.40 (0.27-0.55)	1.3 (1.0-1.7)^c	0.78 (0.60-0.98)^c	1.5 (1.0-2.2)^c
Preceding respiratory tract infection	5	0.87 (0.66-0.96)	0.27 (0.13-0.48)	1.2 (1.1 -1.3)^c	0.48 (0.30-0.72)^c	2.6 (1.6-4.0)^c
Pain bending forward	5	0.72 (0.56-0.84)	0.39 (0.24-0.57)	1.2 (1.0-1.5)^c	0.71 (0.50-0.97)^c	1.70 (0.97-2.70)
Nasal congestion or obstruction	9	0.83 (0.74-0.89)	0.24 (0.14-0.36)	1.1 (1.0-1.2)^c	0.73 (0.56-0.93)^c	1.5 (1.1-2.1)^c
Fatigue or malaise	6	0.62 (0.51-0.71)	0.45 (0.32-0.59)	1.10 (0.99-1.30)	0.86 (0.72-1.00)^c	1.30 (0.98-1.80)
Sneezing	3	0.63 (0.49-0.74)	0.39 (0.31-0.48)	1.00 (0.86-1.20)	0.96 (0.71-1.20)	1.10 (0.70-1.20)
Headache	6	0.50 (0.32-0.67)	0.50 (0.27-0.73)	1.00 (0.71-1.30)	1.00 (0.79-1.40)	1.00 (0.57-1.70)
Allergies by history	3	0.19 (0.16-0.24)	0.79 (0.72-0.85)	0.96 (0.64-1.40)	1.00 (0.93-1.10)	0.96 (0.57-1.50)
Postnasal drip	3	0.74 (0.55-0.87)	0.19 (0.07-0.45)	0.94 (0.73-1.30)	1.50 (0.64-3.40)	0.80 (0.23-2.00)
Previous sinusitis	4	0.59 (0.52-0.65)	0.27 (0.18-0.39)	0.81 (0.71-0.93)^c	1.6 (1.1-2.2)^c	0.55 (0.33-0.83)^c
Signs
Purulent secretions
Middle meatus	5	0.15 (0.07-0.28)	0.95 (0.87-0.98)	3.2 (1.4-6.6)^c	0.90 (0.78-0.97)^c	3.7 (1.5-7.6)^c
Pharyngeal or postnasal	7	0.14 (0.06-0.30)	0.92 (0.77-0.97)	1.8 (1.1-2.8)^c	0.93 (0.87-0.98)^c	2.0 (1.2-3.1)^c
Any nasal	12	0.39 (0.28-0.51)	0.74 (0.63-0.82)	1.50 (0.99-2.30)	0.84 (0.67-1.00)^c	1.90 (0.98-3.30)
Transillumination abnormal	3	0.69 (0.63-0.75)	0.56 (0.50-0.62)	1.6 (1.4-1.9)^c	0.55 (0.44-0.67)^c	3.0 (2.0-4.2)^c
Sinus tenderness
Frontal	3	0.25 (0.09-0.54)	0.75 (0.47-0.91)	1.10 (0.76-1.40)	0.99 (0.86-1.10)	1.10 (0.70-1.60)
Maxillary	12	0.44 (0.28-0.61)	0.49 (0.34-0.64)	0.88 (0.57-1.30)	1.20 (0.80-1.60)	0.81 (0.37-1.30)
Nasal mucosal thickening	3	0.82 (0.27-0.98)	0.30 (0.15-0.51)	1.10 (0.49-1.40)	0.68 (0.09-1.60)	3.00 (0.32-13.00)
Temperature >38° C	7	0.11 (0.07-0.19)	0.87 (0.79-0.92)	0.94 (0.42-1.90)	1.00 (0.91-1.10)	0.94 (0.37-2.10)

ARS = acute rhinosinusitis; DOR = diagnostic odds ratio; LR+ = positive likelihood ratio; LR− = negative likelihood ratio.
Note: Each sign or symptom was reported in 3 or more studies to be included here.
↵a A likelihood ratio near 1.0 means that the test adds little diagnostic information, a likelihood ratio >1 increases the likelihood of disease, and a likelihood ratio <1 decreases the likelihood of disease.
↵b The diagnostic odds ratio is LR+ divided by LR− and is an overall measure of diagnostic discrimination.
↵c Value is significantly < or > 1.0.
↵d Cacosmia is fetid odor on patient’s breath.

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Table 4

Accuracy of Signs and Symptoms of ABRS Diagnosed by Purulent Antral Puncture or Positive Bacterial Culture

Sign or Symptom	# of Studies	Sensitivity (95% CI)	Sensitivity (95% CI)	LR+ (95% CI)^a	LR− (95% CI)^a	DOR (95% CI)^b
Overall clinical impression	3	0.74 (0.61-0.84)	0.80 (0.72-0.87)	3.9 (2.4-5.9)^c	0.33 (0.20-0.50)^c	13.0 (5.0-27)^c
Symptoms
Cacosmia^d	3	0.23 (0.11-0.42)	0.93 (0.59-0.99)	4.3 (0.94-14)	0.86 (0.76-0.99)^c	5.0 (0.74-18)
Pain in teeth	3	0.38 (0.10-0.78)	0.80 (0.37-0.97)	2.0 (1.1-3.7)^c	0.77 (0.50-0.96)^c	2.7 (1.3-4.6)^c
Purulent nasal discharge	3	0.64 (0.45-0.79)	0.50 (0.36-0.63)	1.3 (0.99-1.6)	0.74 (0.47-1.0)	1.8 (0.98-3.2)
Pain bending forward	3	0.64 (0.4-0.79)	0.38 (0.20-0.60)	1.0 (0.87-1.3)	0.95 (0.69-1.3)	1.2 (0.69-1.8)
Nasal congestion or obstruction	4	0.71 (0.57-0.82)	0.25 (0.10-0.52)	0.98 (0.83-1.3)	1.3 (0.70-2.3)	0.88 (0.38-1.8)
Cough	3	0.66 (0.34-0.86)	0.29 (0.12-0.55)	0.93 (0.70-1.1)	1.2 (0.79-1.7)	0.84 (0.45-1.4)
Physical examination
Sinus tenderness, maxillary	5	0.33 (0.13-0.61)	0.57 (0.40-0.73)	0.86 (0.23-2.2)	1.2 (0.55-2.1)	0.97 (0.11-3.9)
Nasal discharge, purulent	5	0.27 (0.20-0.35)	0.66 (0.45-0.82)	0.88 (0.36-1.9)	1.2 (0.57-1.8)	0.83 (0.22-2.3)

ABRS = acute rhinosinusitis; DOR = diagnostic odds ratio; LR+ = positive likelihood ratio; LR− = negative likelihood ratio.
Note: Each sign or symptom was reported in 3 or more studies to be included here.
↵a A likelihood ratio near 1.0 means that the test adds little diagnostic information, a likelihood ratio >1 increases the likelihood of disease, and a likelihood ratio <1 decreases the likelihood of disease.
↵b The diagnostic odds ratio is LR+ divided by LR− and is an overall measure of diagnostic discrimination.
↵c Value is significantly < or > 1.0.
↵d Cacosmia is fetid odor on patient’s breath.

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Table 5

Combinations of Findings and Clinical Decision Rules for the Diagnosis of Acute Sinusitis

Study	Reference Standard	Findings	Interpretation
Study	Reference Standard	Findings	Result	Likelihood Ratio (95% CI)	Probability of Sinusitis, %^a
Diagnosis of ARS
Huang et al,²⁴ 2008^b	Radiograph (n = 205) or CT (n = 12)	Leukocyte esterase: <1+ = 0, 1+ = 2, ≥2+ = 3	4-11	127.0 (8.1-2016.0)	99
		Leukocyte esterase: <1+ = 0, 1+ = 2, ≥2+ = 3	2-3	0.23 (0.10-0.52)	13
		pH: <7.5 = 0, 7.5 = 1, 8.0 = 2, 8.5 = 3 Nitrite: none = 0, light pink = 1, dark pink = 2 Protein: <2+ = 0, 2+ = 1, 3+ = 2, 4+ = 3	0-1	0.00 (0.00-0.06)	0
Lindbaek et al,¹² 1996	CT	Double sickening	4	25.0 (3.5-177.0)	94
		Purulent secretion in nasal cavity	3	1.8 (1.1-3.2)	55
		Purulent rhinorrhea (symptom)	2	0.81 (0.51-1.30)	35
		ESR >10	0-1	0.16 (0.09-0.30)	10
Williams et al,²⁶ 1992	Radiograph	Maxillary toothache	4-5	6.4 (2.2-19.0)	81
		Abnormal transillumination	3	2.6 (1.5-4.4)	63
		Poor response to decongestants or antihistamines	2	1.10 (0.73-1.70)	42
		Poor response to decongestants or antihistamines	1	0.43 (0.27-0.80)	22
		Colored nasal discharge Mucopurulence on examination	0	0.16 (0.04-0.41	10
Van Diujn et al,²⁷ 1992	Ultrasound (A mode)	Beginning with common cold	5	…	89^c
		Purulent rhinorrhea	1-4	…	18-82
		Pain at bending Unilateral maxillary pain Pain in teeth	0	…	11
Diagnosis of ABRS
Berg et al,²⁵ 1988	Purulent antral puncture fluid	Purulent rhinorrhea with unilateral predominance	3-4	7.0 (3.9-12.7)	82
		Purulent rhinorrhea with unilateral predominance	2	1.30 (0.72-1.9)	46
		Local pain with unilateral predominance Bilateral purulent rhinorrhea Pus in nasal cavity	0-1	0.06 (0.02-0.17)	4
Ebell et al,³⁶ 2017	Positive bacterial culture from antral fluid	Tender maxillary sinus (unilateral): 2 points	7-8	5.0 (1.8-14)	77
		Tender maxillary sinus (unilateral): 2 points	4-6	1.8 (1.3-2.5)	55
		Maxillary toothache: 2 points C-reactive protein >15 mg/L: 2 points Preceding upper respiratory tract illness: 1 point Purulent nasal discharge: 1 point Previous sinusitis episodes: −1 point	−1-3	0.35 (0.21-0.56)	19

ABRS = acute bacterial rhinosinusitis; ARS = acute rhinosinusitis; CT = computed tomography; ESR = erythrocyte sedimentation rate; LR = likelihood ratio.
↵a Calculated using the score-specific LR and a pretest probability of 40%, or taken directly from logistic model for each study.
↵b Results obtained from application of a urinalysis dipstick to nasal secretions.
↵c Probability of sinusitis calculated directly from logistic regression, so LR and its CI not estimable. Each variable is assigned a value of 1 for the presence of each finding and 0 for the absence. The score = −2.124 + 1.035*(beginning with common cold) + 0.996*(purulent rhinorrhea) + 0.95*(pain at bending) + 0.64*(unilateral maxillary pain) + 0.606*(pain in the teeth). A person with all findings present would have a maximum score of 2.103. The probability of sinusitis is calculated from exp(score)/[1 + exp(score)], so exp(2.103)/[1 + exp(2.103)]=89%. A person with none of the findings present would have a score of −2.124, or a probability of 11%.

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The Article in Brief

Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis

Mark H. Ebell , and colleagues

Background Although acute rhinosinusitis (sinus inflammation) is the most common reason for outpatient prescription of antibiotics, only about one-third of patients with sinus symptoms have a confirmed bacterial pathogen that is amenable to antibiotics. Helping physicians more accurately identify patients with acute bacterial rhinosinusitis could reduce inappropriate antibiotic use and its harms. This study analyzes existing research to evaluate the accuracy of signs and symptoms of acute rhinosinusitis.

What This Study Found Based on an analysis of existing research, three symptoms can help clinicians identify patients with the bacterial rhinosinusitis. These symptoms include clinical impression (the clinician's preliminary or working diagnosis), pain in the teeth, and bad breath. Acute rhinosinusitis, which may be viral or bacterial, is significantly less likely in patients without nasal discharge, without a complaint of purulent nasal discharge (yellow to green mucus), and in those with normal transillumination (light can be transmitted through the sinuses and is not blocked by secretions). Clinical decision rules for the diagnosis of both acute and acute bacterial rhinosinusitis have not yet been prospectively validated.