Clinical diagnosis of rhinosinusitis is fraught with peril

Reference

Ebell MH, McKay B, Dale A, Guilbault R, Ermias Y. Accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis. Ann Fam Med 2019;17(2):164-172.

Synopsis

This team searched 2 databases for studies of adults and children with suspected rhinosinusitis or acute respiratory tract infection that reported data for the accuracy of at least one sign or symptom. The included studies took place in the outpatient setting and used radiography, ultrasound, computed tomography, or antral puncture as the reference standard. They also searched the reference lists of previous meta-analyses, review articles, and practice guidelines, only including studies in which all patients received the same reference standard. They don't report attempts to find unpublished studies. They used a standard tool to assess the risk of bias for each included study, but don't report if 2 or more reviewers independently assessed studies for inclusion or the risk of bias. Ultimately, the authors included 17 papers that included between 30 and 400 patients. Only 4 studies were at low risk of bias, each of which used purulent fluid or bacterial culture as the reference standard. The overall prevalence of radiographically confirmed rhinosinusitis was 51%, but ranged from 19% to 63% for adults and 57% to 79% for children among the studies. Similarly, the prevalence of confirmed bacterial sinusitis was 31%. The studies of bacterial sinusitis were only conducted in adults; the prevalence ranged from 19% to 51%. Using a positive likelihood ratio greater than 10 or a negative likelihood ratio less than 0.1, no single clinical finding was very useful in ruling in or ruling out sinusitis. The authors also identified several promising clinical prediction rules that incorporate several variables, but none have been prospectively validated.