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Sinusitis: John W. Williams, Jr, MD, MHS, discusses the clinical examination for sinusitis.
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Sinusitis: John W. Williams, Jr, MD, MHS, discusses the clinical examination for sinusitis.
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, editor of JAMA's Medical News and Perspective section. Today we'll be hearing from Dr. John Williams about sinusitis, a topic discussed in a chapter of the Rational Clinical Examination, coauthored by today's guest. Welcome to the podcast, Dr. Williams, and please introduce yourself to our listeners. >> Thank you. I'm John Williams. I'm a general internist and a Professor of Medicine at Duke University. >> Dr. Williams, would you please define sinusitis for our listeners, and explain why it is important during the clinical examination to properly diagnose nasal complaints.
>> Yes. Sinusitis can be defined simply as inflammation of one or more perinasal sinuses, but it usually refers to infection of the sinuses. There was an important study that used MRI to image the sinuses of patients who had experimentally induced common colds, and it shows that the sinuses were inflamed in 8 out of 10 subjects. So viruses, followed by bacteria, are the most common causes of sinusitis. Sinusitis is one of the most common diagnoses made in primary care, accounting for about 20 million visits annually in the U.S. and accounting for between 15 and 20% of all antibiotic prescriptions for adults in outpatient care.
So nasal or sinus symptoms are common, and making an accurate diagnosis is important to selecting the right treatment. >> Among those patients who seek out medical care, what is the prevalence of bacterial sinusitis? >> So among adults who we see in general medical settings, and in whom the clinician suspects acute sinusitis, the prevalence of bacterial sinusitis is about 50 to 60%. >> What is the reference standard for diagnosing sinusitis?
>> The reference standard for diagnosing infectious sinusitis is sinus aspiration and culture, but it's a procedure rarely done in the U.S. except when managing complicated or refractory sinusitis. In general practice, sinus radiographs are a pragmatic reference standard in findings of sinus opacity and air fluid level, or 6 millimeters or more of mucosal thickening is consistent with infection. Sinus CT, or computed tomography, is even more sensitive and is superior for visualizing the ethmoid sinuses, but has higher false positives, so abnormal findings, in patients who actually don't have infectious sinusitis.
It's important to note that in cost effectiveness evaluations, neither sinus radiographs nor sinus CTs are cost effective in managing the typical outpatient with symptoms of acute sinusitis. >> How can clinicians elicit the signs and symptoms of sinusitis? >> Both clinical history and examination are important to getting the diagnosis correct. Examiners should ask about a history of fever, cough, maxillary toothache, purulent nasal discharge, response to over-the-counter medications, such as decongestants or antihistamines, and whether facial pain or headache is exacerbated by bending forward.
In terms of the examination, you should do four basic things. First, you should inspect the nostrils, which can be performed with a short, wide speculum mounted on a handheld otoscope. You want to be sure and direct the speculum posterolaterally to avoid the sensitive nasal septum, and inspect the mucosa for color, characteristic secretions, polyps, and the nasal septum for any deviation. Second, use a tongue blade to tap the maxillary teeth to assess for tenderness.
Third, palpate the frontal and maxillary sinuses for tenderness. And finally, use a light source to transilluminate. Now transillumination requires a dark room, a light source -- I used a mini mag light -- and time for your eyes to adapt to darkness, so 20 to 30 seconds of darkness. Place the light over the infraorbital rim, just below the eye, use your other hand to shield your eyes from the light source, and then have the patient open their mouth and look for light being transmitted through the hard palate.
Repeat the process over the other maxillary sinus. No light transmission, or asymmetry in light transmission from left to right, is abnormal. I found that nights on camping trips are a good place to practice transillumination, and that young children find the practice entertaining. >> I bet they do. Which signs and symptoms are the best predictors of sinusitis? >> So you should remember three symptoms and two signs. So the symptoms are a history of purulent nasal discharge, maxillary toothache, and a poor response to over-the-counter decongestants or antihistamines.
The two signs are abnormal transillumination and purulent discharge visualized in the nares. As the number of signs and symptoms increase, a likelihood of bacterial sinusitis increases. So if a patient has four or more of these findings, the likelihood ratio is 6.4, so greatly increasing the probability of infectious sinusitis. And if none of the findings are present, the likelihood ratio is 0.1, so greatly decreasing the likelihood of acute bacterial sinusitis.
>> Is there anything else you would like to tell our listeners about the clinical examination for sinusitis? >> Yes, I'd say a couple of things. First, clinical guidelines recommend that you make the diagnosis based on the clinical evaluation. So don't order radiographs on any routine basis. Second, there's a new initiative by the National Physician's Alliance, a project called Promoting Good Stewardship in Clinical Practice, and their goal is to develop a top five list of activities where changes in practice could lead to higher quality care and better use of resources.
Management of sinusitis made the top five list. Their recommendation states "don't routinely prescribe antibiotics for acute mild to moderate sinusitis, unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement." They further specify that the symptoms must include purulent nasal secretions and maxillary pain, or facial or dental tenderness to percussion. And finally, they define mild to moderate sinusitis as sinusitis without a high fever, without exquisite pain, and without signs of cellulitis.
>> Thanks very much, Dr. Williams, for this helpful look at diagnosing sinusitis. Additional information about this topic is available in Chapter 45 of the Rational Clinical Examination. This has been Joan Stephenson of JAMA talking with Dr. John Williams about sinusitis for JAMAevidence.
