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Research

Diagnosis of acute rhinosinusitis in primary care: a systematic review of test accuracy

Mark H Ebell, Brian McKay, Ryan Guilbault and Yokabed Ermias
British Journal of General Practice 2016; 66 (650): e612-e632. DOI: https://doi.org/10.3399/bjgp16X686581
Mark H Ebell
Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, US.
Roles: Professor of epidemiology
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Brian McKay
Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, US.
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Ryan Guilbault
Mercer School of Medicine, Macon, Georgia, US.
Roles: Medical student
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Yokabed Ermias
Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, US.
Roles: Student
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Abstract

Background Acute rhinosinusitis (ARS) is a common primary care infection, but there have been no recent, comprehensive diagnostic meta-analyses.

Aim To determine the accuracy of laboratory and imaging studies for the diagnosis of ARS.

Design and setting Systematic review of diagnostic tests in outpatient, primary care, and specialty settings.

Method The authors included studies of patients presenting with or referred for suspected ARS, and used bivariate meta-analysis to calculate summary estimates of test accuracy and the area under the receiver operating characteristic (ROC) curve. The authors also plotted summary ROC curves to explore heterogeneity, cutoffs, and the impact of different reference standards.

Results Using antral puncture as the reference standard, A mode ultrasound (positive likelihood ratio [LR+] 1.71, negative likelihood ratio [LR−] 0.41), B mode ultrasound (LR+ 1.64, LR− 0.69), and radiography (LR+ 2.01, LR− 0.28) had only modest accuracy. Accuracy was higher using imaging as the reference standard for both ultrasound (LR+12.4, LR− 0.35) and radiography (LR+ 9.4, LR− 0.27), although this likely overestimates accuracy. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) both had clear threshold effects, and modest overall accuracy. The LR+ for ESR >30 and >40 were 4.08 and 7.40, respectively. A dipstick of nasal secretions for leucocyte esterase was highly accurate (LR+ 18.4, LR− 0.17) but has not been validated.

Conclusion In general, tests were of limited value in the diagnosis of ARS. Normal radiography helps rule out sinusitis when negative, whereas CRP and ESR help rule in sinusitis when positive, although, given their limited accuracy as individual tests, they cannot be routinely recommended. Prospective studies integrating signs and symptoms with point-of-care CRP, dipstick, and/ or handheld B-mode ultrasound are needed.

  • acute sinusitis
  • acute rhinosinusitis
  • clinical diagnosis
  • clinical decision-making
  • primary care
  • rhinosinusitis
  • sinusitis

INTRODUCTION

Acute rhinosinusitis (ARS) accounts for more than 30 million outpatient visits per year in the US.1 It is defined as inflammation of the paranasal sinuses caused by viral or bacterial infection, and typically presents with facial pain or pressure, purulent nasal discharge, fever, cacosmia or hyposmia, and double-sickening (symptoms that worsen after an initial improvement).2 Although most episodes of ARS are viral, they may also be caused by a bacterial infection.3 A Cochrane review concluded that, in patients diagnosed with ARS based on signs and symptoms, antibiotics increased the likelihood of a cure at 7 to 14 days (number needed to treat = 18), although this was balanced by an increased risk of adverse events (number needed to harm = 8).4 Physicians often treat ARS with antibiotics based on the history and the physical examination, resulting in the widespread use of antibiotics for what is predominantly a viral condition.3 Recent guidelines recommend that clinicians only prescribe antibiotics when acute bacterial rhinosinusitis (ABRS) is suspected because it persists for at least 10 days, or based on double-sickening.3

One strategy to reduce inappropriate antibiotic use is to encourage the use of point-of-care tests such as C-reactive protein (CRP) or imaging to improve diagnostic accuracy. Use of CRP has been shown to reduce antibiotic prescribing rates for acute respiratory tract infections.5 However, practice guidelines generally recommend against the use of imaging because the accuracy of radiography is thought to be poor, ultrasound and radiography are not widely available in the primary care setting, and computed tomography (CT) is expensive and results in potentially harmful radiation exposure.6 In addition, imaging primarily detects fluid in the sinuses and may not distinguish bacterial from viral sinusitis.3,7–9 Antral puncture is the preferred reference standard test, but is not widely used due to the discomfort it causes and a lack of expertise in performing antral puncture in the primary care setting.

Previous systematic reviews have been limited by focusing only on children,10,11 have not identified all relevant studies,11 or are ≥10 years old.10,12 The goal of the current study is to perform an updated, comprehensive systematic review of the accuracy of imaging and laboratory tests for the diagnosis of ARS and ABRS.

METHOD

Inclusion and exclusion criteria

The authors included studies of adults and children with clinically suspected sinusitis or acute respiratory tract infection that reported the accuracy of at least one blood test or imaging study for ARS or ABRS. Acceptable reference standards included radiography, ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) for ARS, and antral puncture revealing purulent fluid or fluid yielding a positive culture for ABRS. Only studies in which all patients received the same reference standard were included, to avoid verification bias. Studies involving hospitalised patients or that recruited patients from highly specialised populations (for example, patients with immunodeficiency, odontogenic sinusitis, or children with brain cancer) were excluded. The authors did not impose any temporal or language limits. Case-control studies were excluded.

How this fits in

This report represents the most comprehensive and methodologically-rigorous systematic review to date of laboratory and imaging studies to diagnose acute rhinosinusitis (ARS). When clinically suspected, the prevalence of sinusitis is approximately 50%. The authors found that C-reactive protein >20 mg/L (LR+ 2.9) and erythrocyte sedimentation rate >30 (LR+4.1) or >40 (LR+ 7.4) significantly increase the likelihood of ARS, whereas normal radiography decreases the likelihood of ARS somewhat (LR− 0.28). The accuracy of ultrasound varied depending on whether it was A or B mode technology, and on the reference standard. B mode ultrasound using antral puncture as the reference standard was not helpful (LR+ 1.6, LR− 0.69). Given the limitations of the evidence base, imaging cannot be routinely recommended for patients with suspected ARS.

In studies that reported findings separately by maxillary, frontal, or ethmoid sinus, only maxillary sinus findings are shown. Whenever individual sinuses as well as results by person are reported, diagnostic accuracy and prevalence are reported by person where possible. Whenever it was possible to use different thresholds (definitions of abnormal) for a test, the threshold that yielded the highest diagnostic odds ratio (DOR, calculated by dividing the positive likelihood ratio [LR+] by the negative likelihood ratio [LR−]) was selected.

Search strategy and data abstraction

The authors used the strategy shown in Appendix 1 to search MEDLINE®. The reference lists of previous meta-analyses, review articles, and practice guidelines for additional articles were also searched. All abstracts were reviewed by at least two investigators, and any article deemed potentially useful by either investigator was reviewed in full. Full articles were also each reviewed by at least two investigators, who evaluated them for inclusion criteria. Two investigators abstracted data regarding study quality and test accuracy. Any disagreements regarding inclusion criteria, quality, or accuracy were resolved via consensus discussion with the principal investigator. The PRISMA flow diagram describing the search is shown in Appendix 2.

Quality assessment

The authors adapted the QUADAS-2 criteria for the study (Appendix 3).13 Quality assessment was done in parallel by two investigators, and any discrepancies were resolved by consensus discussion.

Analytic strategy

The metaprop procedure in R version 3.2.2 was used to perform random effects meta-analysis of the prevalence of sinusitis, stratified by age group, clinical presentation, and reference standard. The authors used the meta-analysis of diagnostic accuracy (mada) procedure in R version 3.2.2 to perform bivariate meta-analysis for each test using the Reitsma procedure, stratified by imaging technology and reference standard where appropriate. Summary measures of sensitivity, specificity, LR+, and LR− are reported. Summary receiver operating characteristic (ROC) curves were drawn to explore sources of heterogeneity and threshold effects for key tests, and the area under the receiver operating characteristic curve (AUC) was calculated for selected tests. Formal testing for heterogeneity was not performed, as it is unreliable when there are small numbers of studies,14 and in particular for diagnostic meta-analysis as it does not account for threshold effects. For example, sensitivity and specificity vary inversely as the threshold for diagnosis changes, often implicitly, and do not necessarily represent heterogeneity of populations.15

RESULTS

Study characteristics

The characteristics of included studies are summarised in Appendix 4. The authors identified a total of 30 studies, 16 enrolling adults,16–31 eight both adults and children,32–39 four enrolling only children,40–43 and two that did not report the age of participants.44,45 Two were retrospective cohort studies,36,44 and the remainder were prospective cohort studies. Two studies enrolled patients with the common cold or a ‘runny nose’,30,40 while the remaining 28 enrolled patients with clinically suspected acute sinusitis. Only four studies were at a low overall risk of bias.19,20,23,40 The remainder were at moderate (n = 11) or high (n = 9) overall risk of bias (Appendix 5).

The authors identified studies of the accuracy of imaging including radiography, screening coronal computed tomography, and ultrasound (both A and B mode). A mode ultrasound is amplitude modulation and is no longer in wide use, whereas B mode or brightness modulation is the more commonly used two-dimensional study. Blood tests studied included CRP, white blood cell count (WBC), and the erythrocyte sedimentation rate (ESR), and other tests included rhinoscopy, a test of nasal secretions, and the accuracy of scintigraphy.

Prevalence of acute rhinosinusitis

The prevalence of acute rhinosinusitis in the included studies is summarised in Table 1 (a more complete version of these results are shown in Appendix 6). It is stratified by population, reference standard, and presenting symptoms. In studies enrolling adults, or a mix of adults and children with clinically suspected acute rhinosinusitis, the prevalence ranged from 16% to 80%, with a pooled prevalence of 48% (95% confidence interval [CI] = 42 to 54). There was no significant difference in prevalence by type of reference standard (antral puncture, radiography, or CT). Studies in children with clinically suspected rhinosinusitis had prevalences between 19% and 57%, with a pooled prevalence of 41% (95% CI = 19 to 67). Two studies enrolled all patients with a cold or runny nose and found a lower prevalence of acute rhinosinusitis of 20% (95% CI = 14 to 29).30,40

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Table 1.

Prevalence of acute rhinosinusitis in the included studies, by population, inclusion criteria, and reference standarda

Accuracy of imaging

The accuracy of imaging studies is summarised in Table 2 (Appendix 7). Because there was no clear pattern of accuracy with regard to studies of children and adults, and due to the small number of studies in children, their results are combined in Table 2.

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Table 2.

Accuracy of imaging studies for acute rhinosinusitis

The most accurate imaging test was limited or screening CT (LR+ 9.01, LR− 0.15, AUC 0.895), but was only evaluated in two small studies at high risk of bias that used full CT as the reference standard.36,44 Radiography was fairly sensitive when compared with antral puncture, but lacked specificity, and was therefore more helpful when negative (LR− 0.28) than when positive (LR+ 2.01). Figure 1a shows a summary ROC curve for radiography.

Figure 1.
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Figure 1.

(a) Summary receiver operating characteristic curve for radiography, with accuracy stratified by the reference standard. (b) Summary receiver operating characteristic curve for ultrasound, with accuracy stratified by the reference standard for A and B mode. CT = computed tomography. MRI = magnetic resonance imaging. Ref std = reference standard.

The accuracy of ultrasound varied depending on the mode (A or B) and the reference standard (antral puncture or imaging). In general, B mode was more accurate than A mode, and studies using antral puncture as the reference standard found much lower accuracy (particularly specificity) than those using imaging. Using antral puncture as the reference standard, both A mode (LR+ 1.71, LR− 0.41, AUC 0.679) and B mode (LR+ 1.64, LR− 0.69, AUC 0.693) ultrasound had only modest accuracy. Figure 1b shows a summary ROC curve for ultrasound, stratified by mode and reference standard.

A sensitivity analysis excluding studies at high risk of bias found no significant difference regarding the accuracy of radiography (LR+ 2.88, LR− 0.27). High-quality studies of ultrasound had a positive likelihood ratio of 2.58 and negative likelihood ratio of 0.46, reflecting the fact that antral puncture was used as the reference standard rather than imaging.

Accuracy of laboratory tests

The accuracy of blood tests and other tests for ARS are shown in Table 3 (study-level data shown in more detail are available from the authors). Summary ROC curves for CRP and ESR are shown in Figures 2a and 2b. Both show clear threshold effects. That is, differences in accuracy are likely to be related to differences in the cutoff or threshold. It was therefore not appropriate to calculate a summary estimate of accuracy for these tests as a group. An ESR <10 is limited evidence against a diagnosis of acute rhinosinusitis (LR− 0.57), while an ESR >30 (LR+ 4.08) or >40 (LR+ 7.40) provide moderate evidence in favour of the diagnosis. Similarly, a CRP <10 mg/L was limited evidence against a diagnosis of ARS (LR− 0.45), while a CRP >20 is limited evidence in favour of the diagnosis (LR+ 2.92). Only one of the four studies of CRP used antral puncture as the reference standard, and it had generally similar results to the imaging studies.19

A single study evaluated the accuracy of a test strip of the sort ordinarily used for diagnosis of urinary tract infection.39 The researchers found that leucocyte esterase and nitrite were highly specific, while pH and protein were highly sensitive. A score that assigned 0 to 3 points to each of these tests successfully identified patients at low (0%), moderate (33%), and high (100%) risk of ARS. However, this study was at high risk of bias because it used imaging rather than antral puncture as the reference standard, and the thresholds for low-, moderate-, and high-risk groups were established post hoc.

The presence of leucocytes in nasal washings was evaluated in three studies, with LR+ ranging from 3.06 to 4.92, and LR− from 0.08 to 0.74.24,40,41 Rhinoscopy for pus in the nasal cavity or throat (LR+ 1.32, LR− 0.47 to 0.93) and the white blood cell count (LR+ 2.23, LR− 0.85) both lacked accuracy for the diagnosis of acute rhinosinusitis.21,24,29

DISCUSSION

Despite being a very common complaint in the outpatient setting, the evidence base for imaging and laboratory tests to diagnose ARS is limited. Many of the studies are ≥20 years old and few are at low risk of bias. Using antral puncture as a reference standard, sinus radiographs are fairly sensitive but have poor specificity. However, they are useful for reducing the likelihood of ARS when negative (LR− 0.28). Although studies comparing ultrasound to imaging (largely radiography) found good accuracy, those using antral puncture as the reference standard found that, like radiography, it lacked specificity. That is likely to be because imaging studies are limited to detection of fluid in the sinuses, which is commonly seen in viral upper respiratory tract infections as well.

Although CT is often recommended as the imaging study of choice for patients with persistent symptoms, chronic sinusitis, or when surgery is being considered,3 the authors identified only two small studies comparing limited or screening CT with full CT of the sinuses,36,44 and no studies directly comparing CT to antral puncture.

C-reactive protein and the erythrocyte sedimentation rate performed similarly as tests for acute rhinosinusitis. In both cases there was no clearly preferred single threshold for defining an abnormal test. A potentially useful strategy would be to define two thresholds and three risk groups, for example, CRP or ESR <10 defining a low-risk group, 10 to 30 a moderate-risk group, and >30 a high-risk group. However, as originally reported in the relevant studies, it is not possible to determine stratum-specific likelihood ratios and predictive values as part of this meta-analysis.

The study by Huang and Small suggests an innovative approach to diagnosis of acute rhinosinusitis, using a dipstick normally used for urinalysis.39 It deserves replication, in particular the very promising risk score based on the dipstick findings.

Strengths and limitations

The authors’ conclusions are limited by the relatively poor quality of many studies, many of which are quite old. There was significant unexplained heterogeneity, for example, among studies of radiography using antral puncture as the reference standard, and therefore summary estimates of accuracy should be interpreted cautiously. An unexpected finding was the similar prevalence of acute rhinosinusitis when using antral puncture as the reference standard compared with imaging. Although the authors expected a lower prevalence with antral puncture as the reference standard, because it was presumably largely detecting only ABRS, it may be that the spectrum of patients in the Scandinavian countries where the antral puncture studies were largely performed may be different, with patients not seeking care unless symptoms are more severe.

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Table 3.

Accuracy of blood tests for the diagnosis of acute rhinosinusitis in adultsa

Figure 2.
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Figure 2.

(a) Summary receiver operating characteristic curve for the accuracy of C-reactive protein as a test for acute rhinosinusitis. (b) Summary receiver operating characteristic curve for the accuracy of erythrocyte sedimentation rate as a test for acute rhinosinusitis. AUROCC = area under the receiver operating characteristic curve. CRP = C-reactive protein. ESR = erythrocyte sedimentation rate.

Strengths of the current study include: an updated and comprehensive search identifying more studies than previous systematic reviews; use of a bivariate meta-analysis; and the use of summary ROC curves to allow a better understanding of heterogeneity due to different reference standard and diagnostic cutoffs.

Implications for research

A condition as common as acute rhinosinusitis deserves a better evidence base. A particular challenge is the choice of a reference standard. Radiography and ultrasound lack specificity, and CT is costly, exposes patients to radiation, and is likely to mistakenly classify many patients with viral respiratory infection as having ARS. Antral puncture revealing purulent fluid is arguably the preferred reference standard. Although some might argue that bacterial culture of antral fluid revealing a bacterial pathogen is the optimal reference standard, cultures may lack sensitivity.

Use of C-reactive protein in particular is promising because it is available as a rapid and relatively inexpensive point-of-care test that has been shown in randomised controlled trials to reduce the use of inappropriate antibiotics for respiratory infections in the primary care setting.46,47 Trials of its use in patients with clinically suspected sinusitis are needed, using clinically helpful cutoffs to identify low-, moderate-, and high-risk patients.

Physicians increasingly have access to high-resolution B mode ultrasound in a handheld device at the point of care.48,49 To date, these devices have not been evaluated for their ability to diagnose ARS. A study evaluating the accuracy of signs and symptoms as well as handheld B mode ultrasound, C-reactive protein, and/or dipstick for leucocyte esterase, nitrite, pH, and protein, and using antral puncture as the reference standard, would be an important contribution to the literature. This could lead to the development and validation of a decision support tool that integrates signs and symptoms with one of these point-of-care tests, to help physicians limit antibiotic therapy to only those patients most likely to benefit.

Appendix 1. Search strategy used in MEDLINE

(rhinosinusitis[Title/Abstract] OR sinusitis[Title/Abstract] OR sinus infection[Title/Abstract] OR sinusitis[MeSH Terms] OR “Paranasal Sinus Diseases”[MeSH Terms]) AND (“medical history taking”[MeSH Terms] OR “physical examination”[MeSH Terms] OR “signs and symptoms”[Title/Abstract] OR “symptoms and signs”[Title/Abstract] OR symptom[Title/Abstract] OR “history and physical” OR ”physical examination” OR “physical exam”[Title/ Abstract] OR “clinical examination”[Title/Abstract] OR ultrasound[Title/Abstract] OR “computed tomogram”[Title/ Abstract] OR “computed tomographic”[Title/Abstract] OR “radiograph”[Title/Abstract] OR “radiographic”[Title/ Abstract] OR “x-ray”[Title/Abstract] OR “computed tomography”[Title/Abstract] OR “radiological”[Title/Abstract] OR “CRP”[Title/Abstract] OR “C-reactive protein”[Title/Abstract] OR “white blood cell count”[Title/Abstract] OR “white cell count”[Title/Abstract] OR“leucocytosis”[Title/Abstract] OR “leucocyte count”[Title/Abstract] OR Westergren”[Title/Abstract] OR “sed rate”[Title/Abstract] OR “sedimentation rate”) NOT (“carotid sinus” OR “sinus rhythm” OR “sinus arrest” OR “aortic sinus” OR “aortic sinuses” OR “cavernous sinus” OR “sinus tachycardia” OR “sinus arrhythmia” OR “cavernous sinuses” OR “sinus tract” OR “sinus tracts” OR “coronary sinus” OR “renalsinus” OR “sinus node” OR “sinusoidal” OR “non-sinus” OR “petrosal sinus” OR “sinus rate” OR “sinus rhythm” OR “sinus cardiac rhythm” OR “sinus cyst” OR “sinusoid”) NOT chronic[Title/Abstract] OR surgery[Title] OR surgical[Title] OR lymphoma OR mycosis OR “sphenoid” OR Wegener’s OR sarcoidosis OR cancer OR postoperative OR myositis OR HIV OR tuberculosis OR fasciitis OR periodontitis OR “dental implant”).

Appendix 2. PRISMA flow diagram of studies selected for meta-analysis.

Figure

Appendix 3. QUADAS-2 instrument, adapted for systematic review of the accuracy of signs and symptoms for the diagnosis of acute sinusitisa

Study, yearQUADAS-2 study design questions
Patient selectionIndex testReference stdFlow & timingOverall
1234567891011121314151617
ConsecutiveNot case-controlExclusion criteriaRisk of biasApplicabilityIndex blindedThreshold pre-specifiedRisk of biasApplicabilityAntral puncture usedReference blindedRisk of biasApplicabilityAll got reference standardAll had same ref standardAll accounted forRisk of biasL = 0, M = 1, and H = 2+ with high likelihood of bias
Adults
Hansen, 1995YYYLLYULLYULLYYYLL
van Buchem, 1995YYYLLYULLYYLLYYYLL
Laine, 1998YYYLLYYLLYYLLYYYLL
Bergstedt,1980NYYHLYYLLYYLLYYYLM
Savolainen, 1997aNYYHLYULLYYLLYYYLM
Savolainen, 1997bNYYHLYULLYYLLYYYLM
Puhakka, 2000YYYLLYYLLNYHLYYYLM
Young, 2003YYYLLYYLLNYHLYYYLM
Kuusela, 1983YYYLLUYHLYULLYYYLM
Berg, 1981NYYHLUYHLYYLLYYYLH
Rohr, 1986UYYHLYYLLNYHLYYYLH
Jensen, 1987UYYHLYYLLNUHLYYYLH
Lindbaek, 1996UYYHLYYLLNUHLYYYLH
Varonen, 2003NYYHLYYLLNYHLYYYLH
Berger, 2011NYYHLYYLLNYHLYYYLH
Lewander, 2012NYYHLYYLLNYHLYYYLH
Adults and children
Watt-Boolsen, 1977NYYHLYYLLYULLYYYLM
Shapiro, 1986YYYLLYYLLNYHLYYYLM
McNeill, 1963NYYHLYYLLYNHLYYNHH
Berg, 1985NYYHLYYLLYULLYYNHH
Gianoli,1992NYYHLYYLLNYHLYYYLH
Ghatasheh, 2000NYYHLYULLNYHLYYYLH
Awaida, 2004NYYHLYYLLNYHLYYYLH
Huang, 2008YYYLLYNHLNUHLYYYLH
Children
van Buchem, 1992YYYLLYYLLYULLYYYLL
Reilly, 1989YYYLLYYLLNYHLYYYLM
Visca, 1995NYUHUYULNYUHLYYYLH
Fufezan, 2010UYYHLYYLLNYHLYYYLH
Not reported
Dobson, 1996NYYHLUYHLNUHLYYYLH
Goodman, 1995NYYHLYYLLNYHLYYYLH
  • ↵a Overall risk of bias was low (L) if all domains were at low risk of bias, moderate (M) if one domain was at high risk of bias, and high (H) if two or more domains were at high risk of bias.

  • Ref = reference. Std = standard.

QUADAS-2 instrument, adapted for systematic review of the accuracy of signs and symptoms for the diagnosis of acute sinusitis.a Definitions of questions 1–17 for QUADAS-2

Patient selection, questions 1–5

  • 1. Was a consecutive or random sample of patients enrolled? (Y/N/U)

    • Y: Study enrolled consecutive patients or a random sample of consecutive patients from a primary care, urgent care, or emergency department setting

    • N: A convenience sample or other non-consecutive or non-random sample was used, or it only included patients referred for diagnostic imaging or to an ENT clinic (this does not address exclusion criteria, see question 3)

    • U: Uncertain

  • 2. Was the study designed to avoid a case-control design? (Y/N/U)

    • Y: The study population was drawn from a cohort that included patients with a spectrum of disease

    • N: The study population consisted of patients with known disease and healthy controls

    • U: Uncertain

  • 3. Did the study design avoid inappropriate exclusion criteria? (Y/N/U)

    • Y: There were no inappropriate exclusion criteria, such as excluding those with uncertain findings

    • N: The study used inappropriate exclusion criteria

    • U: Uncertain

  • 4. Patient selection risk of bias: What is the likelihood that patient selection could have introduced bias? (L/H/U)

    • L: Low likelihood of bias due to patient selection or enrolment (‘Yes’ to question 1, 2, and 3)

    • H: High likelihood of bias due to patient selection (‘No’ to question 1, 2, or 3)

    • U: Unable to judge degree of bias

  • 5. Concerns about patient selection applicability: Are there concerns that included patients and setting do not match the review question? (L/H/U)

    • L: Low risk of bias — the patients or settings are from the outpatient setting and have clinically suspected acute sinusitis or acute respiratory tract infection

    • H: High risk of bias — the patients or settings do not match the review question, for example, a group of patients hospitalised, or from a specialised population, or patients with subacute or chronic sinusitis

    • U: Uncertain

Index test, questions 6–9

  • 6. Were index test results interpreted without knowledge of the reference standard? (Y/N/U)

    • Y: Yes

    • N: No (including when index and reference standard were performed by the same observer, although blinding was not addressed)

    • U: Uncertain

  • 7. If a threshold was used for the index test, was it pre-specified? (Y/N/U)

    • Y: The threshold was pre-specified, or there was no threshold mentioned

    • N: The threshold was established post hoc

    • U: A threshold was used but it is not clear when it was specified

  • 8. Index test risk of bias: What is the likelihood that conduct of the index test could have introduced bias? (L/H/U)

    • L: Low likelihood of bias — ‘Yes’ to question 6, and ‘Yes’ or ‘Uncertain’ to question 7

    • H: High likelihood of bias due to failure to mask to reference standard — ‘No’ or ‘Uncertain’ to question 6 or ‘No’ to question 7

    • U: Uncertain

  • 9. Concerns regarding index test applicability: Are there concerns that the index test differs from those specified in the review question? (L/H/U)

    • L: Low likelihood — the index test in this study is a laboratory or imaging test

    • H: High likelihood — the index test in this study may not be a laboratory or imaging test

    • U: Uncertain

Reference standard test, questions 10–13

  • 10. Is the reference standard likely to correctly classify patients as having acute sinusitis? (Y/N/U)

    • Y: Yes, used antral puncture

    • N: No, used another reference standard

    • U: Uncertain

  • 11. Was the reference standard interpreted without knowledge of the index test? (Y/N/U)

    • Y: Yes, reference standard interpretation masked to index test results

    • N: No, reference standard interpretation not masked to index test results

    • U: Uncertain

  • 12. Reference standard risk of bias: Could conduct or interpretation of the reference standard have introduced bias? (L/H/U)

    • L: Low likelihood of bias due to the reference standard (‘Yes’ to question 9, ‘Yes’ or ‘Uncertain’ to question 10)

    • H: High likelihood of bias due to inadequate reference standard (‘No’ to question 9 or 10)

    • U: Uncertain

  • 13. Concerns regarding applicability of the reference standard: Are there concerns that the target conditions defined by the reference standard do not match the review question? (L/H/U)

    • L: Low likelihood of bias — that is, the reference standard was intended to detect acute sinusitis

    • H: High likelihood of bias — that is, the reference standard was not intended to detect acute sinusitis

    • U: Uncertain

Patient flow and timing, questions 14–17

  • 14. Did all patients receive a reference standard? (Y/N/U)

    • Y: Yes, all patients received some sort of reference standard (no partial verification bias)

    • N: No, some patients did not receive any reference standard (partial verification bias)

    • U: Uncertain

  • 15. Did all patients receive the same reference standard? (Y/N/U)

    • Y: Yes, all used the same reference standard (no differential verification bias)

    • N: No, the reference standard varied depending on the results of the index test (differential verification bias)

    • U: Uncertain

  • 16. Were all patients included in the analysis? (Y/N/U)

    • Y: Yes, all patients were properly accounted for in the analysis

    • N: No, some patients were not accounted for or dropped out for unclear reasons

    • U: Uncertain

  • 17. Patient flow risk of bias: Could patient flow have introduced bias? (L/H/U)

    • L: Low likelihood of bias based on absence of partial verification bias and good follow-up (‘Yes’ to question 14 and 15, ‘Yes’ or ‘Uncertain’ to question 16)

    • H: High likelihood of bias based on partial verification bias or poor follow-up (‘No’ to question 14 or 15, or significant number of patients lost to follow-up in question 16)

    • U: Uncertain

Appendix 4. Characteristics of included studies, by population and sorted by year of publication (with individual study-level data)

Study, yearPopulationSettingNumber in studyMean age and/or age range, yearsReference standardCountryYear(s)
Adults
Bergstedt, 198017Adults with clinically suspected maxillary sinusitisENT clinic48Range 17 to 79Antral aspiration showing purulent aspirateSwedenNR
Berg, 198116Adults with clinically suspected sinusitis of at least 3 weeks’ durationENT clinic50Mean age 46AP revealing purulent dischargeSwedenNR
Kuusela, 198318Young adults (largely male) with clinically suspected acute sinusitisMilitary clinic105NRAP showing purulent fluidFinlandNR
Rohr, 198627Adults with clinically suspected acute sinusitisMedicine outpatient clinic99Range 18 to 74Radiograph showing mucosal thickening or opacification >4 mmUSNR
Jensen, 198726Adults with clinically suspected acute sinusitisENT clinic138 (253 sinuses)Mean age 33Radiograph showing mucosal thickening >6 mm, fluid, or complete opacificationSwedenNR
Hansen, 1995a19Consecutive adults suspected of having acute maxillary sinusitis by their GPPrimary care clinic174Median 35, range 18 to 65CT scan abnormal and purulent or mucopurulent material from APDenmark1992 to 1994
van Buchem, 199523Adults with clinically suspected acute maxillary sinusitisPrimary care with referral to ENT clinic11342% 18 to 29, 34% 30 to 44, 16% 45 to 59, and 9% 60 or olderAP showing fluid or flocculesNetherlandsNR
Lindbaek, 199624Adults clinically diagnosed by a primary care doctor with acute sinusitis requiring antibioticsPrimary care201Mean 37.8, range 15 to 83CT scan showing air-fluid level or complete opacificationNorway1993
Savolainen, 199721Young adult men with suspected acute maxillary sinusitis <3 weeks’ durationENT clinic (military)176Mean 20.5AP with positive bacterial cultureFinlandNR
Savolainen, 199722Young adult men with suspected acute maxillary sinusitis <30 days’ durationENT clinic (military)161 (322 sinuses)Mean 29, range 17 to 68AP yields fluidFinlandNR
Laine, 199820Consecutive adult patients with clinically suspected acute maxillary sinusitis, duration <30 daysPrimary care clinic39Median 37, range 16 to 68Nasal aspirate with purulent or mucopurulent materialFinland1992 to 1993
Puhakka, 2000b30Convenience sample of young adult students with symptoms of common cold <48 hoursPrimary care clinic200 (394 sinuses)Mean 24MRI using same criteria for accuracy of ultrasound and radiographsFinlandNR
Young, 200329Adults with clinically suspected sinusitis (purulent nasal discharge and maxillary pain) of 2 to 28 days’ duration, median 4 days’ durationPrimary care clinic251Median 34Latent class model incorporating CRP, radiographs (air-fluid levels or opacity), and clinical findingsSwitzerlandNR
Varonen, 200328Consecutive adults with clinically suspected acute sinusitis <30 days’ duration, 72% more than 5 daysPrimary care clinic148Mean 39.7, range 18 to 75Sinus radiographs (AP and Waters’ view) showing total opacification, air-fluid level, or mucosal thickening ≥6 mmFinland1998 to 1999
Berger, 201125Consecutive adults with clinically suspected acute bacterial rhinosinusitis between 5 days’ and 4 weeks’ durationENT clinic104Mean 44Abnormal sinus radiograph (AP and Waters’ view with air-fluid level, complete opacification, or ≥6 mm mucosal thickening)Israel2003 to 2006
Lewander, 201231Adults referred for CT for clinically suspected sinus diseaseRadiology clinic4057 for men, 54 for women, range 22 to 84CT scan showing any opacification or obstruction of the ostiomeatal complexSweden2008 to 2009
Adults and children
McNeill, 196333Adults and children referred for clinically suspected sinusitisENT clinic150 (242 sinuses)Inclusion range 10 and older.
Age 10–19 (n= 22), 20–29 (n= 35), 30–39 (39), 40–49 (n= 31), 50 and older (n= 23)
For radiography: AP showing mucopus, or pus. For clinical signs: radiography showing mucosal thickening or any opacityNorthern IrelandNR
Watt-Boolsen, 197734Adults and children with clinically suspected maxillary sinusitisENT clinic286 (468 sinuses)Range 3 to 93AP with return of cloudy fluidDenmarkNR
Berg, 198532Adults and children with clinically suspected sinusitisENT clinic90Mean 37, range 10 to 75AP showing purulent fluidSwedenNR
Shapiro, 198637Consecutive adults and children with clinically suspected acute sinusitisAllergy and paediatric clinics75Median age 10, range 2 to 72Radiograph showing at least 3 mm mucosal thickening, clouding, opacification, or air-fluid levelUSNR
Gianoli, 199235Adults and children undergoing CT for evaluation of clinically suspected sinusitisRadiology clinic41Mean 40, range 5 to 80CT scan abnormal (> 4 mm mucosal thickening or opacification, excluding solitary polyps)USNR
Ghatasheh, 200038Adults and children with suspected acute maxillary sinusitis referred from emergency department, primary care, or ENT clinics for sinus radiographyRadiology clinic50 (100 sinuses)Mean 23.4, range 6 to 50Sinus radiograph (Waters‘ view only) showing mucosal thickening, air-fluid levels, or complete opacificationJordanNR
Awaida, 200436Adults and children referred for sinus CT scanRadiology clinic51Mean 40.7, range 11 to 70CT scan abnormalUS1999 to 2000
Huang, 200839Consecutive adults and children with clinically suspected acute sinusitis less than 3 weeks’ durationAllergy clinic217Range 4 to 61. Age 4 to 9 (n= 89), age 10 to 19 (n= 101), age 20 and older (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 cystUSNR
Children
Reilly, 198943Children with clinically suspected acute sinusitisENT clinic53 (106 sinuses)Median age 6, age range 2 to 16Radiograph showing opacification or mucosal thickening >4 mmUS1985
van Buchem, 199240Consecutive children presenting with runny nosePrimary care clinic46 (93 sinuses)Range 2 to 12AP showing purulent fluid or positive bacterial cultureNetherlands1984 to 1985
Visca, 199541Children with clinically suspected sinusitisRespiratory clinic at paediatric hospital30Range 5 to 15CT scan abnormal in coronal projectionItalyNR
Fufezan, 201042Children with clinically suspected sinusitis, including poorly controlled asthmaPaediatric clinic67Range 4 to 16Sinus radiographs with total opacity of the maxillary sinus, air-fluid level, or mucosal thickeningRomaniaNR
Not reported
Goodman, 199544Convenience sample of patients with clinically suspected sinusitisSinus referral clinic44NRCT scan showing incomplete aeration, air-fluid level, or mucosal thickeningUSNR
Dobson, 199645Patients with clinically suspected maxillary sinusitisENT clinic25 (50 sinuses)NRSinus radiographs showing mucosal thickening, air-fluid level, or complete opacificationUKNR
  • ↵a Two other publications by Hansen are excluded as they used the same group of patients.

  • ↵b Reported results for both MRI and radiography as reference standard for ultrasound. Only MRI results are used.

  • AP = antral puncture. CRP = C-reactive protein. CT = computed tomography. MRI = magnetic resonance imaging. NR = not reported.

Appendix 5. The risk of bias in QUADAS-2 study design domains.

Figure

Appendix 6. Prevalence of acute sinusitis in the included studies, by population, inclusion criteria, and reference standarda

StudyReference standardSinusitis/totalPrevalence, % (95% CI)
Adults, or adults and children with clinically suspected sinusitis
Berg, 1981AP25/5050.0
Berg, 1985AP43/9047.8
Bergstedt, 1980AP23/4847.9
Hansen, 1995AP92/17452.9
Kuusela, 1983AP82/15652.6
Laine, 1998AP23/7231.9
McNeill, 1963AP100/24241.3
Savolainen, 1997aAP165/23470.5
Savolainen, 1997bAP187/23479.9
van Buchem, 1995AP71/20335.0
Watt-Boolsen, 1997AP221/46847.2
Pooled subtotal:49 (42 to 57)
Gianoli, 1992CT11/6716.4
Goodman, 1995CT60/8868.2
Lewander, 2012CT14/8017.5
Awaida, 2004CT32/5162.7
Lindbaek, 1996CT127/20163.2
Pooled subtotal:44 (23 to 67)
Berger, 2011Rad52/10450.0
Shapiro, 1986Rad63/15042.0
Jensen, 1987Rad120/25347.4
Rohr, 1986Rad91/19846.0
Dobson, 1996Rad28/5056.0
Ghatasheh, 2000Rad54/10054.0
Huang, 2008Rad151/21769.6
Varonen, 2003Rad13/3240.6
Young, 2003Rad67/24127.8
Pooled subtotal:48 (39 to 57)
Pooled subtotal, any reference standard:48 (42 to 54)
Children with clinically suspected sinusitis
Visca, 1995CT17/3056.7
Fufezan, 2010Rad71/13453.0
Reilly, 1989Rad18/9618.8
Pooled subtotal:41 (19 to 67)
Patients with acute respiratory tract infection
van Buchem, 1992 (children)AP17/10715.9
Puhakka, 2000 (adults)MRI94/39423.9
Pooled subtotal:20 (14 to 29)
Overall total46 (40 to 53)
  • ↵a Subtotals pooled using a random effects model. If a study reports different numbers of patients with different signs and symptoms, the data for the greatest number of patients reported were used.

  • AP = antral puncture revealing purulence. CT = computed tomography. MRI = magnetic resonance imaging. Rad = radiography.

Appendix 7. Accuracy of imaging studies for diagnosis of acute sinusitis

StudyRef stdPop’nTPFPFNTNSensitivity (95% CI)Specificity (95% CI)LR+ (95% CI)LR− (95% CI)AUC
Radiography
Antral puncture as reference standard
Berg, 1981APA2517081.000.321.470.00
Bergstedt, 1980APA2318071.000.281.390.00
Laine, 1998APA1419480.610.9829.830.40
Savolainen, 1997bAPA1741813290.930.622.430.11
van Buchem, 1995APA533914810.790.682.430.31
McNeill, 1963APB825418880.820.622.160.29
Watt-Boolsen, 1977APB19416127860.880.351.350.35
Kuusela, 1983APA682114530.830.722.960.24
van Buchem, 1992APC12595310.710.341.080.85
Summary0.85 (0.77 to 0.90)0.56 (0.38 to 0.73)2.01 (1.40 to 3.05)0.28 (0.19 to 0.39)0.820
Imaging as reference standard
Young, 2003LCA5436131370.810.793.870.25
Puhakka, 2000MRIA1606580.731.0073.000.27
Visca, 1995CTC167160.940.461.750.13
Summary0.80 (0.66 to 0.89)0.84 (0.31 to 0.98)9.37 (1.27 to 39.6)0.27 (0.16 to 0.48)0.841
Summary (all)0.84 (0.78 to 0.89)0.63 (0.44 to 0.78)2.36 (1.57 to 3.68)0.27 (0.20 to 0.34)0.836
UltrasoundMode
A mode, AP as reference standard
Laine, 1998APA (Sinuscan 101)A14239260.610.531.300.74
Savolainen, 1997bAPA (Sinuscan 102)A180337140.960.301.370.13
Kuusela, 1983APA (Sinuscan 101)A582724470.710.641.970.45
Berg, 1985APA (Sinuson 810)B271416330.630.702.110.53
Summary0.79 (0.52 to 0.93)0.54 (0.36 to 0.71)1.71 (1.42 to 2.08)0.41 (0.19 to 0.68)0.679
B mode, AP as reference standard
van Buchem, 1992aAPB (3.5 Mhz sector scanner Philips SP 3000)C22513630.130.720.471.21
van Buchem, 1995APB (5 Mhz sectorscan)A51337680.880.672.690.18
Summary0.53 (0.03 to 0.98)0.69 (0.61 to 0.77)1.64 (0.10 to 3.2)0.69 (0.03 to 1.36)0.693
A mode, imaging as reference standard
Varonen, 2003RadA (Sinuscan 102)A1211180.920.9517.50.08
Puhakka, 2000MRIA (Sinuscan 102)A1438550.640.9512.30.38
Shapiro, 1986RadA (Echosine)B333430530.520.611.340.78
Jensen, 1987RadA (Sinuson 810)A7715431180.640.895.690.40
Reilly, 1989RadA (Sinus V)C1028860.560.9824.40.45
Rohr, 1986RadA (Echosine)A26417450.600.927.410.43
Summary0.62 (0.55 to 0.69)0.91 (0.79 to 0.96)7.64 (2.95 to 17.1)0.42 (0.32 to 0.54)0.702
B mode, imaging as reference standard
Ghatasheh, 2000RadB (not stated)B42012460.781.0078.000.22
Fufezan, 2010RadB (Sonoace 8000 EX)C50121620.700.9844.370.30
Dobson, 1996RadB (Acuson 128)NR2206220.791.0079.000.21
Gianoli, 1992CTB (5 Mhz sectorscan)B1110551.000.9856.000.00
Summary0.75 (0.67 to 0.81)0.98 (0.94 to 0.99)38.4 (12.7 to 88.3)0.26 (0.20 to 0.34)0.897
Summary (AP)AP0.73 (0.49 to 0.88)0.58 (0.47 to 0.69)1.72 (1.32 to 2.12)0.48 (0.24 to 0.81)0.659
Summary (imaging)Imaging0.68 (0.61 to 0.73)0.94 (0.88 to 0.97)12.4 (5.1 to 26.0)0.35 (0.28 to 0.43)0.796
Summary (all)0.71 (0.61 to 0.79)0.83 (0.71 to 0.91)4.40 (2.46 to 7.48)0.35 (0.25 to 0.48)0.820
Screening CT
Goodman, 1995CTNR5634250.930.898.710.07
Awaida, 2004CTB2626170.810.897.360.21
Summary (all)0.88 (0.71 to 0.96)0.89 (0.77 to 0.95)9.01 (3.77 to 18.3)0.15 (0.05 to 0.33)0.895
  • ↵a Excluding this study as an outlier due to its very low sensitivity, the results for the remaining studies using antral puncture as the reference standard are: sensitivity 0.80 (95% CI = 0.60 to 0.92), specificity 0.58 (95% CI = 0.43 to 0.71), positive likelihood ratio 1.89 (95% CI = 1.48 to 2.45), and negative likelihood ratio 0.35 (95% CI = 0.16 to 0.60).

  • A = patient population of adults. AP = antral puncture showing purulent fluid. AUC = area under the receiver operating characteristic curve. B = patient population of both adults and children. C = patient population of children. CT = computed tomography. FN = false negative. FP = false positive. LC = latent class analysis. LR+ = positive likelihood ratio. LR− = negative likelihood ratio. NR = not reported. MRI = magnetic resonance imaging. Pop’n = population. Rad = radiography. Ref std = reference standard. TN = true negative. TP = true positive

Appendix 8. Accuracy of blood tests for the diagnosis of acute sinusitis in adultsa

StudyRef stdTPFPFNTNSensitivity (95% CI)Specificity (95% CI)LR+ (95% CI)LR− (95% CI)DORAUC
CRP >10 mg/L
Hansen, 1995AP673225490.730.601.840.454.09
CRP>20–25 mg/L
Hansen, 1995AP481844630.520.782.350.61
Lindbaek, 1996CT28698670.220.922.700.85
Savolainen, 1997aBC51486350.370.903.630.70
Young, 2003Rad3228351460.480.842.970.62
Summary0.39 (0.29 to 0.50)0.87 (0.80 to 0.91)2.92 (2.17 to 3.98)0.71 (0.60 to 0.80)4.11
CRP>40–49 mg/L
Lindbaek, 1996CT122114710.100.973.480.93
Savolainen, 1997aBC273110360.200.922.560.87
Hansen, 1995AP30862730.330.903.300.75
Summary0.22 (0.15 to 0.30)0.91 (0.84 to 0.95)2.46 (1.45 to 3.91)0.86 (0.77 to 0.93)2.860.721
ESR >10
Lindbaek, 1996CT893237410.710.561.610.52
Savolainen, 1997aBC911646230.660.591.620.57
Hansen, 1995AP21211170.660.896.230.38
Summary0.68 (0.63 to 0.72)0.58 (0.50 to 0.65)1.60 (1.33 to 1.97)0.57 (0.46 to 0.68)2.81
ESR >20
Lindbaek, 1996CT40886650.320.892.900.77
van Buchem, 1995AP14639500.260.892.470.82
Hansen, 1995AP291428460.510.772.180.64
Summary0.36 (0.23 to 0.51)0.86 (0.75 to 0.92)2.55 (1.68 to 3.74)0.74 (0.61 to 0.85)3.45
ESR >30
Hansen, 1995AP23566740.260.944.080.795.16
ESR >40
Savolainen, 1997aBC261111380.190.977.400.838.910.684
WBC>10
Lindbaek, 1996CT31895650.250.892.250.85
Savolainen, 1997aBC355102340.260.871.990.85
Summary0.25 (0.20 to 0.31)0.88 (0.81 to 0.93)2.23 (1.29 to 3.66)0.85 (0.78 to 0.94)2.620.710
  • ↵a No studies with children were identified. Where results for more than one study are presented, a summary estimate is shown.

  • AP = antral puncture revealing purulent fluid. AUC = area under the receiver operating characteristic curve. BC = bacterial culture of antral fluid positive for pathogenic bacteria. CRP = C-reactive protein. CT = computed tomography. DOR = diagnostic odds ratio (positive likelihood ratio divided by negative likelihood ratio). ESR = erythrocyte sedimentation rate. FN = false negative. FP = false positive. LR+ = positive likelihood ratio. LR− = negative likelihood ratio. Rad = radiography. Ref std = reference standard. TN = true negative. TP = true positive. WBC = white blood cells.

Appendix 9. Accuracy of miscellaneous tests for the diagnosis of acute sinusitis

TestStudyRef stdPop’nTPFPFNTNSensSpecLR+LR−
Clinical nasal secretion score ≥4Huang, 2008RadB14407660.951.0095.000.05
Leucocyte esterase ≥1+ in nasal secretionsHuang, 2008RadB126325630.830.9518.360.17
Nitrite >1.0 in nasal secretionsHuang, 2008RadB78473550.520.937.620.52
pH >7 in nasal secretionsHuang, 2008RadB145386280.960.421.670.09
Protein >2.0 in nasal secretionsHuang, 2008RadB145146520.960.794.530.05
Leucocytes in sinus washingsvan Buchem, 1995APA562711930.840.783.710.21
Leucocytes in sinus washingsvan Buchem, 1992APC459750.310.944.920.74
Leucocytes in nasal secretionsVisca, 1995CTC164190.940.693.060.08
Flexible endoscopyBerger, 2011RadA43179350.830.672.530.26
Rhinoscopy — pus in nasal cavityYoung, 2003RadA5510812660.820.381.320.47
Rhinoscopy — pus in throatYoung, 2003RadA1733511410.250.811.320.93
Scintigraphy (probably or definitely abnl)Bergstedt, 1980APA2122230.910.9211.410.09
Diode gas laser spectroscopy (frontal sinus)Lewander, 2012CTA1242620.860.9414.140.15
Diode gas laser spectroscopy (maxillary sinus)Lewander, 2012CTA7411530.390.935.540.66
  • A = patient population of adults. Abnl = abnormal. AP = antral puncture showing purulent fluid. B = patient population of both adults and children. C = patient population of children. CT = computed tomography. FN = false negative. FP = false positive. LR+ = positive likelihood ratio. LR− = negative likelihood ratio. Pop’n = population. Rad = radiography. Ref std = reference standard. Sens = sensitivity. Spec = specificity. TP = true positive. TN = true negative.

Notes

Funding

None.

Ethical approval

Not applicable.

Provenance

Freely submitted; externally reviewed.

Competing interests

The authors have declared no competing interests.

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  • Received December 11, 2015.
  • Revision requested February 16, 2016.
  • Accepted March 29, 2016.
  • © British Journal of General Practice 2016

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British Journal of General Practice: 66 (650)
British Journal of General Practice
Vol. 66, Issue 650
September 2016
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Diagnosis of acute rhinosinusitis in primary care: a systematic review of test accuracy
Mark H Ebell, Brian McKay, Ryan Guilbault, Yokabed Ermias
British Journal of General Practice 2016; 66 (650): e612-e632. DOI: 10.3399/bjgp16X686581

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Diagnosis of acute rhinosinusitis in primary care: a systematic review of test accuracy
Mark H Ebell, Brian McKay, Ryan Guilbault, Yokabed Ermias
British Journal of General Practice 2016; 66 (650): e612-e632. DOI: 10.3399/bjgp16X686581
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  • Top
  • Article
    • Abstract
    • INTRODUCTION
    • METHOD
    • RESULTS
    • DISCUSSION
    • Appendix 1. Search strategy used in MEDLINE
    • Appendix 2. PRISMA flow diagram of studies selected for meta-analysis.
    • Appendix 3. QUADAS-2 instrument, adapted for systematic review of the accuracy of signs and symptoms for the diagnosis of acute sinusitisa
    • Appendix 4. Characteristics of included studies, by population and sorted by year of publication (with individual study-level data)
    • Appendix 5. The risk of bias in QUADAS-2 study design domains.
    • Appendix 6. Prevalence of acute sinusitis in the included studies, by population, inclusion criteria, and reference standarda
    • Appendix 7. Accuracy of imaging studies for diagnosis of acute sinusitis
    • Appendix 8. Accuracy of blood tests for the diagnosis of acute sinusitis in adultsa
    • Appendix 9. Accuracy of miscellaneous tests for the diagnosis of acute sinusitis
    • Notes
    • REFERENCES
  • Figures & Data
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Keywords

  • acute sinusitis
  • acute rhinosinusitis
  • clinical diagnosis
  • clinical decision-making
  • primary care
  • rhinosinusitis
  • sinusitis

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