Original articlesComparison of ultrasound, radiography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systematic review
Introduction
Acute maxillary sinusitis (AMS) is one of the most frequent diagnoses in primary health care. Nasal complaints, allergy, and rhinitis are common, and distinguishing between rhinitis and sinusitis is not always simple. Most often the diagnosis of AMS is based on symptoms and clinical examination alone. In Northern Europe and in the Netherlands the sinus ultrasound performed by clinicians has gained wide acceptance in the diagnosis of AMS and in part displaced sinus radiographs. In the United States computed tomography has also been used in the diagnosis of AMS, while in Europe it is used only in secondary care.
The diagnostic criteria for AMS are not well established. Most often it is defined as inflammation of the paranasal sinus mucosa with retention in the sinuses [1]. Sinus puncture is considered as the gold standard in the diagnosis of sinusitis. However, it is invasive and not easily accepted by the patients. Radiography and computed tomography (CT) have also been used as reference standards. The problem with both of them is that they may produce a number of false-positive results (mucosal thickening or polyps, cysts, or anomalies). To our knowledge, there are no studies in which CT had been compared to sinus puncture. However, there is evidence that patients with the common cold and even nonsymptomatic patients may have pathological findings in the CT of sinuses 1, 2, 3.
The difficulties in indicating the retention in maxillary sinuses have led to the overdiagnosing of AMS and to overtreatment with antibiotics. In most countries the current practice is to treat suspected AMS with antibiotics [4]. In Finland, more than 90% of patients with symptoms of suspected sinusitis receive a course of antibiotics at their first visit to a general practitioner when the diagnosis is based on clinical examination only [5].
The aim of our study was to evaluate through a systematic review of the research literature the efficacy of clinical examination, ultrasound, and radiography as diagnostic measures for AMS in unselected populations. A second aim was to put some proposed meta-analytical approaches to test.
Section snippets
Search strategy
We searched the Medline database from 1966 to April 1999 and the Finnish medical database, Medic, from 1977 onwards using a variety of both Medical Subject Heading (MeSH) terms and textword options. Two investigators (H.V. and M.M.) independently assessed the database searches to find potential study articles. Reference lists of pertinent articles and reviews were used to identify more studies. We hand-searched volumes dating from 1980 on of four important journals in the field (Journal of
Search results
The Medline searches yielded 1054 references and Medic search yielded 49. Altogether 168 abstracts were printed for further examination. One investigator (H.V.) critically rated the study articles and the questionable studies were discussed with the other reviewers. A total of 49 studies concerning the diagnosis of maxillary sinusitis in adults were retrieved. The results of the literature searches and the primary reasons for study exclusion are presented in Table 1. Eleven articles met our
Discussion
In our meta-analysis, radiography was the most accurate method to diagnose sinusitis in unselected patients. Ultrasound was almost as accurate but the results of ultrasound were heterogeneous. This may be a result of differences in who performs the scan, in the equipment used, or in the aims of use: ultrasound was not accurate in predicting cysts or mucosal thickening in sinuses. However, an ultrasound finding of back-wall echo indicating retention in the sinuses was a strong evidence to
Conclusions
Clinical examination is not a reliable method for the diagnosis of AMS. If a correct diagnosis is considered important (i.e., if antibiotic treatment is effective despite claims to the contrary), ultrasound or radiography should be used as diagnostic aids. In the diagnostic test evaluations more attention should be paid to study methodology and to the interplay between diagnostic output and therapeutic options. The diagnosis of AMS is rarely studied in primary care settings, which is sad as the
Acknowledgements
We wish to thank Drs. Jens Georg Hansen and Karri Laine, who consented to sending us their original data, and Dr. Joseph Lau, who provided us with the Meta-Test software for diagnostic meta-analysis.
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