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Red Streak Predicts Acute Sinusitis in Adults

Am Fam Physician. 2007 Feb 15;75(4):559.

Background: Upper respiratory infections account for more than 30 million U.S. physician office visits each year; another 28 million visits are made for chronic sinusitis and allergic rhinitis. From a cost and convenience perspective, it is not practical to offer diagnostic imaging for patients with sinusitis who are not candidates for surgical intervention. A red streak resulting from nasal drainage often is visible on the oropharyngeal mucosa. Thomas and Aizin tried to determine whether this red streak in the lateral recess of the oropharynx could be helpful in diagnosing acute sinusitis.

The Study: Patients with nasal symptoms who visited an urgent care center were recruited for the study. Their symptoms included nasal drainage, congestion, obstruction, or facial pain. Patients with self-diagnosed sinusitis also were included. Participants' medical histories and 10 physical examination findings, including sinus transillumination and presence of a red streak, were evaluated. All underwent coronal computed tomography (CT), and the findings were corroborated with a second evaluator. A neuroradiologist interpreted the CT images for air-fluid levels.

Results: Of the 73 patients included, 60 completed the study, and 27 patients were diagnosed with acute sinusitis. A red streak in the lateral recess of the oropharynx was identified in 30 patients. The red streak also was associated with acute sinusitis on CT with a positive likelihood ratio (LR) of 2.11 and a negative LR of 0.44 (see accompanying table).

Conclusion: The authors conclude that the red streak was positively associated with the diagnosis of acute sinusitis, which is a physical finding that has not been studied previously. They note that it is reproducible, simple to evaluate, and requires no special equipment. Transillumination also correlated with the diagnosis, but facial pain did not.

Likelihood Ratios for Selected History and Physical Examination Findings in the Diagnosis of Sinusitis

Finding LR+ LR−

Maxillary opacity on transillumination

1.89

0.56

Facial pain/percussion tenderness

0.59/0.42

1.88/1.88

Symptom duration > 10 days

1.89

0.46


LR = likelihood ratio.

Likelihood Ratios for Selected History and Physical Examination Findings in the Diagnosis of Sinusitis

View Table

Likelihood Ratios for Selected History and Physical Examination Findings in the Diagnosis of Sinusitis

Finding LR+ LR−

Maxillary opacity on transillumination

1.89

0.56

Facial pain/percussion tenderness

0.59/0.42

1.88/1.88

Symptom duration > 10 days

1.89

0.46


LR = likelihood ratio.

Source

Thomas C, Aizin V. Brief report: a red streak in the lateral recess of the oropharynx predicts acute sinusitis. J Gen Intern Med. September 2006;21:986–8.

editor's note: This study used CT as the comparison standard rather than radiography. In a previous study that used CT, it was found that a return of symptoms after a cold, purulent rhinorrhea and secretions, and an erythrocyte sedimentation rate greater than 10 mm per hour had independent associations with sinusitis.1 Other studies have used radiography to establish reference criteria. According to a review by the Agency for Healthcare Research and Quality, the presence of three or four of four nasal symptoms—purulent rhinorrhea with unilateral predominance, local pain with unilateral predominance, bilateral purulent rhinorrhea, and pus in the nasal cavity—has an equivalent diagnostic accuracy to that of sinus radiography, which has been shown to have a sensitivity of 76 percent and a specificity of 79 percent.2 In an earlier study, these criteria were developed into a prediction rule.3 The oropharyngeal red streak may aid in the development of a more reliable predictive model.—c.w.

 

REFERENCES

1. Lindbæk M, Hjortdahl P, Johnson UL. Use of symptoms, signs, and blood tests to diagnose acute sinus infections in primary care: comparison with computed tomography. Fam Med. 1996;28:183–8.

2. Agency for Healthcare Research and Quality. Diagnosis and treatment of acute bacterial rhinosinusitis. Summary. Rockville, M.D.: Agency for Healthcare Research and Quality, 1999. Accessed September 29, 2006, at: http://www.ahrq.gov/clinic/epcsums/sinussum.htm.

3. Williams JW Jr, Simel DL, Roberts L, Samsa GP. Clinical evaluation for sinusitis. Making the diagnosis by history and physical examination. Ann Intern Med. 1992;117:705–10.


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