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Clinical Evaluation for Sinusitis: Making the Diagnosis by History and Physical Examination

John W. Williams Jr, MD, MHS; David L. Simel, MD, MHS; LeRoy Roberts, MD; and Greg P. Samsa, PhD
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Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, 29 April-1 May 1992.

Grant Support: By HSR&D grant 89-065.A and the A.W. Mellon Foundation.

Requests for Reprints: John W. Williams, Jr., MD, Audie L. Murphy Memorial Veterans Hospital, HC, 7400 Merton Minter Boulevard, San Antonio, TX 78284.

Current Author Addresses: Dr. Williams: Audie L. Murphy Memorial Veterans Hospital, HC, 7400 Merton Minter Boulevard, San Antonio, TX 78284.

Drs. Simel and Samsa: Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705.

Dr. Roberts: Fayetteville Diagnostic Center, Fayetteville, NC 28304.

Ann Intern Med. 1992;117(9):705-710. doi:10.7326/0003-4819-117-9-705
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Objective: To identify the most useful clinical examination findings for the diagnosis of acute and subacute sinusitis.

Design: Prospective comparison of clinical findings with radiographs.

Setting: General medicine clinics at a university-affiliated Veterans Affairs Medical Center.

Patients: Two hundred forty-seven consecutive adult men with rhinorrhea (51%), facial pain (22%), or self-suspected sinusitis (27%) (median age, 50 years; median duration of symptoms, 11.5 days).

Measurements: Patients were examined by a principal investigator (86%) or by a staff general internist, internal medicine resident (postgraduate year 2 or 3), or physician assistant, all blinded to radiographic results. All examiners recorded the presence or absence of 16 historical items, 5 physical examination items, and the clinical impression for sinusitis (high, intermediate, or low probability). The criterion standard was paranasal sinus radiographs (4 views), which were interpreted by radiologists blinded to clinical findings.

Results: Thirty-eight percent of patients meeting entrance criteria had sinusitis. Sensitivity, specificity, and likelihood ratios were measured for clinical items. Logistic regression analysis showed five independent predictors of sinusitis: maxillary toothache (odds ratio, 2.9), transillumination (odds ratio, 2.7), poor response to nasal decongestants or antihistamines (odds ratio, 2.4), colored nasal discharge reported by the patient (odds ratio, 2.2), or mucopurulence seen during examination (odds ratio, 2.9). The overall clinical impression was more accurate than any single finding: high probability (likelihood ratio, 4.7), intermediate (likelihood ratio, 1.4), low probability (likelihood ratio, 0.4).

Conclusions: General internists, focusing on five clinical findings and their overall clinical impression, can effectively stratify male patients with sinus symptoms as having a high, intermediate, or low probability of sinusitis.







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