Infection and even inflammation were NOT reliably present in the scans of patients with classic sinusitis symptoms. Chronic sinusitis can be difficult to diagnose precisely and sometimes even more difficult to treat.
Increasingly, experts are suggesting that antibiotics may be wildly overprescribed for this condition.
In a recent prospective study, patients referred to a single sinus expert for classic sinusitis symptoms were methodically evaluated with computed tomography (CT) scans and nasal endoscopy.
Of 125 consecutive patients, only 75 (60%) had evidence of sinusitis on CT scan (meatal obstruction, air-fluid levels, or mucosal thickening [one area with >10 mm thickening, or any thickening involving at least 4 sinuses]).
A decreased sense of smell predicted an abnormal CT scan, but headache, facial pain and difficulty sleeping were all more common in the patients with a normal scan.
Further, the worse the reported facial pain, the less likely the scan was to show abnormalities.
Purulent secretions were found on endoscopy in only 18 patients, all of whom had abnormal CT scans.
Standard pathogens associated with bacterial sinusitis were identified in only five of these patients.
No environmental exposures (including alcohol, tobacco, pets, and mold) could distinguish patients with normal scans from the others.
Comment from Abigail Zuger, MD in Journal Watch:
This series emphasizes not only the absence of standard bacterial pathogens in chronic sinusitis, but also the frequent absence of sinusitis itself in those who present with the usual symptoms.
The authors suggest that confounding diagnoses such as migraine headaches are often overlooked in these patients. They recommend that antibiotics be prescribed only if mucopurulence is seen on endoscopy and call for “a moratorium on the widespread practice . . . of long-term empiric antibiotics” in these patients.
Finally, they note that much of the chronic sinusitis literature includes cases identified without this careful evaluation and should thus be viewed “with extreme skepticism.”
CITATION: Ferguson BJ et al. Prospective observational study of chronic rhinosinusitis: Environmental triggers and antibiotic implications.Clin Infect Dis 2012 Jan 1; 54:62. [Medline® Abstract]