Acute Sinusitis vs Upper Respiratory Tract Infection
Acute Sinusitis vs Upper Respiratory Tract Infection
Background: The purpose of our study was to examine how physicians diagnose sinusitis in practice. We addressed three specific questions: (1) what clinical factors do physicians look for in evaluating and caring for patients with suspected sinusitis, (2) to what extent do physicians use transillumination and radiograph evaluations in diagnosing sinusitis, and (3) how does the diagnosis of sinusitis influence the decision to prescribe antibiotic therapy?
Methods: We conducted a retrospective review using charts from 25 local family physicians who volunteered to participate in the study. After selecting a random sample of charts of adult patients treated for sinusitis and for upper respiratory tract infection (URI) by each physician, we reviewed the charts to determine the nature of the information collected to differentiate between sinusitis and URI.
Results: Rhinorrhea, sinus tenderness, visualization of purulent secretions, and a history of sinusitis were significant predictors of the diagnosis of sinusitis. Antibiotics were prescribed for 98.4% of patients with sinusitis and 13.1% of patients with URI.
Conclusions: This sample of physicians based the diagnosis of sinusitis on three prominent clinical findings, which were also significant factors in diagnosing sinusitis in previous studies. The history of sinusitis might influence patient and physician expectations for the diagnosis.
The diagnosis of acute bacterial sinusitis is frequently made on clinical grounds. A body of literature has examined the accuracy of the clinical diagnosis of sinusitis and the specific factors that influence the physician in making the diagnosis. Use of ancillary techniques, such as transillumination, radiograph examinations, sonography, computed tomographic scanning, and laboratory studies have also been explored. The recent Agency for Health Care Policy and Research (AHCPR) evidence report on diagnosis and treatment of acute bacterial rhinosinusitis concluded, "limited evidence suggests that clinical criteria . . . may have a diagnostic accuracy similar to that of sinus radiography." The consensus has arisen from this literature that the clinical diagnosis of sinusitis is a valid approach.
The specific clinical factors physicians emphasize when diagnosing sinusitis have only recently begun to be examined. In a previous study the authors developed a series of simulated case histories based on clinical factors described in the literature on sinusitis. The cases were presented to a sample of family physicians to determine which factors most strongly influenced their decision to diagnose sinusitis and prescribe antibiotics. The study also examined the extent to which physicians reported the use of transillumination and radiograph examinations in the diagnosis of sinusitis.
The previous study found that the diagnosis of sinusitis is strongly influenced by the number of clinical factors present. Individual factors with a significant influence on the diagnosis included a history of maxillary or facial pain, a history of colored nasal discharge, and lack of response to decongestants. Physical findings of sinus tenderness, purulent drainage visualized on nasal examination, and fever also significantly influenced the diagnosis. Each of these factors had a similar influence on the physicians' decision to prescribe antibiotics. Smoking history as a factor in the simulated cases had a minimal impact on the diagnosis and treatment of sinusitis. Sixty percent of the physicians in the study stated that they perform transillumination. The median estimated percentage of cases for which radiographs would be obtained was 6.25%.
A recent study by Hueston and colleagues examined practice patterns of resident physicians in differentiating between sinusitis and upper respiratory tract infection (URI). Their report concluded that residents relied on unreliable clinical findings (sinus tenderness and sinus pressure) to diagnose sinusitis, with the possibility of overdiagnosis and overtreatment.
Although the use of simulated cases in the previous study provided insight into the medical decision-making process, it might not accurately reflect what physicians actually do in practice. The purpose of our study was to examine how experienced physicians diagnose sinusitis in practice. The following specific questions were addressed: (1) Which clinical factors do physicians look for in evaluating and treating patients with suspected sinusitis? (2) To what extent do physicians use transillumination and radiograph evaluations in diagnosing sinusitis? (3) How does the diagnosis of sinusitis influence the decision to prescribe antibiotic therapy?
Background: The purpose of our study was to examine how physicians diagnose sinusitis in practice. We addressed three specific questions: (1) what clinical factors do physicians look for in evaluating and caring for patients with suspected sinusitis, (2) to what extent do physicians use transillumination and radiograph evaluations in diagnosing sinusitis, and (3) how does the diagnosis of sinusitis influence the decision to prescribe antibiotic therapy?
Methods: We conducted a retrospective review using charts from 25 local family physicians who volunteered to participate in the study. After selecting a random sample of charts of adult patients treated for sinusitis and for upper respiratory tract infection (URI) by each physician, we reviewed the charts to determine the nature of the information collected to differentiate between sinusitis and URI.
Results: Rhinorrhea, sinus tenderness, visualization of purulent secretions, and a history of sinusitis were significant predictors of the diagnosis of sinusitis. Antibiotics were prescribed for 98.4% of patients with sinusitis and 13.1% of patients with URI.
Conclusions: This sample of physicians based the diagnosis of sinusitis on three prominent clinical findings, which were also significant factors in diagnosing sinusitis in previous studies. The history of sinusitis might influence patient and physician expectations for the diagnosis.
The diagnosis of acute bacterial sinusitis is frequently made on clinical grounds. A body of literature has examined the accuracy of the clinical diagnosis of sinusitis and the specific factors that influence the physician in making the diagnosis. Use of ancillary techniques, such as transillumination, radiograph examinations, sonography, computed tomographic scanning, and laboratory studies have also been explored. The recent Agency for Health Care Policy and Research (AHCPR) evidence report on diagnosis and treatment of acute bacterial rhinosinusitis concluded, "limited evidence suggests that clinical criteria . . . may have a diagnostic accuracy similar to that of sinus radiography." The consensus has arisen from this literature that the clinical diagnosis of sinusitis is a valid approach.
The specific clinical factors physicians emphasize when diagnosing sinusitis have only recently begun to be examined. In a previous study the authors developed a series of simulated case histories based on clinical factors described in the literature on sinusitis. The cases were presented to a sample of family physicians to determine which factors most strongly influenced their decision to diagnose sinusitis and prescribe antibiotics. The study also examined the extent to which physicians reported the use of transillumination and radiograph examinations in the diagnosis of sinusitis.
The previous study found that the diagnosis of sinusitis is strongly influenced by the number of clinical factors present. Individual factors with a significant influence on the diagnosis included a history of maxillary or facial pain, a history of colored nasal discharge, and lack of response to decongestants. Physical findings of sinus tenderness, purulent drainage visualized on nasal examination, and fever also significantly influenced the diagnosis. Each of these factors had a similar influence on the physicians' decision to prescribe antibiotics. Smoking history as a factor in the simulated cases had a minimal impact on the diagnosis and treatment of sinusitis. Sixty percent of the physicians in the study stated that they perform transillumination. The median estimated percentage of cases for which radiographs would be obtained was 6.25%.
A recent study by Hueston and colleagues examined practice patterns of resident physicians in differentiating between sinusitis and upper respiratory tract infection (URI). Their report concluded that residents relied on unreliable clinical findings (sinus tenderness and sinus pressure) to diagnose sinusitis, with the possibility of overdiagnosis and overtreatment.
Although the use of simulated cases in the previous study provided insight into the medical decision-making process, it might not accurately reflect what physicians actually do in practice. The purpose of our study was to examine how experienced physicians diagnose sinusitis in practice. The following specific questions were addressed: (1) Which clinical factors do physicians look for in evaluating and treating patients with suspected sinusitis? (2) To what extent do physicians use transillumination and radiograph evaluations in diagnosing sinusitis? (3) How does the diagnosis of sinusitis influence the decision to prescribe antibiotic therapy?
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