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The Common Cold in Patients with a History of Recurrent Sinusitis Increased Symptoms and Radiologic Sinusitislike Findings
METHODS: We recruited 2 series of volunteer cases from February 1, 1996, to December 31, 1996. Twenty-three adults who claimed to have suffered from recurrent sinusitis and 25 who had never had sinusitis were examined during the period of a self-diagnosed cold of 48 to 96 hours’ duration and again after 21 days. Symptom scores were recorded, nasoendoscopy and computed tomography scans were performed, and viral and bacterial specimens were taken.
RESULTS: The patients with a history of sinusitis had significantly higher mean symptom scores than the control patients (P=.04) and had radiologic sinusitislike changes more often (65% [15] vs 36% [9]; difference 29% [95% confidence interval, 2%-56%]; P=.04). The viral etiology of the common cold (verified in 67% of the episodes) was similar in both groups. Pathogenic bacteria were isolated from the middle meatus in 24% (6) of the control patients and only 9% (2) of the sinusitis-prone patients (P=.15). On the basis of the symptomatology, radiologic findings, and bacterial cultures only 2 patients in the sinusitis-prone group should have been treated with antimicrobials.
CONCLUSIONS: Some patients are susceptible to both sinusitislike symptoms and radiologic findings during viral common colds. This may cause them to consult their physicians earlier and more often during viral colds, which may result in unnecessary antibiotic treatments. Nasopharyngeal bacteriological cultures may prove to be useful in ruling out bacterial sinusitis.
Sinusitis is the most common condition for which antibiotics are prescribed in ambulatory practice, according to the National Ambulatory Medical Care Survey.1 There are many patients who are given a diagnosis of sinusitis and treated with antimicrobials during almost all common colds. Chronic sinusitis is the most common self-reported chronic illness in the United States.2 Our experience is that patients who have suffered from recurrent sinusitis episodes often seek medical help during an early stage of a respiratory infection. This may lead to a viral common cold being unnecessarily treated with antibiotics, because the diagnosis of bacterial sinusitis remains difficult to make.
We studied whether sinusitis-prone patients have more severe or different symptoms compared with healthy controls at the beginning of a respiratory infection that could increase their consultation prevalence. Also, we evaluated whether there are differences in the clinical and radiologic findings between these 2 groups that could lead the physicians to regard the disease as bacterial sinusitis. To do this we compared these items and the microbiologic findings during one episode of a common cold in patients with a history of recurrent sinusitis and in patients who had never had sinusitis.
Methods
Patients
The patients were recruited by solicitations for volunteers with a community-acquired common cold by advertising in a newspaper distributed in Oulu, a city in Finland with approximately 120,000 inhabitants. A trained nurse screened the volunteers for eligibility by telephone in a way designed to mask the specific criteria for enrollment in the study. Two sets of volunteers were enrolled. The sinusitis-prone group included persons who claimed to have suffered from at least 2 yearly episodes of acute maxillary sinusitis during the previous 2 years. The control group consisted of persons who had never had clinical sinusitis. The other criteria were: aged older than 18 years, symptoms of acute common cold for 48 to 96 hours, presence of nasal symptoms, no chronic sinusitis or nasal polyps, no previous paranasal surgery, no ongoing antibiotic treatment, no pregnancy, and no diagnosed immunologic disorder. The Ethical Committee of the University of Oulu approved our study, and written informed consent was obtained from all patients.
To assess the selection process, we gathered data on the persons contacting the study nurse during one randomly selected week of the inclusion period (week 51, 1996). During this 1 week, 81 patients contacted the nurse. Of these, 43 were excluded because they had symptoms for more than 96 hours, 23 because they had had too few previous sinusitis episodes, 4 because they had operations for sinus problems, 4 because they had been taking an antibiotic treatment during the previous month, and 4 because they did not have nasal symptoms, leaving 3 patients (4%) who entered the study.
The patients were unaware of the aims of our study. They were asked to complete questionnaires containing items on various background factors. To study allergic background, we performed skin prick tests with 18 common inhalants (Prick-Lancett, Ewo Care AB, Gislaved, Sweden) as described previously,3 measured total serum immunoglobulin E (IgE) with the QuantiCLONE Total IgE Kit (Kallestad Diagnostics, Inc, Chaska, Minn), and recorded nasal eosinophilia (proportion of eosinophils exceeding 10% of nucleated cells on nasal smear).
Symptoms and Signs
The date of recruitment to the study was called day 1. The study patients filled in a form twice a day concerning their symptoms on days 1, 2, and 3. To determine a score for each symptom, they rated the following 10 using a scale from 0 (not present) to 10 (very severe): runny nose, nasal stuffiness, sneezing, sore throat, facial pain, cough, fatigue or lethargy, muscle aches, chills, and headache. The individual symptom scores were summed for each subject, resulting in a total score calculated separately for each day and overall. On day 21, only the presence of any acute symptoms was recorded.
An ear, nose, and throat specialist examined all patients on days 1 and 21. The examiner knew the subject’s history but was unaware of all other findings. Nasoendoscopy was performed with a rigid 4-mm Storz 0° endoscope, and various pathologic findings were recorded.
Radiologic Examinations
We viewed coronal computed tomographic (CT) slices including the nasal passages and all the paranasal sinuses on days 1 and 21 (Sytec 3000 Plus or HiSpeed Advantage scanner, General Electric Medical Systems, Milwaukee, Wis). Two experienced radiologists and 3 ear, nose, and throat specialists evaluated the CT scans independently from a hard copy. In cases of disagreement the 2 groups reassessed the finding jointly to reach consensus. The reviewers were blinded to all other parameters including the history. The radiologic sinusitislike changes included total opacification, an air-fluid level, or more than 5-mm mucosal thickening. Also, the presence of an air-fluid level or total opacification in any sinus was recorded.
Microbiologic Studies
Viral antigens from the nasal mucus were detected by time-resolved fluoroimmunoassay for the following common respiratory viruses on day 1: adenovirus; respiratory syncytial virus; parainfluenza types 1, 2, and 3; and influenza A and B.4 Virus cultures from nasopharyngeal swaps for these viruses and for rhinovirus were done using the Ohio strain HeLa cells and human foreskin fibroblasts according to a procedure described previously.5 Rhinoviruses were also detected by reverse transcription-polymerase chain reaction (PCR).6,7 Some of the picorna viruses could not be identified further with these PCR assays. Mycoplasma immunoglobulin M (IgM) antibodies from the serum samples taken on day 21 were measured with 2 commercial kits (SeroMP, Savyon Diagnostics Ltd, Israel; and Mycoplasma pneumoniae IgM ELISA, Novum Diagnostica GmbH, Germany). A true-positive result in both tests was required for a definitive diagnosis. Specimens for aerobic and anaerobic bacterial cultures were taken from the nasopharynx and with the help of an endoscope from the middle meatus on day 1. The swabs were inoculated onto normal and chocolated sheep blood agar plates and onto fastidious anaerobe agar plates containing sheep blood (Lab M, Bury, England), according to routine procedures.
Treatment
On the basis of the overall clinical impression (no specific criteria were given) and radiologic findings, the patients designated to have bacterial sinusitis were given either amoxicillin 500 mg 3 times daily for 7 days, or trimethoprim-sulfamethoxazole 160 mg plus 800 mg twice daily for 7 days in case of penicillin allergy. All of the patients were allowed nasal decongestants and mild analgesics.
Statistical Analysis
To analyse the relationship between the different variables and the history of recurrent or no sinusitis, we performed the {c}2 test in case of proportions, the Student t test for normally distributed continuous variables, and the Mann-Whitney U test on nonparametric variables. All significance tests of hypotheses were 2 tailed.
Results
Patients
During 2 periods between February 1 and May 15, 1996, and August 15 and December 31, 1996, a total of 52 patients were enrolled, 26 in the sinusitis-prone group and 26 in the control group. The patients in both series were enrolled in even numbers during the entire study period (16 sinusitis-prone patients and 12 control patients in the first period and 10 and 14 patients, respectively, in the second). Three sinusitis-prone patients and one control subject were excluded because of an ongoing antimicrobial treatment, a broken CT apparatus at the time of the follow-up visit, nasal polyps in nasoendoscopy, and one doubtful sinusitis episode in a control subject’s history. Thus, 48 patients completed the study: 23 in the sinusitis-prone group and 25 in the control group. One sinusitis-prone subject did not return the symptom scores and was excluded from the analyses of the symptoms.
The background characteristics of the patients are shown in Table 1. The sinusitis-prone patients reported a significantly higher mean number of common cold episodes per year than the control patients (P=.01), but the 2 groups were similar in terms of the other background characteristics.
Symptoms and Signs
Both the sinusitis-prone patients and the control patients had symptoms for an average of 3 days before day 1 (mean duration=3.0 days [standard deviation (SD) =1] and mean duration=3.2 days [SD=1], respectively). The control patients had markedly lower overall mean symptom scores than the sinusitis-prone patients (144 [SD=70] vs 177 [SD=74]; P=.04), the difference increasing during days 1 to 3 Figure 1. Facial pain was more common and more severe among the sinusitis-prone patients than among the control patients (73% [16] vs 24% [6]; P=.001 and median scores 5 [range 0-43] vs 0 [0-26]; P=.002), but the frequency and severity of the other symptoms were similar in the 2 groups (data not shown). On day 21, 2 sinusitis-prone patients (9%) and 4 control patients (16%) still reported symptoms.
The distributions of patients having various pathologic nasoendoscopic findings were similar in the sinusitis-prone group and the control group on day 1 Table 2. None of the pathologic nasoendoscopic findings correlated with the presence of facial pain. By day 21, the frequencies of pathologic nasoendoscopic findings had dropped similarly in the 2 groups.
Radiologic Findings
The sinusitis-prone patients had radiologic sinusitislike changes significantly more often both overall (65% [15] vs 36% [9], difference=29% [95% confidence interval (CI), 2%-56%]; P=.04) and in the maxillary sinus (56% [13] vs 28% [7]; P=.05) than the control patients on day 1 Table 2. In contrast, the distributions of patients having an air-fluid level or total opacification in any sinus were similar in the 2 groups. The symptom scores were similar for the patients with and without radiologic sinusitis in both groups (data not shown). On day 21, the proportions of patients with radiologic sinusitis had dropped, particularly in the sinusitis-prone group, and the 2 groups were similar. Of the 15 patients who had radiologic sinusitis on day 21, 7 (47%) had been given antibiotics and 6 (40%) still had acute symptoms, but these 2 factors were unrelated to each other (P=.20).
Microbiologic Findings
Viral etiology of the common cold was verified in 67% (32) of the patients Table 3. The proportions of sinusitis-prone patients and control patients with viral infection were similar (70% [16] vs 64% [16]; P=.68). The most frequent virus was rhinovirus, which was detected in 35% (8) and 20% (5) of the sinusitis-prone and control patients, respectively. The number of patients having pathogenic bacteria (Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis) isolated from the nasopharynx was significantly greater among the controls than the sinusitis-prone patients (40% [10] vs 9% [2], difference 31% [95% CI, 9%-54%]; P <.01). This same difference was also seen in the cultures taken from the middle meatus, although it was not statistically significant (24% [6] vs 9% [2]; P=.15, respectively). The nasopharyngeal culture findings of the smoking and nonsmoking patients were similar (19% [3] vs 31% [10]; P=.36, respectively). One control subject had a Fusobacterium species, but no other pathogenic anaerobic bacteria were found. The presence of either verified viral infection or pathogenic bacteria isolated from the nasopharynx was not related to radiologic sinusitislike changes in both groups (data not shown).
Treatment
Altogether 13 patients were considered to have bacterial sinusitis based on clinical and radiologic criteria, and 10 were given amoxycillin and 3 sulpha-trimethoprim. The sinusitis-prone patients were treated with antimicrobials more often than the control patients (43% [10] vs 12% [3]; P=.02). None of the patients consulted another physician or received any other prescription during the study. Two of the 10 sinusitis-prone patients and 2 of the 3 control patients considered to have bacterial sinusitis on the basis of the symptoms and signs and radiologic findings had pathogenic bacteria isolated from the nasopharynx. Thus, if a positive nasopharyngeal bacterial culture had been used as an additional criterion for antimicrobial treatment only 4 patients would have been treated.
Discussion
We found that the patients who had suffered from recurrent sinusitis episodes had significantly higher symptom scores and radiologic sinusitislike changes more often during an ordinary viral common cold than the patients who had never had sinusitis. The patients with a history of sinusitis also had more prolonged symptoms and more facial pain than did the control patients. The viral etiology of the common cold was verified in two thirds of the episodes, and it was similar in both groups. Yet, pathogenic bacteria were found rarely in the middle meatus especially among the sinusitis-prone patients.
We were unable to find any explanation for these differences in the symptom scores and radiologic findings between the sinusitis-prone and control patients during a common cold. It was not explained by allergy or the etiology of the infection. Also, symptom scores were not related to radiologic changes, which is in agreement with the results of an earlier study.8 Differing psychologic factors may also affect the symptom scores. Men have been shown to exaggerate their cold symptoms,9 and smoking has been found to predispose persons to common cold10; however, even these variables and other background characteristics were similar in our sinusitis-prone patients and control patients. Nonatopic nasal hyperreactivity and permanent mucosal changes in the nose and sinuses are other possible explanations for the differences.
The more severe and prolonged symptoms and facial pain during common colds may cause sinusitis-prone patients to seek medical help earlier and more often than healthy patients. The knowledge of having a tendency for recurrent sinusitis episodes may further strengthen this behavior. Also, facial pain is a symptom that people do not usually regard as part of a common cold but rather as a symptom related to sinusitis. Our finding is in agreement with that of Hansen and collegues11 who found that previous sinusitis was a factor that lead patients without bacterial sinusitis to seek medical help for respiratory symptoms.
Since the diagnostic reference standard (maxillary puncture with bacterial culture) is not suitable for routine use in differentiating bacterial sinusitis from viral respiratory infection, certain specific symptoms and signs have been suggested to be used for this purpose.12 A recent study showed that clinicians tend to rely on varied historical and physical examination criteria for this purpose.13 Also, a history of sinus infections was strongly connected to physicians’ tendency to give a diagnosis of sinusitis.13
Although the role and benefits of imaging remain unclear, it is increasingly used to evaluate patients with colds.14 The majority of patients with a common cold have been shown to have widespread radiologic sinus changes that resolve spontaneously.15-17 In our study, 65% of the sinusitis-prone patients had radiologic sinusitislike changes, which is a much higher proportion than that among the healthy controls (35%), the latter figure being in agreement with the earlier reports.17 The severe symptoms and the high frequency of radiologic sinusitislike changes during a common cold make the patients with a sinusitis history particularly susceptible to be given a diagnosis of bacterial sinusitis, leading to unnecessary prescriptions for antibiotics.
We would need an objective diagnostic test in addition to symptomatology and radiologic findings to differentiate bacterial sinusitis from viral respiratory infection in sinusitis-prone patients who seek medical help during an early phase of a respiratory infection. A pathogen-positive bacteriologic culture collected endoscopically from the middle meatus would have been useful in this respect. If this finding had been used in addition to the clinical and radiologic criteria for the diagnosis of bacterial sinusitis, the number of antimicrobial treatments in our series would have decreased from 10 to 2 in the sinusitis-prone group and from 3 to 2 in the control group. Since endoscopically collected samples are not suitable for routine use in primary care, nasopharyngeal culture is an alternative method. Nasal cultures have been considered inaccurate in the diagnosis of bacterial sinusitis, because they give false-positive results.16 However, there is evidence that a pathogen-positive nasal culture is fairly sensitive to acute bacterial maxillary sinusitis.18 In our series, compared with the endoscopically obtained culture findings from the middle meatus, the nasopharyngeal samples also gave a few false-positive results, but only in the control patients. Further studies are needed to clarify the usefulness of this method in diagnosing true bacterial sinusitis.
We do not know how many of the patients actually had bacteriological sinusitis in our series, because we did not do maxillary punctures with bacteriologic cultures. However, we think most had a viral disease at the time of the first examination, because bacterial sinusitis usually follows viral respiratory infection after 5 to 7 days. The study patients had symptoms for an average of 3 days. Secondly, only 5 patients (10%), 2 sinusitis-prone patients and 3 controls, had both a pathogenic bacterium isolated from the middle meatus and an air-fluid level or total opacification in any of the sinuses in the CT scan. Although the precise value of endoscopically obtained culture findings in sinus disease remains controversial16 there is increasing evidence to suggest that this method could be valuable.19 A finding of an air-fluid level or total opacification in CT scan has been shown to correlate with bacterial sinusitis,11 and patients with this finding have benefited from antibiotic treatment.20 The sinusitis-prone patients and the control patients were similar for all these findings.
Limitations
The patients who participated in our study were volunteers, but they were unaware of the aims of the study. The selection process was similar for the control patients and the sinusitis-prone patients. Proper symptoms were required for inclusion in both groups, which may have caused more serious cases to be selected. The patients were not recruited during the worst period of seasonal allergies (from the end of May to the beginning of August), to avoid having allergy symptoms confound the cold symptoms. Different viruses may cause different symptoms, and to avoid this bias both groups were enrolled evenly during the study period.
Conclusions
Patients with a history of recurrent sinusitis have more severe symptoms and have radiologic sinusitislike changes more often during common colds than patients with no history of sinusitis. This may result in overdiagnoses of bacterial sinusitis for patients with an earlier history of sinusitis. A pathogen-positive nasopharyngeal culture has been shown sensitive for bacterial sinusitis. Therefore, a strategy of culturing nasopharyngeal secretions of the patients suspected of having bacterial sinusitis and treating only the patients who have pathogenic bacteria in their nasopharynx would help physicians avoid unnecessary prescriptions of antimicrobials. We recommend such a strategy for sinusitis-prone patients
1. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-04.
2. Collins JG. Prevalence of selected chronic conditions, United States, 1983-1985, no. 155. Hyattsville, Md: National Center for Health Statistics; 1988.
3. Subcommittee on Skin Tests of the European Academy of Allergology and Clinical Immunology: methods for skin testing. In: Dreborg S, ed. Skin tests used in type I allergy testing. Allergy 1989;44(suppl):22-30.
4. Arstila PP, Halonen PE. Direct antigen detection. In: Lennette EH, Halonen P, Murphy FA, eds. Laboratory diagnosis of infectious diseases: principle and practice. New York, NY: Springer-Verlag, 1988;60-75.
5. Al-Nakib W, Tyrrell DAJ. Picorna viridae: rhinoviruses-common cold viruses. In: Lennette EH, Halonen P, Murphy FA, eds. Laboratory diagnosis of infectious diseases: principle and practice. New York, NY: Springer-Verlag; 1988;723-42.
6. Hyypiä T, Auvinen P, Maaronen M. Polymerase chain reaction for human picornaviruses. J Gen Virol 1989;70:3261-68.
7. Halonen P, Rocha E, Hierholzer J, et al. Detection of enteroviruses and rhinoviruses in clinical specimens by PCR and liquid-phase hybridization. J Clin Microbiol 1995;33:648-53.
8. Bhattacharyya T, Piccirillo J, Wippold II F. Relationship between patient-based descriptions of sinusitis and paranasal sinus computed tomographic findings. Arch Otolaryngol Head Neck Surg 1997;123:1189-92.
9. MacIntyre S, Pritchard C. Comparisons between self-assessed and observer-assessed presence and severity of colds. Soc Sci Med 1989;29:1243-48.
10. Cohen S, Tyrrell DA, Russell MA, Jarvis MJ, Smith AP. Smoking, alcohol consumption, and susceptibility to the common cold. Am J Public Health 1993;83:1277-83.
11. Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting acute maxillary sinusitis in a general practice population. BMJ 1995;311:233-36.
12. Williams JW, Jr, Aguilar C, Makela M, et al. Antibiotic therapy for acute sinusitis: a systematic literature review. In: Douglas R, Bridges-Webb C, Glasziou P, Lozano J, Steinhoff M, Wang E, eds. Acute respiratory infections module of the Cochrane Library. Oxford, England: Update Software; 1997.
13. Hueston WJ, Eberlein C, Johnson D, Mainous III AG. Criteria used by clinicians to differentiate sinusitis from viral upper respiratory infection. J Fam Pract 1998;46:487-92.
14. Kaliner MA, Osguthorpe JD, Fireman P, et al. Sinusitis: bench to bedside. Current findings, future directions. J Allergy Clin Immunol 1997;99:S829-48.
15. Gwaltney JM, Jr, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med 1994;330:25-30.
16. Gwaltney JM, Jr. Acute community-acquired sinusitis: state-of-the-art clinical article. Clin Infect Dis 1996;23:1209-25.
17. Puhakka T, Mäkelä MJ, Alanen A, et al. Sinusitis in the common cold. J Allergy Clin Immunol 1998;102:403-08.
18. Jousimies-Somer HR, Savolainen S, Ylikoski JS. Comparison of the nasal bacterial floras in two groups of healthy patients and in patients with acute maxillary sinusitis. J Clin Microbiol 1989;27:2736-43.
19. Vogan JC, Bolger WE, Keyes AS. Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures. Otolaryngol Head Neck Surg 2000;122:370-73.
20. Lindbaek M, Hjortdahl P, Johnsen UL-H. Randomised, double blind, placebo controlled trial of penicillin V and amoxycillin in treatment of acute sinus infections in adults. BMJ 1996;313:325-29.
Related Resources:
- Johns Hopkins Asthma & Allergy page Information on epidemiology, triggers, drug therapy and immunotherapy. Case studies and other features. www.hopkins-allergy.org/sinusitis/index.html
- National Institute of Allergy and Infectious Diseases Information on NIAID research projects and opportunities, publications, as well as the agency’s Immune Tolerance Network www.niaid.nih.gov/default.htm
- Common Cold Centre General information for patients www.cf.ac.uk/biosi/associates/cold/info.html
METHODS: We recruited 2 series of volunteer cases from February 1, 1996, to December 31, 1996. Twenty-three adults who claimed to have suffered from recurrent sinusitis and 25 who had never had sinusitis were examined during the period of a self-diagnosed cold of 48 to 96 hours’ duration and again after 21 days. Symptom scores were recorded, nasoendoscopy and computed tomography scans were performed, and viral and bacterial specimens were taken.
RESULTS: The patients with a history of sinusitis had significantly higher mean symptom scores than the control patients (P=.04) and had radiologic sinusitislike changes more often (65% [15] vs 36% [9]; difference 29% [95% confidence interval, 2%-56%]; P=.04). The viral etiology of the common cold (verified in 67% of the episodes) was similar in both groups. Pathogenic bacteria were isolated from the middle meatus in 24% (6) of the control patients and only 9% (2) of the sinusitis-prone patients (P=.15). On the basis of the symptomatology, radiologic findings, and bacterial cultures only 2 patients in the sinusitis-prone group should have been treated with antimicrobials.
CONCLUSIONS: Some patients are susceptible to both sinusitislike symptoms and radiologic findings during viral common colds. This may cause them to consult their physicians earlier and more often during viral colds, which may result in unnecessary antibiotic treatments. Nasopharyngeal bacteriological cultures may prove to be useful in ruling out bacterial sinusitis.
Sinusitis is the most common condition for which antibiotics are prescribed in ambulatory practice, according to the National Ambulatory Medical Care Survey.1 There are many patients who are given a diagnosis of sinusitis and treated with antimicrobials during almost all common colds. Chronic sinusitis is the most common self-reported chronic illness in the United States.2 Our experience is that patients who have suffered from recurrent sinusitis episodes often seek medical help during an early stage of a respiratory infection. This may lead to a viral common cold being unnecessarily treated with antibiotics, because the diagnosis of bacterial sinusitis remains difficult to make.
We studied whether sinusitis-prone patients have more severe or different symptoms compared with healthy controls at the beginning of a respiratory infection that could increase their consultation prevalence. Also, we evaluated whether there are differences in the clinical and radiologic findings between these 2 groups that could lead the physicians to regard the disease as bacterial sinusitis. To do this we compared these items and the microbiologic findings during one episode of a common cold in patients with a history of recurrent sinusitis and in patients who had never had sinusitis.
Methods
Patients
The patients were recruited by solicitations for volunteers with a community-acquired common cold by advertising in a newspaper distributed in Oulu, a city in Finland with approximately 120,000 inhabitants. A trained nurse screened the volunteers for eligibility by telephone in a way designed to mask the specific criteria for enrollment in the study. Two sets of volunteers were enrolled. The sinusitis-prone group included persons who claimed to have suffered from at least 2 yearly episodes of acute maxillary sinusitis during the previous 2 years. The control group consisted of persons who had never had clinical sinusitis. The other criteria were: aged older than 18 years, symptoms of acute common cold for 48 to 96 hours, presence of nasal symptoms, no chronic sinusitis or nasal polyps, no previous paranasal surgery, no ongoing antibiotic treatment, no pregnancy, and no diagnosed immunologic disorder. The Ethical Committee of the University of Oulu approved our study, and written informed consent was obtained from all patients.
To assess the selection process, we gathered data on the persons contacting the study nurse during one randomly selected week of the inclusion period (week 51, 1996). During this 1 week, 81 patients contacted the nurse. Of these, 43 were excluded because they had symptoms for more than 96 hours, 23 because they had had too few previous sinusitis episodes, 4 because they had operations for sinus problems, 4 because they had been taking an antibiotic treatment during the previous month, and 4 because they did not have nasal symptoms, leaving 3 patients (4%) who entered the study.
The patients were unaware of the aims of our study. They were asked to complete questionnaires containing items on various background factors. To study allergic background, we performed skin prick tests with 18 common inhalants (Prick-Lancett, Ewo Care AB, Gislaved, Sweden) as described previously,3 measured total serum immunoglobulin E (IgE) with the QuantiCLONE Total IgE Kit (Kallestad Diagnostics, Inc, Chaska, Minn), and recorded nasal eosinophilia (proportion of eosinophils exceeding 10% of nucleated cells on nasal smear).
Symptoms and Signs
The date of recruitment to the study was called day 1. The study patients filled in a form twice a day concerning their symptoms on days 1, 2, and 3. To determine a score for each symptom, they rated the following 10 using a scale from 0 (not present) to 10 (very severe): runny nose, nasal stuffiness, sneezing, sore throat, facial pain, cough, fatigue or lethargy, muscle aches, chills, and headache. The individual symptom scores were summed for each subject, resulting in a total score calculated separately for each day and overall. On day 21, only the presence of any acute symptoms was recorded.
An ear, nose, and throat specialist examined all patients on days 1 and 21. The examiner knew the subject’s history but was unaware of all other findings. Nasoendoscopy was performed with a rigid 4-mm Storz 0° endoscope, and various pathologic findings were recorded.
Radiologic Examinations
We viewed coronal computed tomographic (CT) slices including the nasal passages and all the paranasal sinuses on days 1 and 21 (Sytec 3000 Plus or HiSpeed Advantage scanner, General Electric Medical Systems, Milwaukee, Wis). Two experienced radiologists and 3 ear, nose, and throat specialists evaluated the CT scans independently from a hard copy. In cases of disagreement the 2 groups reassessed the finding jointly to reach consensus. The reviewers were blinded to all other parameters including the history. The radiologic sinusitislike changes included total opacification, an air-fluid level, or more than 5-mm mucosal thickening. Also, the presence of an air-fluid level or total opacification in any sinus was recorded.
Microbiologic Studies
Viral antigens from the nasal mucus were detected by time-resolved fluoroimmunoassay for the following common respiratory viruses on day 1: adenovirus; respiratory syncytial virus; parainfluenza types 1, 2, and 3; and influenza A and B.4 Virus cultures from nasopharyngeal swaps for these viruses and for rhinovirus were done using the Ohio strain HeLa cells and human foreskin fibroblasts according to a procedure described previously.5 Rhinoviruses were also detected by reverse transcription-polymerase chain reaction (PCR).6,7 Some of the picorna viruses could not be identified further with these PCR assays. Mycoplasma immunoglobulin M (IgM) antibodies from the serum samples taken on day 21 were measured with 2 commercial kits (SeroMP, Savyon Diagnostics Ltd, Israel; and Mycoplasma pneumoniae IgM ELISA, Novum Diagnostica GmbH, Germany). A true-positive result in both tests was required for a definitive diagnosis. Specimens for aerobic and anaerobic bacterial cultures were taken from the nasopharynx and with the help of an endoscope from the middle meatus on day 1. The swabs were inoculated onto normal and chocolated sheep blood agar plates and onto fastidious anaerobe agar plates containing sheep blood (Lab M, Bury, England), according to routine procedures.
Treatment
On the basis of the overall clinical impression (no specific criteria were given) and radiologic findings, the patients designated to have bacterial sinusitis were given either amoxicillin 500 mg 3 times daily for 7 days, or trimethoprim-sulfamethoxazole 160 mg plus 800 mg twice daily for 7 days in case of penicillin allergy. All of the patients were allowed nasal decongestants and mild analgesics.
Statistical Analysis
To analyse the relationship between the different variables and the history of recurrent or no sinusitis, we performed the {c}2 test in case of proportions, the Student t test for normally distributed continuous variables, and the Mann-Whitney U test on nonparametric variables. All significance tests of hypotheses were 2 tailed.
Results
Patients
During 2 periods between February 1 and May 15, 1996, and August 15 and December 31, 1996, a total of 52 patients were enrolled, 26 in the sinusitis-prone group and 26 in the control group. The patients in both series were enrolled in even numbers during the entire study period (16 sinusitis-prone patients and 12 control patients in the first period and 10 and 14 patients, respectively, in the second). Three sinusitis-prone patients and one control subject were excluded because of an ongoing antimicrobial treatment, a broken CT apparatus at the time of the follow-up visit, nasal polyps in nasoendoscopy, and one doubtful sinusitis episode in a control subject’s history. Thus, 48 patients completed the study: 23 in the sinusitis-prone group and 25 in the control group. One sinusitis-prone subject did not return the symptom scores and was excluded from the analyses of the symptoms.
The background characteristics of the patients are shown in Table 1. The sinusitis-prone patients reported a significantly higher mean number of common cold episodes per year than the control patients (P=.01), but the 2 groups were similar in terms of the other background characteristics.
Symptoms and Signs
Both the sinusitis-prone patients and the control patients had symptoms for an average of 3 days before day 1 (mean duration=3.0 days [standard deviation (SD) =1] and mean duration=3.2 days [SD=1], respectively). The control patients had markedly lower overall mean symptom scores than the sinusitis-prone patients (144 [SD=70] vs 177 [SD=74]; P=.04), the difference increasing during days 1 to 3 Figure 1. Facial pain was more common and more severe among the sinusitis-prone patients than among the control patients (73% [16] vs 24% [6]; P=.001 and median scores 5 [range 0-43] vs 0 [0-26]; P=.002), but the frequency and severity of the other symptoms were similar in the 2 groups (data not shown). On day 21, 2 sinusitis-prone patients (9%) and 4 control patients (16%) still reported symptoms.
The distributions of patients having various pathologic nasoendoscopic findings were similar in the sinusitis-prone group and the control group on day 1 Table 2. None of the pathologic nasoendoscopic findings correlated with the presence of facial pain. By day 21, the frequencies of pathologic nasoendoscopic findings had dropped similarly in the 2 groups.
Radiologic Findings
The sinusitis-prone patients had radiologic sinusitislike changes significantly more often both overall (65% [15] vs 36% [9], difference=29% [95% confidence interval (CI), 2%-56%]; P=.04) and in the maxillary sinus (56% [13] vs 28% [7]; P=.05) than the control patients on day 1 Table 2. In contrast, the distributions of patients having an air-fluid level or total opacification in any sinus were similar in the 2 groups. The symptom scores were similar for the patients with and without radiologic sinusitis in both groups (data not shown). On day 21, the proportions of patients with radiologic sinusitis had dropped, particularly in the sinusitis-prone group, and the 2 groups were similar. Of the 15 patients who had radiologic sinusitis on day 21, 7 (47%) had been given antibiotics and 6 (40%) still had acute symptoms, but these 2 factors were unrelated to each other (P=.20).
Microbiologic Findings
Viral etiology of the common cold was verified in 67% (32) of the patients Table 3. The proportions of sinusitis-prone patients and control patients with viral infection were similar (70% [16] vs 64% [16]; P=.68). The most frequent virus was rhinovirus, which was detected in 35% (8) and 20% (5) of the sinusitis-prone and control patients, respectively. The number of patients having pathogenic bacteria (Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis) isolated from the nasopharynx was significantly greater among the controls than the sinusitis-prone patients (40% [10] vs 9% [2], difference 31% [95% CI, 9%-54%]; P <.01). This same difference was also seen in the cultures taken from the middle meatus, although it was not statistically significant (24% [6] vs 9% [2]; P=.15, respectively). The nasopharyngeal culture findings of the smoking and nonsmoking patients were similar (19% [3] vs 31% [10]; P=.36, respectively). One control subject had a Fusobacterium species, but no other pathogenic anaerobic bacteria were found. The presence of either verified viral infection or pathogenic bacteria isolated from the nasopharynx was not related to radiologic sinusitislike changes in both groups (data not shown).
Treatment
Altogether 13 patients were considered to have bacterial sinusitis based on clinical and radiologic criteria, and 10 were given amoxycillin and 3 sulpha-trimethoprim. The sinusitis-prone patients were treated with antimicrobials more often than the control patients (43% [10] vs 12% [3]; P=.02). None of the patients consulted another physician or received any other prescription during the study. Two of the 10 sinusitis-prone patients and 2 of the 3 control patients considered to have bacterial sinusitis on the basis of the symptoms and signs and radiologic findings had pathogenic bacteria isolated from the nasopharynx. Thus, if a positive nasopharyngeal bacterial culture had been used as an additional criterion for antimicrobial treatment only 4 patients would have been treated.
Discussion
We found that the patients who had suffered from recurrent sinusitis episodes had significantly higher symptom scores and radiologic sinusitislike changes more often during an ordinary viral common cold than the patients who had never had sinusitis. The patients with a history of sinusitis also had more prolonged symptoms and more facial pain than did the control patients. The viral etiology of the common cold was verified in two thirds of the episodes, and it was similar in both groups. Yet, pathogenic bacteria were found rarely in the middle meatus especially among the sinusitis-prone patients.
We were unable to find any explanation for these differences in the symptom scores and radiologic findings between the sinusitis-prone and control patients during a common cold. It was not explained by allergy or the etiology of the infection. Also, symptom scores were not related to radiologic changes, which is in agreement with the results of an earlier study.8 Differing psychologic factors may also affect the symptom scores. Men have been shown to exaggerate their cold symptoms,9 and smoking has been found to predispose persons to common cold10; however, even these variables and other background characteristics were similar in our sinusitis-prone patients and control patients. Nonatopic nasal hyperreactivity and permanent mucosal changes in the nose and sinuses are other possible explanations for the differences.
The more severe and prolonged symptoms and facial pain during common colds may cause sinusitis-prone patients to seek medical help earlier and more often than healthy patients. The knowledge of having a tendency for recurrent sinusitis episodes may further strengthen this behavior. Also, facial pain is a symptom that people do not usually regard as part of a common cold but rather as a symptom related to sinusitis. Our finding is in agreement with that of Hansen and collegues11 who found that previous sinusitis was a factor that lead patients without bacterial sinusitis to seek medical help for respiratory symptoms.
Since the diagnostic reference standard (maxillary puncture with bacterial culture) is not suitable for routine use in differentiating bacterial sinusitis from viral respiratory infection, certain specific symptoms and signs have been suggested to be used for this purpose.12 A recent study showed that clinicians tend to rely on varied historical and physical examination criteria for this purpose.13 Also, a history of sinus infections was strongly connected to physicians’ tendency to give a diagnosis of sinusitis.13
Although the role and benefits of imaging remain unclear, it is increasingly used to evaluate patients with colds.14 The majority of patients with a common cold have been shown to have widespread radiologic sinus changes that resolve spontaneously.15-17 In our study, 65% of the sinusitis-prone patients had radiologic sinusitislike changes, which is a much higher proportion than that among the healthy controls (35%), the latter figure being in agreement with the earlier reports.17 The severe symptoms and the high frequency of radiologic sinusitislike changes during a common cold make the patients with a sinusitis history particularly susceptible to be given a diagnosis of bacterial sinusitis, leading to unnecessary prescriptions for antibiotics.
We would need an objective diagnostic test in addition to symptomatology and radiologic findings to differentiate bacterial sinusitis from viral respiratory infection in sinusitis-prone patients who seek medical help during an early phase of a respiratory infection. A pathogen-positive bacteriologic culture collected endoscopically from the middle meatus would have been useful in this respect. If this finding had been used in addition to the clinical and radiologic criteria for the diagnosis of bacterial sinusitis, the number of antimicrobial treatments in our series would have decreased from 10 to 2 in the sinusitis-prone group and from 3 to 2 in the control group. Since endoscopically collected samples are not suitable for routine use in primary care, nasopharyngeal culture is an alternative method. Nasal cultures have been considered inaccurate in the diagnosis of bacterial sinusitis, because they give false-positive results.16 However, there is evidence that a pathogen-positive nasal culture is fairly sensitive to acute bacterial maxillary sinusitis.18 In our series, compared with the endoscopically obtained culture findings from the middle meatus, the nasopharyngeal samples also gave a few false-positive results, but only in the control patients. Further studies are needed to clarify the usefulness of this method in diagnosing true bacterial sinusitis.
We do not know how many of the patients actually had bacteriological sinusitis in our series, because we did not do maxillary punctures with bacteriologic cultures. However, we think most had a viral disease at the time of the first examination, because bacterial sinusitis usually follows viral respiratory infection after 5 to 7 days. The study patients had symptoms for an average of 3 days. Secondly, only 5 patients (10%), 2 sinusitis-prone patients and 3 controls, had both a pathogenic bacterium isolated from the middle meatus and an air-fluid level or total opacification in any of the sinuses in the CT scan. Although the precise value of endoscopically obtained culture findings in sinus disease remains controversial16 there is increasing evidence to suggest that this method could be valuable.19 A finding of an air-fluid level or total opacification in CT scan has been shown to correlate with bacterial sinusitis,11 and patients with this finding have benefited from antibiotic treatment.20 The sinusitis-prone patients and the control patients were similar for all these findings.
Limitations
The patients who participated in our study were volunteers, but they were unaware of the aims of the study. The selection process was similar for the control patients and the sinusitis-prone patients. Proper symptoms were required for inclusion in both groups, which may have caused more serious cases to be selected. The patients were not recruited during the worst period of seasonal allergies (from the end of May to the beginning of August), to avoid having allergy symptoms confound the cold symptoms. Different viruses may cause different symptoms, and to avoid this bias both groups were enrolled evenly during the study period.
Conclusions
Patients with a history of recurrent sinusitis have more severe symptoms and have radiologic sinusitislike changes more often during common colds than patients with no history of sinusitis. This may result in overdiagnoses of bacterial sinusitis for patients with an earlier history of sinusitis. A pathogen-positive nasopharyngeal culture has been shown sensitive for bacterial sinusitis. Therefore, a strategy of culturing nasopharyngeal secretions of the patients suspected of having bacterial sinusitis and treating only the patients who have pathogenic bacteria in their nasopharynx would help physicians avoid unnecessary prescriptions of antimicrobials. We recommend such a strategy for sinusitis-prone patients
METHODS: We recruited 2 series of volunteer cases from February 1, 1996, to December 31, 1996. Twenty-three adults who claimed to have suffered from recurrent sinusitis and 25 who had never had sinusitis were examined during the period of a self-diagnosed cold of 48 to 96 hours’ duration and again after 21 days. Symptom scores were recorded, nasoendoscopy and computed tomography scans were performed, and viral and bacterial specimens were taken.
RESULTS: The patients with a history of sinusitis had significantly higher mean symptom scores than the control patients (P=.04) and had radiologic sinusitislike changes more often (65% [15] vs 36% [9]; difference 29% [95% confidence interval, 2%-56%]; P=.04). The viral etiology of the common cold (verified in 67% of the episodes) was similar in both groups. Pathogenic bacteria were isolated from the middle meatus in 24% (6) of the control patients and only 9% (2) of the sinusitis-prone patients (P=.15). On the basis of the symptomatology, radiologic findings, and bacterial cultures only 2 patients in the sinusitis-prone group should have been treated with antimicrobials.
CONCLUSIONS: Some patients are susceptible to both sinusitislike symptoms and radiologic findings during viral common colds. This may cause them to consult their physicians earlier and more often during viral colds, which may result in unnecessary antibiotic treatments. Nasopharyngeal bacteriological cultures may prove to be useful in ruling out bacterial sinusitis.
Sinusitis is the most common condition for which antibiotics are prescribed in ambulatory practice, according to the National Ambulatory Medical Care Survey.1 There are many patients who are given a diagnosis of sinusitis and treated with antimicrobials during almost all common colds. Chronic sinusitis is the most common self-reported chronic illness in the United States.2 Our experience is that patients who have suffered from recurrent sinusitis episodes often seek medical help during an early stage of a respiratory infection. This may lead to a viral common cold being unnecessarily treated with antibiotics, because the diagnosis of bacterial sinusitis remains difficult to make.
We studied whether sinusitis-prone patients have more severe or different symptoms compared with healthy controls at the beginning of a respiratory infection that could increase their consultation prevalence. Also, we evaluated whether there are differences in the clinical and radiologic findings between these 2 groups that could lead the physicians to regard the disease as bacterial sinusitis. To do this we compared these items and the microbiologic findings during one episode of a common cold in patients with a history of recurrent sinusitis and in patients who had never had sinusitis.
Methods
Patients
The patients were recruited by solicitations for volunteers with a community-acquired common cold by advertising in a newspaper distributed in Oulu, a city in Finland with approximately 120,000 inhabitants. A trained nurse screened the volunteers for eligibility by telephone in a way designed to mask the specific criteria for enrollment in the study. Two sets of volunteers were enrolled. The sinusitis-prone group included persons who claimed to have suffered from at least 2 yearly episodes of acute maxillary sinusitis during the previous 2 years. The control group consisted of persons who had never had clinical sinusitis. The other criteria were: aged older than 18 years, symptoms of acute common cold for 48 to 96 hours, presence of nasal symptoms, no chronic sinusitis or nasal polyps, no previous paranasal surgery, no ongoing antibiotic treatment, no pregnancy, and no diagnosed immunologic disorder. The Ethical Committee of the University of Oulu approved our study, and written informed consent was obtained from all patients.
To assess the selection process, we gathered data on the persons contacting the study nurse during one randomly selected week of the inclusion period (week 51, 1996). During this 1 week, 81 patients contacted the nurse. Of these, 43 were excluded because they had symptoms for more than 96 hours, 23 because they had had too few previous sinusitis episodes, 4 because they had operations for sinus problems, 4 because they had been taking an antibiotic treatment during the previous month, and 4 because they did not have nasal symptoms, leaving 3 patients (4%) who entered the study.
The patients were unaware of the aims of our study. They were asked to complete questionnaires containing items on various background factors. To study allergic background, we performed skin prick tests with 18 common inhalants (Prick-Lancett, Ewo Care AB, Gislaved, Sweden) as described previously,3 measured total serum immunoglobulin E (IgE) with the QuantiCLONE Total IgE Kit (Kallestad Diagnostics, Inc, Chaska, Minn), and recorded nasal eosinophilia (proportion of eosinophils exceeding 10% of nucleated cells on nasal smear).
Symptoms and Signs
The date of recruitment to the study was called day 1. The study patients filled in a form twice a day concerning their symptoms on days 1, 2, and 3. To determine a score for each symptom, they rated the following 10 using a scale from 0 (not present) to 10 (very severe): runny nose, nasal stuffiness, sneezing, sore throat, facial pain, cough, fatigue or lethargy, muscle aches, chills, and headache. The individual symptom scores were summed for each subject, resulting in a total score calculated separately for each day and overall. On day 21, only the presence of any acute symptoms was recorded.
An ear, nose, and throat specialist examined all patients on days 1 and 21. The examiner knew the subject’s history but was unaware of all other findings. Nasoendoscopy was performed with a rigid 4-mm Storz 0° endoscope, and various pathologic findings were recorded.
Radiologic Examinations
We viewed coronal computed tomographic (CT) slices including the nasal passages and all the paranasal sinuses on days 1 and 21 (Sytec 3000 Plus or HiSpeed Advantage scanner, General Electric Medical Systems, Milwaukee, Wis). Two experienced radiologists and 3 ear, nose, and throat specialists evaluated the CT scans independently from a hard copy. In cases of disagreement the 2 groups reassessed the finding jointly to reach consensus. The reviewers were blinded to all other parameters including the history. The radiologic sinusitislike changes included total opacification, an air-fluid level, or more than 5-mm mucosal thickening. Also, the presence of an air-fluid level or total opacification in any sinus was recorded.
Microbiologic Studies
Viral antigens from the nasal mucus were detected by time-resolved fluoroimmunoassay for the following common respiratory viruses on day 1: adenovirus; respiratory syncytial virus; parainfluenza types 1, 2, and 3; and influenza A and B.4 Virus cultures from nasopharyngeal swaps for these viruses and for rhinovirus were done using the Ohio strain HeLa cells and human foreskin fibroblasts according to a procedure described previously.5 Rhinoviruses were also detected by reverse transcription-polymerase chain reaction (PCR).6,7 Some of the picorna viruses could not be identified further with these PCR assays. Mycoplasma immunoglobulin M (IgM) antibodies from the serum samples taken on day 21 were measured with 2 commercial kits (SeroMP, Savyon Diagnostics Ltd, Israel; and Mycoplasma pneumoniae IgM ELISA, Novum Diagnostica GmbH, Germany). A true-positive result in both tests was required for a definitive diagnosis. Specimens for aerobic and anaerobic bacterial cultures were taken from the nasopharynx and with the help of an endoscope from the middle meatus on day 1. The swabs were inoculated onto normal and chocolated sheep blood agar plates and onto fastidious anaerobe agar plates containing sheep blood (Lab M, Bury, England), according to routine procedures.
Treatment
On the basis of the overall clinical impression (no specific criteria were given) and radiologic findings, the patients designated to have bacterial sinusitis were given either amoxicillin 500 mg 3 times daily for 7 days, or trimethoprim-sulfamethoxazole 160 mg plus 800 mg twice daily for 7 days in case of penicillin allergy. All of the patients were allowed nasal decongestants and mild analgesics.
Statistical Analysis
To analyse the relationship between the different variables and the history of recurrent or no sinusitis, we performed the {c}2 test in case of proportions, the Student t test for normally distributed continuous variables, and the Mann-Whitney U test on nonparametric variables. All significance tests of hypotheses were 2 tailed.
Results
Patients
During 2 periods between February 1 and May 15, 1996, and August 15 and December 31, 1996, a total of 52 patients were enrolled, 26 in the sinusitis-prone group and 26 in the control group. The patients in both series were enrolled in even numbers during the entire study period (16 sinusitis-prone patients and 12 control patients in the first period and 10 and 14 patients, respectively, in the second). Three sinusitis-prone patients and one control subject were excluded because of an ongoing antimicrobial treatment, a broken CT apparatus at the time of the follow-up visit, nasal polyps in nasoendoscopy, and one doubtful sinusitis episode in a control subject’s history. Thus, 48 patients completed the study: 23 in the sinusitis-prone group and 25 in the control group. One sinusitis-prone subject did not return the symptom scores and was excluded from the analyses of the symptoms.
The background characteristics of the patients are shown in Table 1. The sinusitis-prone patients reported a significantly higher mean number of common cold episodes per year than the control patients (P=.01), but the 2 groups were similar in terms of the other background characteristics.
Symptoms and Signs
Both the sinusitis-prone patients and the control patients had symptoms for an average of 3 days before day 1 (mean duration=3.0 days [standard deviation (SD) =1] and mean duration=3.2 days [SD=1], respectively). The control patients had markedly lower overall mean symptom scores than the sinusitis-prone patients (144 [SD=70] vs 177 [SD=74]; P=.04), the difference increasing during days 1 to 3 Figure 1. Facial pain was more common and more severe among the sinusitis-prone patients than among the control patients (73% [16] vs 24% [6]; P=.001 and median scores 5 [range 0-43] vs 0 [0-26]; P=.002), but the frequency and severity of the other symptoms were similar in the 2 groups (data not shown). On day 21, 2 sinusitis-prone patients (9%) and 4 control patients (16%) still reported symptoms.
The distributions of patients having various pathologic nasoendoscopic findings were similar in the sinusitis-prone group and the control group on day 1 Table 2. None of the pathologic nasoendoscopic findings correlated with the presence of facial pain. By day 21, the frequencies of pathologic nasoendoscopic findings had dropped similarly in the 2 groups.
Radiologic Findings
The sinusitis-prone patients had radiologic sinusitislike changes significantly more often both overall (65% [15] vs 36% [9], difference=29% [95% confidence interval (CI), 2%-56%]; P=.04) and in the maxillary sinus (56% [13] vs 28% [7]; P=.05) than the control patients on day 1 Table 2. In contrast, the distributions of patients having an air-fluid level or total opacification in any sinus were similar in the 2 groups. The symptom scores were similar for the patients with and without radiologic sinusitis in both groups (data not shown). On day 21, the proportions of patients with radiologic sinusitis had dropped, particularly in the sinusitis-prone group, and the 2 groups were similar. Of the 15 patients who had radiologic sinusitis on day 21, 7 (47%) had been given antibiotics and 6 (40%) still had acute symptoms, but these 2 factors were unrelated to each other (P=.20).
Microbiologic Findings
Viral etiology of the common cold was verified in 67% (32) of the patients Table 3. The proportions of sinusitis-prone patients and control patients with viral infection were similar (70% [16] vs 64% [16]; P=.68). The most frequent virus was rhinovirus, which was detected in 35% (8) and 20% (5) of the sinusitis-prone and control patients, respectively. The number of patients having pathogenic bacteria (Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis) isolated from the nasopharynx was significantly greater among the controls than the sinusitis-prone patients (40% [10] vs 9% [2], difference 31% [95% CI, 9%-54%]; P <.01). This same difference was also seen in the cultures taken from the middle meatus, although it was not statistically significant (24% [6] vs 9% [2]; P=.15, respectively). The nasopharyngeal culture findings of the smoking and nonsmoking patients were similar (19% [3] vs 31% [10]; P=.36, respectively). One control subject had a Fusobacterium species, but no other pathogenic anaerobic bacteria were found. The presence of either verified viral infection or pathogenic bacteria isolated from the nasopharynx was not related to radiologic sinusitislike changes in both groups (data not shown).
Treatment
Altogether 13 patients were considered to have bacterial sinusitis based on clinical and radiologic criteria, and 10 were given amoxycillin and 3 sulpha-trimethoprim. The sinusitis-prone patients were treated with antimicrobials more often than the control patients (43% [10] vs 12% [3]; P=.02). None of the patients consulted another physician or received any other prescription during the study. Two of the 10 sinusitis-prone patients and 2 of the 3 control patients considered to have bacterial sinusitis on the basis of the symptoms and signs and radiologic findings had pathogenic bacteria isolated from the nasopharynx. Thus, if a positive nasopharyngeal bacterial culture had been used as an additional criterion for antimicrobial treatment only 4 patients would have been treated.
Discussion
We found that the patients who had suffered from recurrent sinusitis episodes had significantly higher symptom scores and radiologic sinusitislike changes more often during an ordinary viral common cold than the patients who had never had sinusitis. The patients with a history of sinusitis also had more prolonged symptoms and more facial pain than did the control patients. The viral etiology of the common cold was verified in two thirds of the episodes, and it was similar in both groups. Yet, pathogenic bacteria were found rarely in the middle meatus especially among the sinusitis-prone patients.
We were unable to find any explanation for these differences in the symptom scores and radiologic findings between the sinusitis-prone and control patients during a common cold. It was not explained by allergy or the etiology of the infection. Also, symptom scores were not related to radiologic changes, which is in agreement with the results of an earlier study.8 Differing psychologic factors may also affect the symptom scores. Men have been shown to exaggerate their cold symptoms,9 and smoking has been found to predispose persons to common cold10; however, even these variables and other background characteristics were similar in our sinusitis-prone patients and control patients. Nonatopic nasal hyperreactivity and permanent mucosal changes in the nose and sinuses are other possible explanations for the differences.
The more severe and prolonged symptoms and facial pain during common colds may cause sinusitis-prone patients to seek medical help earlier and more often than healthy patients. The knowledge of having a tendency for recurrent sinusitis episodes may further strengthen this behavior. Also, facial pain is a symptom that people do not usually regard as part of a common cold but rather as a symptom related to sinusitis. Our finding is in agreement with that of Hansen and collegues11 who found that previous sinusitis was a factor that lead patients without bacterial sinusitis to seek medical help for respiratory symptoms.
Since the diagnostic reference standard (maxillary puncture with bacterial culture) is not suitable for routine use in differentiating bacterial sinusitis from viral respiratory infection, certain specific symptoms and signs have been suggested to be used for this purpose.12 A recent study showed that clinicians tend to rely on varied historical and physical examination criteria for this purpose.13 Also, a history of sinus infections was strongly connected to physicians’ tendency to give a diagnosis of sinusitis.13
Although the role and benefits of imaging remain unclear, it is increasingly used to evaluate patients with colds.14 The majority of patients with a common cold have been shown to have widespread radiologic sinus changes that resolve spontaneously.15-17 In our study, 65% of the sinusitis-prone patients had radiologic sinusitislike changes, which is a much higher proportion than that among the healthy controls (35%), the latter figure being in agreement with the earlier reports.17 The severe symptoms and the high frequency of radiologic sinusitislike changes during a common cold make the patients with a sinusitis history particularly susceptible to be given a diagnosis of bacterial sinusitis, leading to unnecessary prescriptions for antibiotics.
We would need an objective diagnostic test in addition to symptomatology and radiologic findings to differentiate bacterial sinusitis from viral respiratory infection in sinusitis-prone patients who seek medical help during an early phase of a respiratory infection. A pathogen-positive bacteriologic culture collected endoscopically from the middle meatus would have been useful in this respect. If this finding had been used in addition to the clinical and radiologic criteria for the diagnosis of bacterial sinusitis, the number of antimicrobial treatments in our series would have decreased from 10 to 2 in the sinusitis-prone group and from 3 to 2 in the control group. Since endoscopically collected samples are not suitable for routine use in primary care, nasopharyngeal culture is an alternative method. Nasal cultures have been considered inaccurate in the diagnosis of bacterial sinusitis, because they give false-positive results.16 However, there is evidence that a pathogen-positive nasal culture is fairly sensitive to acute bacterial maxillary sinusitis.18 In our series, compared with the endoscopically obtained culture findings from the middle meatus, the nasopharyngeal samples also gave a few false-positive results, but only in the control patients. Further studies are needed to clarify the usefulness of this method in diagnosing true bacterial sinusitis.
We do not know how many of the patients actually had bacteriological sinusitis in our series, because we did not do maxillary punctures with bacteriologic cultures. However, we think most had a viral disease at the time of the first examination, because bacterial sinusitis usually follows viral respiratory infection after 5 to 7 days. The study patients had symptoms for an average of 3 days. Secondly, only 5 patients (10%), 2 sinusitis-prone patients and 3 controls, had both a pathogenic bacterium isolated from the middle meatus and an air-fluid level or total opacification in any of the sinuses in the CT scan. Although the precise value of endoscopically obtained culture findings in sinus disease remains controversial16 there is increasing evidence to suggest that this method could be valuable.19 A finding of an air-fluid level or total opacification in CT scan has been shown to correlate with bacterial sinusitis,11 and patients with this finding have benefited from antibiotic treatment.20 The sinusitis-prone patients and the control patients were similar for all these findings.
Limitations
The patients who participated in our study were volunteers, but they were unaware of the aims of the study. The selection process was similar for the control patients and the sinusitis-prone patients. Proper symptoms were required for inclusion in both groups, which may have caused more serious cases to be selected. The patients were not recruited during the worst period of seasonal allergies (from the end of May to the beginning of August), to avoid having allergy symptoms confound the cold symptoms. Different viruses may cause different symptoms, and to avoid this bias both groups were enrolled evenly during the study period.
Conclusions
Patients with a history of recurrent sinusitis have more severe symptoms and have radiologic sinusitislike changes more often during common colds than patients with no history of sinusitis. This may result in overdiagnoses of bacterial sinusitis for patients with an earlier history of sinusitis. A pathogen-positive nasopharyngeal culture has been shown sensitive for bacterial sinusitis. Therefore, a strategy of culturing nasopharyngeal secretions of the patients suspected of having bacterial sinusitis and treating only the patients who have pathogenic bacteria in their nasopharynx would help physicians avoid unnecessary prescriptions of antimicrobials. We recommend such a strategy for sinusitis-prone patients
1. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-04.
2. Collins JG. Prevalence of selected chronic conditions, United States, 1983-1985, no. 155. Hyattsville, Md: National Center for Health Statistics; 1988.
3. Subcommittee on Skin Tests of the European Academy of Allergology and Clinical Immunology: methods for skin testing. In: Dreborg S, ed. Skin tests used in type I allergy testing. Allergy 1989;44(suppl):22-30.
4. Arstila PP, Halonen PE. Direct antigen detection. In: Lennette EH, Halonen P, Murphy FA, eds. Laboratory diagnosis of infectious diseases: principle and practice. New York, NY: Springer-Verlag, 1988;60-75.
5. Al-Nakib W, Tyrrell DAJ. Picorna viridae: rhinoviruses-common cold viruses. In: Lennette EH, Halonen P, Murphy FA, eds. Laboratory diagnosis of infectious diseases: principle and practice. New York, NY: Springer-Verlag; 1988;723-42.
6. Hyypiä T, Auvinen P, Maaronen M. Polymerase chain reaction for human picornaviruses. J Gen Virol 1989;70:3261-68.
7. Halonen P, Rocha E, Hierholzer J, et al. Detection of enteroviruses and rhinoviruses in clinical specimens by PCR and liquid-phase hybridization. J Clin Microbiol 1995;33:648-53.
8. Bhattacharyya T, Piccirillo J, Wippold II F. Relationship between patient-based descriptions of sinusitis and paranasal sinus computed tomographic findings. Arch Otolaryngol Head Neck Surg 1997;123:1189-92.
9. MacIntyre S, Pritchard C. Comparisons between self-assessed and observer-assessed presence and severity of colds. Soc Sci Med 1989;29:1243-48.
10. Cohen S, Tyrrell DA, Russell MA, Jarvis MJ, Smith AP. Smoking, alcohol consumption, and susceptibility to the common cold. Am J Public Health 1993;83:1277-83.
11. Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting acute maxillary sinusitis in a general practice population. BMJ 1995;311:233-36.
12. Williams JW, Jr, Aguilar C, Makela M, et al. Antibiotic therapy for acute sinusitis: a systematic literature review. In: Douglas R, Bridges-Webb C, Glasziou P, Lozano J, Steinhoff M, Wang E, eds. Acute respiratory infections module of the Cochrane Library. Oxford, England: Update Software; 1997.
13. Hueston WJ, Eberlein C, Johnson D, Mainous III AG. Criteria used by clinicians to differentiate sinusitis from viral upper respiratory infection. J Fam Pract 1998;46:487-92.
14. Kaliner MA, Osguthorpe JD, Fireman P, et al. Sinusitis: bench to bedside. Current findings, future directions. J Allergy Clin Immunol 1997;99:S829-48.
15. Gwaltney JM, Jr, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med 1994;330:25-30.
16. Gwaltney JM, Jr. Acute community-acquired sinusitis: state-of-the-art clinical article. Clin Infect Dis 1996;23:1209-25.
17. Puhakka T, Mäkelä MJ, Alanen A, et al. Sinusitis in the common cold. J Allergy Clin Immunol 1998;102:403-08.
18. Jousimies-Somer HR, Savolainen S, Ylikoski JS. Comparison of the nasal bacterial floras in two groups of healthy patients and in patients with acute maxillary sinusitis. J Clin Microbiol 1989;27:2736-43.
19. Vogan JC, Bolger WE, Keyes AS. Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures. Otolaryngol Head Neck Surg 2000;122:370-73.
20. Lindbaek M, Hjortdahl P, Johnsen UL-H. Randomised, double blind, placebo controlled trial of penicillin V and amoxycillin in treatment of acute sinus infections in adults. BMJ 1996;313:325-29.
Related Resources:
- Johns Hopkins Asthma & Allergy page Information on epidemiology, triggers, drug therapy and immunotherapy. Case studies and other features. www.hopkins-allergy.org/sinusitis/index.html
- National Institute of Allergy and Infectious Diseases Information on NIAID research projects and opportunities, publications, as well as the agency’s Immune Tolerance Network www.niaid.nih.gov/default.htm
- Common Cold Centre General information for patients www.cf.ac.uk/biosi/associates/cold/info.html
1. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997;278:901-04.
2. Collins JG. Prevalence of selected chronic conditions, United States, 1983-1985, no. 155. Hyattsville, Md: National Center for Health Statistics; 1988.
3. Subcommittee on Skin Tests of the European Academy of Allergology and Clinical Immunology: methods for skin testing. In: Dreborg S, ed. Skin tests used in type I allergy testing. Allergy 1989;44(suppl):22-30.
4. Arstila PP, Halonen PE. Direct antigen detection. In: Lennette EH, Halonen P, Murphy FA, eds. Laboratory diagnosis of infectious diseases: principle and practice. New York, NY: Springer-Verlag, 1988;60-75.
5. Al-Nakib W, Tyrrell DAJ. Picorna viridae: rhinoviruses-common cold viruses. In: Lennette EH, Halonen P, Murphy FA, eds. Laboratory diagnosis of infectious diseases: principle and practice. New York, NY: Springer-Verlag; 1988;723-42.
6. Hyypiä T, Auvinen P, Maaronen M. Polymerase chain reaction for human picornaviruses. J Gen Virol 1989;70:3261-68.
7. Halonen P, Rocha E, Hierholzer J, et al. Detection of enteroviruses and rhinoviruses in clinical specimens by PCR and liquid-phase hybridization. J Clin Microbiol 1995;33:648-53.
8. Bhattacharyya T, Piccirillo J, Wippold II F. Relationship between patient-based descriptions of sinusitis and paranasal sinus computed tomographic findings. Arch Otolaryngol Head Neck Surg 1997;123:1189-92.
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Related Resources:
- Johns Hopkins Asthma & Allergy page Information on epidemiology, triggers, drug therapy and immunotherapy. Case studies and other features. www.hopkins-allergy.org/sinusitis/index.html
- National Institute of Allergy and Infectious Diseases Information on NIAID research projects and opportunities, publications, as well as the agency’s Immune Tolerance Network www.niaid.nih.gov/default.htm
- Common Cold Centre General information for patients www.cf.ac.uk/biosi/associates/cold/info.html