The Institute for Clinical Systems Improvement recommends that radiology be used only if initial treatment has failed, and notes that a primary goal of its guideline was to reduce the number of x-rays that physicians order for this diagnosis.16
The American College of Radiology’s criteria for sinusitis in the pediatric population ranked several radiographic studies based on their appropriateness for given clinical conditions. This review17 suggests that no imaging is appropriate if symptoms have persisted <10 days. For patients with symptoms lasting >10 days and with persistent fever, CT scan is recommended.
CLINICAL COMMENTARY
Jon Neher, MD
Valley Medical Center Family Practice Residency, Renton, Wash
In acute bacterial sinusitis, the history and physical have somewhat limited sensitivity and specificity. Unfortunately, imaging studies add little valuable information. Primary care physicians must therefore be reconciled to some degree of diagnostic error.
The risks associated with under-diagnosis are small, since most cases of mild sinusitis will resolve spontaneously without treatment. The risks of over-diagnosis include increased antibiotic costs, side effects, allergic reactions, and the development of resistant organisms. It is prudent, therefore, to make the diagnosis only when multiple suggestive historical and exam elements are present and to avoid giving antibiotics to patients with mild, nonspecific illnesses.