Original articlesMeta-analysis of diagnostic tests for acute sinusitis
Introduction
Acute sinusitis is one of the most common conditions for which patients seek care from physicians [1]. Annually in the United States, almost three million patients are diagnosed with acute sinusitis [2]. Because acute sinusitis may often be caused by bacterial infection, patients with symptoms compatible with this syndrome frequently receive antibiotics. As a result, acute sinusitis is the fifth most common reason for outpatient antibiotic prescription [3].
The most accurate and cost-effective methods for diagnosing acute sinusitis remain uncertain [4]. Diagnostic tests utilized in this setting include radiography, computed tomography, magnetic resonance imaging, and, in some European countries, ultrasonography. Sinus puncture, performed by otolaryngologists, may be considered the “gold standard” test for this condition, and purulent secretions on aspiration provide direct evidence for sinus inflammation 4, 5. Nonetheless, sinus puncture can only rarely be clinically justified, given its cost, inconvenience, and associated patient discomfort. Radiography and ultrasonography are more easily incorporated into a general medical practice, but techniques and diagnostic criteria have varied 6, 7, 8, 9, 10. Often the diagnosis of sinusitis is made on clinical grounds, but the accuracy of the clinical evaluation is unclear [11]. Inaccurate diagnosis of acute sinusitis leads to suboptimal clinical outcomes. Failure to treat patients with acute sinusitis with antibiotics may delay symptom resolution [12]. Inadequate antibiotic treatment can lead to chronic sinusitis and, in rare cases, serious bacterial complications [13]. On the other hand, unnecessary antibiotic use adds to medical costs and treatment side effects, and hastens the emergence of antibiotic-resistant microorganisms [14]. Reliable information on diagnostic test performance might allow development of more cost-effective treatment strategies for the management of patients with acute sinusitis symptoms.
We conducted a meta-analysis of published data to evaluate diagnostic tests for acute sinusitis. Summary estimates of how these tests perform provide a basis for their rational use and highlight areas where more research is needed.
Section snippets
Methods
To identify published studies comparing diagnostic tests in acute sinusitis, we conducted a MEDLINE literature search for English language articles published between 1966 and October 1998, using the sensitive (but nonspecific) strategy “sinusitis (MeSH heading or textword) AND human.” This strategy identified 4070 articles; after a review of identified titles and abstracts, several hundred of these articles deemed potentially relevant were retrieved. Detailed examination of retrieved articles
Description of studies and study subjects
Thirteen studies were included, five of which provided comparisons of more than two tests (Table 1). Eleven studies were conducted in Europe, including all of those utilizing sinus puncture as a reference test. Two studies were conducted in the United States 18, 19. Six studies recruited patients from a hospital or emergency room setting, three recruited from physicians' offices, one recruited from both settings, and three did not describe the study setting. In most studies, the physicians
Discussion
Acute sinusitis is common among patients presenting for evaluation of symptoms consistent with this disorder. The studies that used sinus aspiration as a reference test demonstrated that approximately half of symptomatic patients in a general medical clinic will have acute sinusitis 4, 6. In otolaryngology clinics, where referred patients would more often be expected to have sinusitis, the prevalence of acute sinusitis was as high as 83% [9].
Sinus puncture and aspiration may be the most valid
Conclusions
Better information on the performance of diagnostic tests may allow a more complete understanding of their role in patient management and research. It may be possible to construct a hierarchy of diagnostic tests, allowing the selection of the most appropriate test for each specific purpose. At the top of such a hierarchy would likely remain sinus puncture, the “gold standard” test. However, because of its invasive nature, puncture will likely be suitable only for research purposes. This
Acknowledgements
This work was conducted by the New England Medical Center Evidence-based Practice Center under contract from the Agency for Healthcare Research and Quality (AHRQ) (contract no. 290-97-0019). Additional support was provided by AHRQ grants T32 HS00060 and R25 HS09796. Parts of this manuscript have been included in the evidence report provided to AHRQ. We thank the technical experts (Drs. Michael Benninger, Larry Culpepper, Aidan Long, Anne Meneghetti, Eli Rebeiz, Carol Sakala, Ellen Wald, John
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