Tuesday, April 5, 2011

Myserable symptoms mark chronic sinusitis (Part II)

ACPInternist brings another interesting article regarding sinusitis. Here you can read the full version.

From the January ACP Internist, copyright © 2011 by the American College of Physicians
By Kathy Holliman

Looking into the sinuses: What’s the preferred first-line diagnostic tool?

Diagnostic testing is recommended for chronic sinusitis, either computed tomography (CT) of the sinuses or a nasal endoscopy, but there is disagreement about which should be the first-line diagnostic tool.

Raymond G. Slavin, MACP, a professor of internal medicine and molecular microbiology and immunology at St. Louis University School of Medicine in Missouri, said that a diagnosis can be made without either of these tests, but “if there is any question, a limited CT scan can be helpful.” It is considered the gold standard for diagnosis.

A CT scan can be most useful if the symptoms are vague, the physical findings are equivocal, or there has been a poor response to the initial management, according to 2005 guidelines from the American Academy of Allergy, Asthma and Immunology (AAAAI). One study cited in the guidelines found, however, that more than 50% of patients with a strong history of chronic sinusitis had a normal CT scan.

According to 2007 guidelines from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF), patient symptoms and quality of life “do not necessarily correlate with the extent of disease seen on CT,” but the CT does offer an objective method for monitoring chronic disease, and it can quantify the extent of the inflammation.

Dr. Slavin, chief editor of the AAAAI guidelines, said that if a patient is not responding to therapy, a fiberoptic endoscopy, or rhinoscopy, is a valuable option. “Rhinoscopy can be useful to see the drainage from the middle meatus, and you can also appreciate the nasal polyps that don’t show up that well on the routine nasoscopic exam.”

Nasal endoscopy, less expensive than a CT scan, can often provide a diagnosis, thus sparing the patient the radiation from a CT scan, said Neil Bhattacharyya, MD, one of the authors of the AAO-HNSF guidelines and associate professor of otology and laryngology at Harvard Medical School. “If I scope and see small polyps or purulence in the nose, I don’t need to order a CT scan. I know the patient has chronic sinusitis so I’m going to start treating aggressively. You don’t always have to order the gold standard test,” he said. The ability to potentially avoid a CT scan is important given recent concerns about the effects of cumulative radiation exposure from medical imaging.

Research published by Dr. Bhattacharyya and a colleague in the July 2010 Otolaryngology-Head and Neck Surgery found that nasal endoscopy improved the diagnostic accuracy of chronic sinusitis. The odds ratio of a true diagnosis of chronic sinusitis among the 202 adult patients in the study improved from 1.1 with use of CT to 4.6 (95% CI, 2.3 to 9.2) with use of endoscopy. Dr. Bhattacharyya said that endoscopy should be emphasized as an early diagnostic tool and that CT could be reserved for patients who have not responded to treatment.

Nasodren is a registered trademark by Hartington Pharmaceutical. We are not responsible of the articles published in this blog, as we merely provide useful information to our readers. The copyright of this article belongs to: January ACP Internist, copyright © 2011 by the American College of Physicians. Here you can read the full version.

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