Do I really have sinusitis: matching imaging to “chronic sinus symptoms”?

The non-medical concept of chronic sinus symptoms can really affect the true diagnosis. One of the most common clinical dilemmas is discussing incidental or insignificant radiologic findings with a patient that has a rhintis condition (allergy or otherwise) but has a radiology report that they have ‘sinusitis’. Chronic, episodic or recurrent sinonasal symptoms are often suspected as ‘sinus’ in origin. However, other conditions can produce these symptoms such as rhinitis and migraine.

However, the concept of a perfect computed tomography ONLY equalling a normal state is false. Minor mucosal thickenings of the paranasal sinuses are part the ‘normal’ spectrum and incidental findings also include simple mucosal cysts (often incorrectly labelled as “nasal polyp’). A recent systematic review on the radiologic findings from a normal sinus cavity was publsihed this year. When patients have “chronic sinus symptoms” they are often describing chronic sino-nasal symptoms and the interpretation of the CT scan is essential to see if the symptoms really match the imaging.

This was the topic of recent ENT watch episode that you can watch here.

From this review of  ‘normal’ or asymptomatic patients, a total of 950 articles were identified, of which 33 manuscripts met the inclusion criteria. The included studies involved 16,966 sinonasally asymptomatic subjects. The mean Lund-mackay (LM) score was 2.24 (95% CI, 1.61-2.87), and an LM score of ≥4 in 14.71% (95% CI, 6.86-24.82%) was present across all general asymptomatic population groups. Mucous retention cysts were noted in 13% (95% CI, 8.33-18.55%) and maxillary mucosal thickening of ≥2 mm in 17.73% (95% CI, 8.67-29.08%).

“Chronic sinus symptoms’ and a patient’s age

The other important factor is that  the age of presentation is a significant distinguishing feature between persistent rhinitis and chronic rhinosinusitis. Symptom presentation among patients with persistent rhinitis (PR) and those with chronic rhinosinusitis (CRS) often overlaps. The sinonasal presentation of rhinorrhea, postnasal drip, nasal congestion, nasal itching, sneezing, facial pressure, facial pain, and headache are all common. Colloquially, many patients simply refer to any form of sinonasal symptoms as “sinus” or ”sinusitis,” but often patients simply have a rhinitis reaction. Otolaryngologists rely on both nasal endoscopy and computerized tomography (CT) to differentiate between PR and CRS. However in a recent study of n=651 patients presenting with chronic sino-nasal symptoms, younger age alone was an independant predictor of having a rhintiis condition rather than the diagnosis of chronic sinuitis.

When the data from this study is extracted the diagnostic characteristics for  Age as a predictor of those patients presenting with sino-nasal symptoms and the final diagnosis of allergic rhinitis over sinus disease; 

N: number of participants; PPV: positive predictive value; NPV: negative predictive value; LR+: positive likelihood ratio; LR-: negative likelihood ratio; DOR: diagnostic odds ratio.

Having a simple understanding of the age and the imaging of the patient who presents with  ‘chronic sinus symptoms’ is a simple start to getting the diagnosis right.