Sinus Radiographs Research Articles

Osteochondroma of the coronoid process (Jacob's disease)

J Oral Maxillofac Surg 60:1354-1356, 2002

Laparoscopic antireflux surgery for supraesophageal complications of gastroesophageal reflux disease

Gastroesophageal reflux disease can result in such supraesophageal complications as hoarseness, sore throat, cough, bronchitis, asthma, recurrent pneumonia, intermittent choking, chest pain, and ear pain. Appropriate patient care involves careful evaluation to decide on medical or surgical therapy. Preoperative testing must include endoscopy, 24-hour esophageal pH monitoring, and esophageal manometry. Additional evaluations, such as barium swallow, chest x-ray, bronchoscopy, and sinus radiographs, may be required. Medical treatment improves gastroesophageal reflux and supraesophageal symptoms. However, surgical therapy seems to provide better long-term results. A profile that predicts the best response to medical therapy has not been identified, although the best results with surgery are achieved in patients with nocturnal asthma, onset of reflux before pulmonary symptoms, laryngeal inflammation, and a good response to medical treatment.

Do symptoms and initial clinical probability predict the radiological diagnosis of acute sinusitis in children?

To evaluate the value of signs and symptoms in children for the radiological diagnosis of acute sinusitis. Prospective cohort study. University-affiliated tertiary care hospital. All children presenting with symptoms suggestive of acute sinusitis for whom sinus radiographs were ordered. Data were collected on the presence of specific symptoms and the initial probability of sinusitis. Criterion-based radiological diagnoses were made. Three hundred ninety-two consecutive children were seen; 257 children had a radiological diagnosis of acute sinusitis (66%), 128 patients (33%) presented with complete opacity of at least one sinus and 14 (4%) children had an air-fluid level. Sensitivity, specificity, predictive values and likelihood ratios were measured for clinical findings. Classical symptoms (rhinorrhea lasting more than 10 days and purulent rhinorrhea) increased the likelihood ratios the most (1.3 and 1.34, respectively). Logistic regression showed two independent predictors: purulent rhinorrhea (odds ratio 2.0) and the presence of acute otitis media (odds ratio 2.6). The initial clinical probability was more accurate than any other single finding: high probability (likelihood ratio 2.0), intermediate probability (likelihood ratio 1.1) and low probability (likelihood ratio 0.6). Classical symptoms are predictive of the presence of acute sinusitis as diagnosed on sinus radiographs. The physician's overall clinical impression, expressed as an initial probability, was superior to any single historical or examination finding in the diagnosis of acute sinusitis.

Principles of appropriate antibiotic use for acute rhinosinusitis in adults: Background

The following principles of appropriate antibiotic use for adults with acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in adults who are not immunocompromised.1.Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections.2.Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever.3.Sinus radiography is not recommended for diagnosis in routine cases.4.Acute rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms—especially those with unilateral facial pain—regardless of duration of illness. For initial treatment, the most narrow-spectrum agent active against the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be used.[Hickner JM, Bartlett JG, Besser RE, Gonzales R, Hoffman JR, Sande A. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Ann Emerg Med. June 2001;37:703-710.]

Azithromycin versus amoxicillin/clavulanate in the treatment of acute sinusitis

Purpose: To compare the efficacy and tolerability of a 3-day course of azithromycin with a 10-day course of amoxicillin/clavulanic acid in the treatment of acute sinusitis in adults. Patients and Methods: One hundred adult patients with acute sinusitis were included in an open, randomized study. Clinical diagnosis of sinusitis was confirmed by nasal endoscopy, sinus radiography, and (when possible) by culture of sinus aspirate. Patients were randomized to receive azithromycin (500 mg once daily for 3 days) or amoxicillin/clavulanate (625 mg every 8 hours for 10 days). Results: A significantly faster resolution of signs and symptoms of sinusitis was observed in the azithromycin-treated patients. By the end of therapy (days 10–12), 95% of the patients in the azithromycin group and 74% in the amoxicillin/clavulanate group were cured. The remaining patients' conditions were improved. By the follow-up visit, cure was achieved in 98% of the azithromycin-treated patients, and 91 % of the amoxicillin/clavulanate-treated patients. Treatment failure was observed in three patients from the amoxicillin/clavulanate group, and relapse occurred in one patient from each group. Bacteriologic eradication was achieved in 23 of 23 and 21 of 24 patients treated with azithromycin and amoxicillin/clavulanate, respectively. Both drugs were well tolerated. Two patients (4%) from the azithromycin group and five patients (10%) from the amoxicillin/clavulanate group reported mild gastrointestinal disturbances. Conclusions: In adults with acute sinusitis, a 3-day course of azithromycin was as effective and well tolerated as a 10-day course of amoxicillin/clavulanic acid. A significantly simpler dosage regimen and faster clinical effect were the advantages of azithromycin.

Chronic cough: the spectrum and the frequency of etiologies

Background: Chronic cough is a common symptom that requires the systematic diagnostic approach for proper evaluation. Postnasal drip syndrome(PNDS), bronchial asthma, gastroesophageal reflux disease(GERD), and chronic bronchitis are among the common causes. This study was conducted to evaluate the spectrum and the frequency of the causes of chronic cough. Methods: We prospectively evaluated 93 patients who had chronic cough despite normal chest radiographic finding. History and physical examination were done along with paranasal sinus radiograph, spirometry, bronchoprovocation test and 24-hours' ambulatory aesophageal pH monitoring as necessary. Results: Forty-nine(52%) of the 93 patients had PNDS, 15 patients(16%) bronchitis, 10 patients(11%) asthma, 4 patients (4%) GERD, 7 patients (8%) both PNDS and asthma, 4 patients (4%) undiagnosed condition and 4 patients(4%) were taking ACE inhibitor. Sixty-nine percent of the patients with PNDS improved after follow up, 73% patients with bronchitis, 80% patients with asthma, 50% patients with GERD, 100% patients with both PNDS and asthma, and 100% patients with ACE inhibitor. Conclusion: PNDS was the most common causes of chronic cough. Bronchitis was the second and asthma the third in frequency. The etiology of chronic cough can be determined easily by history and physical examination, successful therapy initiated in most patients. The response to specific therapy also was important in evaluation of chronic cough.

Interobserver agreement in assessing plain radiographs of maxillary sinus

Interrater agreement of six observers in interpreting maxillary sinus plain X-ray films was assessed. Patients aged 1–15 years old were enrolled and X-rays in the Caldwell and Waters’s views were requested to confirm diagnosis of sinusitis or after antimicrobial therapy for a pre-existing sinusitis. One-hundred and one pairs of maxillary sinus radiographs from 101 patients were submitted to an independent and blind interpretation by three radiologists and three pediatricians. Each maxillary sinus was separately analyzed. Kappa statistic was used to measure interobserver agreement. A fair degree of agreement among the six raters was found on analyzing these films: 0.39 (95% CI, 0.36–0.41) for the right maxillary sinus and 0.37 (95% CI, 0.34–0.39) for the left one. These results stress literature data on the limits of plain radiographs for diagnosing maxillary sinusitis. The necessity of knowing the clinical findings while interpreting the exams also was depicted.

Cefprozil versus Cefuroxime Axetil in the Treatment of Acute Sinusitis

The objective of this multicentre, randomised, open-label, general practice (GP) study was to evaluate the efficacy and tolerability of cefprozil (Cefzil(trade mark), Bristol-Myers Squibb) compared with that of cefuroxime axetil (Ceftin((R)), Glaxo Wellcome) in the treatment of adult subjects with acute sinusitis. Typical of the GP setting, diagnosis was made based solely on clinical signs and symptoms of acute disease. Sinus radiography was performed post-randomisation. A total of 381 adolescent and adult patients were randomly assigned to 10 days' treatment with either cefprozil, 500mg orally twice daily (n = 191), or cefuroxime axetil, 250mg orally twice daily (n = 190). Based on predefined criteria, treatments were found to be equally effective in terms of proportions of patients in the per-protocol population that were cured, improved or failed (p = 0.20). Similar results were observed when the evaluation was performed on the subset of patients with radiographic evidence of sinusitis and when the evaluation was based on the investigator's judgement. Similar rates of adverse events were observed in the two treatment groups. In summary, cefprozil 500mg twice daily is as well tolerated and as effective as cefuroxime axetil 250mg twice daily for the treatment of adolescent and adult patients with clinical signs and symptoms of acute sinusitis.

Clinical features and characteristics of paranasal sinus effusion in allergic sinusitis

Plain paranasal sinus radiographs including occipitofrontal and occipitomental views often show abnormal shadows in patients with allergic rhinitis. For that reason, the relationship between chronic sinusitis and allergy has been discussed for many years. Type I allergy is thought to be involved in the sinusitis which is called allergic sinusitis. However, there is not enough information pertaining to this disorder. In order to determine the clinical feature and the characteristics of paranasal sinus effusion in allergic sinusitis, we investigated the differences between 20 patients with allergic sinusitis and 20 with non-allergic chronic sinusitis used as controls. Clinical symptoms (nasal discharge, nasal obstruction, headache, postnasal discharge) and anterior rhinoscopic findings (nasal discharge, nasal edema), clinical examinations (type of x ray maxillary sinus shadow, bacteriology of nasal discharge), and pathological features of the paranasal sinus effusion were examined and compared in the two kind of sinusitis. Pathological findings of the effusion sampled from 14 patients with allergic sinusitis and 15 with non-allergic sinusitis included the number of eosinophils, activated eosinophils and neutrophils, concentrations of interleukin (IL)-1 beta, IL-4, IL-5, IL-8, and concentrations of leukotriene C4/D4/E4 and prostaglandin E2. The incidence and degree of postnasal discharge as a symptom and a nasal finding were lower in allergic sinusitis patients than in the controls. Microorganisms were detected less frequently in the allergic group. The number of eosinophils, activated eosinophils and neutrophils was higher in the paranasal sinus effusion of the patients with allergic sinusitis. The concentrations (ng/mg of protein) of IL-1 beta and IL-8 showed no difference between the two groups, but IL-4, and IL-5 were more prevalent per mg of protein in the effusion of allergic sinusitis patients. These findings suggest that the clinical features of allergic sinusitis include a low incidence and degree of postnasal discharge and a low rate of detection of bacteria, and that the sinus effusion is characterized by the presence of more eosinophils, activated eosinophils, and IL-5 than in those of chronic sinusitis.

Improvement of bronchial hyperresponsiveness in asthmatic children treated for concomitant sinusitis.

There appears to be an association between sinusitis and asthma. The effect on bronchial hyperresponsiveness of clinical therapy for sinusitis in children may help to decipher whether sinusitis and asthma are independent manifestations of the same disease. To evaluate the effect of clinical treatment for sinusitis in patients with rhinitis and/or asthma on symptoms and on bronchial hyperresponsiveness to methacholine. Open label, randomized, non-treatment control in a teaching hospital in São Paulo, Brazil. Forty-six atopic and 20 normal children were studied. The atopic children consisted of 18 with allergic rhinitis (12 without sinusitis and 6 with sinusitis), and 28 children with rhinitis with asthma (13 with normal sinus radiographs and 15 with complete opacification of the maxillary sinuses). Methacholine PC20 was determined before and 30 days after treatment with nasal saline, sulfamethoxazole-trimethoprim, antihistamine/decongestant, and five days of prednisone. Sinus radiographs were also repeated. The only patients with increase in methacholine PC20 were patients with rhinitis and asthma with opacified maxillary sinuses at entry and who at 30 days had normal sinus radiographs (P < .05). In this study, children with allergic rhinitis and sinusitis with asthma improved their bronchial hyperresponsiveness to methacholine and decreased their symptoms with appropriate response of their sinuses to clinical therapy.

Headache etiology in a pediatric emergency department.

Headache may be the presenting complaint of serious diagnoses such as meningitis, brain tumor, or shunt malfunction, yet no previous studies have examined the spectrum of diagnoses for the pediatric emergency department (ED) population with a chief complaint of headache. In 1993, 53,988 visits were made to the ED of an urban children's hospital. Six hundred ninety-six patients (1.3%) had a chief complaint of headache. Half of these visits, distributed randomly throughout the year, were chosen for review; total sample size was 288. Patient age ranged from two to 18 years (2-5 years, 24.3%; 6-12 years, 57.6%; 13-18 years, 18.1%). The spectrum of ED diagnoses included viral illness (39.2%), sinusitis (16.0%), migraine (15.6%), post-traumatic headache (6.6%), streptococcal pharyngitis (4.9%), and tension headache (4.5%). No cases of brain tumor or bacterial meningitis were identified at the time of ED visit. The only serious neurologic conditions diagnosed were 15 cases of viral meningitis (5.2%), one shunt malfunction, one newly diagnosed hydrocephalus, one Burkitt's lymphoma patient with newly diagnosed CNS infiltration, and one punctate hemorrhage post head trauma. Two thirds of patients had radiologic and/or laboratory tests. Positive findings were as follows: 45.6% of sinus radiographs, 16.3% of rapid streptococcal antigen tests, 60.9% of lumbar punctures, and 19.0% of brain imaging studies. The frequency of serious and nonserious conditions as a cause of headache was compared to data from general EDs. Serious conditions presenting with the chief complaint of headache in the pediatric ED were not common in our population. The most frequent diagnoses in our review were viral illness, sinusitis, and migraine, in contrast to adult studies in which tension headache and migraine were most common. Only 6.6% of patients had serious neurologic diagnoses, which is in the range reported for general EDs. Of the serious conditions in our study, 80% were viral meningitis.

Value of sinus radiographs in the diagnosis of maxillary sinus disease: interobserver agreement on sinus radiographs by otolaryngologists and radiologists

Variability between observers and specificity of sinus radiographic findings are subject to discussion. The aim of this study was to assess interobserver variability, between four physicians, two otolaryngologists and two radiologists, in the evaluation of 100 maxillary sinus radiographs. Equal agreement was found within the specialties when rating radiographs as normal or abnormal (80%). Kappa values for interobserver agreement were 0.45 for otolaryngologists and 0.58 for radiologists, both representing fair to good agreement. Otolaryngologists reported more abnormalities (67 vs, 57). Agreement on specific findings (complete opacity, fluid level and mucosal swelling) was fair to good (kappa values between 0.38 and 0.83). Agreement between the four physicians was lower on all outcomes. It is concluded that interobserver variability is within acceptable limits and justifies the continued use of conventional sinus radiographs for confirmation of maxillary sinus disease.

Identification by frontal sinus pattern in forensic anthropology

The authors report forensic cases from the literature, as well as two personal homicide cases, of identification through comparison of frontal sinus radiographs. A general discussion about identification using frontal sinus X-rays is presented, pointing out the reliability of the method, in reference to the uniqueness of the frontal sinus in humans, but also some difficulties, especially in reference to the distance, orientation and angle of the X-ray technique.

Limited axial CT of the paranasal sinuses in screening for sinusitis.

E valuation of sinusitis. which affects 50 million people in the United States, is a major contributor to health care expenditures. Although empiric antibiotic treatment of all patients with symptoms of sinusitis is controversial I I j, most treated patients respond to initial antibiotic therapy. Radiographic documentation of sinus disease is desirable in certain patients. especially to determine the need for more comprehensive and protracted antibiotic regimens (with additional office visits) in patients whose symptoms persist after mitial therapy. Radiographic distinction of sinusitis from rhinitis can be useful in patients predisposed to rhinitis. because both can have identical clinical pictures. Such patients include smokers or those with allergies or a history of occupational exposure. Radiographic identification of isolated nasal disease (i.e., swollen turbinates) is important because rhinitis is usually treated symptomatically or with lifestyle changes. CT scans have been shown to be superior to standard sinus radiographs in evaluating recurrent sinusitis, particularly ethmoid and sphenoid sinusitis in children 12-4]. The use of sinus CT has focused mainly on coronal screening studies before functional endoscopic sinonasal surgery. Coronal CT requires prone positioning for prolonged periods ( I 520 mm) of time while 20 or more slices are obtained through the paranasal sinuses. A reliable, more comfortable, and less expensive screening examination to replace plain films is desirable in these patients.

Invasive Aspergillus Sinusitis in Pediatric Bone Marrow Transplant Patients: Evaluation and Management

To evaluate the following: the incidence of invasive Aspergillus sinusitis (AS); the value of surveillance nasal cultures and screening radiologic studies in predicting AS; the clinical criteria used to decide on surgical biopsy in patients suspected of having AS; the surgical and medical management of AS; and the outcome of AS in the peritransplantation period of children who underwent bone marrow transplantation. Retrospective medical chart review. Tertiary care children's hospital. Eighty pediatric patients who underwent bone marrow transplantation for a variety of refractory malignant neoplasms or lymphohematopoietic disorders at the Children's National Medical Center, Washington, DC, from April 1, 1988, to September 30, 1993. Diagnostic surgical biopsies, surgical débridement, and treatment with amphotericin B. Resolution of AS and discharge from the hospital. Seventy-two patients had screening sinus radiographs, 27 of which showed abnormalities. Aspergillus sinusitis developed in three of the patients with abnormal screening radiographs. Fifty-eight patients had screening nasal cultures. One culture was positive for Aspergillus, and histopathologically proved AS developed in this patient. Twelve diagnostic biopsies were done in nine patients. Three biopsy specimens showed histopathologic evidence of AS. The three patients with AS were successfully treated with aggressive surgical and medical therapy and were discharged from the hospital. The incidence of AS was 4% (3/80) in the patients who underwent bone marrow transplantation. Screening radiographs, while not a good predictor of AS, have a role in evaluation of patients undergoing bone marrow transplantation to define preexisting sinus disease. Screening nasal cultures do not reliably predict AS. When AS is suspected and diagnostic biopsy is considered, the seven clinical criteria outlined in this article should be used. Survival of immunocompromised patients with AS requires early diagnosis and aggressive surgical and medical therapy.

Rhinocerebral Mucormycosis

Rhinocerebral Mucormycosis

Computed Tomography (CT) Scan Findings of the Paranasal Sinuses in Cystic Fibrosis

Nearly all patients with cystic fibrosis (CF) have abnormal findings on plain paranasal sinus radiographs. To establish this relationship more accurately, 58 CF patients with nasal symptoms were evaluated with paranasal sinus computed tomography (CT). Bilateral medial displacement of the lateral nasal wall in the middle meatus and uncinate process demineralization were seen in 43 patients (74%). Three patients (5%) had unilateral displacement and uncinate demineralization. Ten patients had maxillary sinus opacification, two patients (3.5%) had unremarkable paranasal sinuses on CT, and another patient (2%) had normal findings on one side. Although the vast majority of CF patients do have paranasal sinus abnormalities, we found on CT scan a progression of abnormalities that range from normal sinuses to pansinus disease, and in 74%, bilateral medial displacement of the lateral nasal wall and uncinate process demineralization.

Shortcomings of lateral sinus radiograph in the preoperative determination of the extent of endonasal endoscopic sinus surgery

Lateral sinus radiograph is helpful in determining the distances between certain anatomic landmarks in preparation for endonasal endoscopic sinus surgery. However, some misleading factors limit the usefulness of this radiograph. In this study these distances were measured in 49 patients and compared with measurements obtained from another imaging modality, magnetic resonance imaging, which provides more accurate measurements. Results show a discrepancy in the measurements of distances between some of these landmarks that cannot be explained by the factor of magnification alone on the sinus radiographs. Statistical analysis of the results for women revealed a significant discrepancy between the distances from the nasal spine to the midfovea ethmoidalis, the sphenoethmoid junction, and the posterior sphenoid wall as measured on MR images and those as measured on lateral sinus radiographs (P < .05). For men the same was true for the distances from the nasal spine to the midfovea ethmoidalis and the posterior sphenoid wall (P < .05). It is concluded that there should be reservations in the surgical application of data provided by the lateral sinus radiograph before endoscopic sinus surgery.

Evaluation of maxillary sinus aspiration in patients with fever of unknown origin.

The value of diagnostic maxillary sinus aspiration in patients with abnormal findings on sinus radiographs and fever of unknown origin is unclear. To better define indications for this procedure, the results of 51 sinus aspirations in 34 patients with fevers of unknown origin and abnormal findings on sinus radiographs were analyzed retrospectively. Results of aerobic and anaerobic cultures were evaluated in the context of clinical signs and symptoms at the time of the maxillary sinus puncture. Typical symptoms of paranasal sinus disease were found to be the best predictor of a positive culture. Of patients with sinusitis complaints, 86.4% had culture-positive aspirations, whereas only 8.3% of patients without clinical symptoms of sinusitis had culture-positive aspirations. This study indicates that symptoms of sinus disease play an important role in determining the benefit of sinus aspiration in this group of patients.

Acute sinusitis in children: is the Water's view sufficient?

The purpose of this study was to examine the utility of the Water's view in the diagnosis of acute sinusitis in children. The records of all pediatric (less than 18 years old) patients who underwent sinus radiography for suspected acute sinusitis between February 1991 and November 1992 were reviewed. All radiographs were reviewed by an attending radiologist and the interpretation of the Water's (occipitomental) view alone was compared to that of a three-view (anterior/posterior, lateral, Water's) series. Fifty-two three-view sinus series were obtained on pediatric patients during the study period. Twenty-eight patients were diagnosed with acute sinusitis based on the three-view series. When compared to the three-view series, the single Water's view had a sensitivity of 89%, specificity of 83%, positive predictive value of 87%, and negative predictive value of 87%. The overall accuracy of the Water's view in diagnosing childhood acute sinusitis was 87%. The authors conclude that the Water's view is usually sufficient in the evaluation of suspected acute sinusitis in children.