Diagnostic Imaging Pathways - Sinusitis (Acute)
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This pathway provides guidance on the imaging of patients with acute sinusitis.
Date reviewed: July 2014
Date of next review: 2017/2018
Published: October 2014
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
SYMBOL | RRL | EFFECTIVE DOSE RANGE |
![]() | None | 0 |
![]() | Minimal | < 1 millisieverts |
![]() | Low | 1-5 mSv |
![]() | Medium | 5-10 mSv |
![]() | High | >10 mSv |
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Teaching Points
Teaching Points
- Imaging is indicated in acute sinusitis if
- There is inadequate response to medical therapy
- There are numerous episodes of acute bacterial sinusitis in a year
- There is a clinical suspicion of intracranial or intraorbital complications
- The patient is immunocompromised
- A CT scan of the sinuses is the recommended imaging modality if indicated
a_sin
Acute Sinusitis
- Acute sinusitis is a clinical diagnosis and is defined as a rhinosinusitis that has persisted for between 7 and 28 days, with the presence of two or more major sinus symptoms or at least one major and two minor sinus symptoms 5
- Acute sinusitis is normally diagnosed on clinical grounds, and imaging is not usually required. However, there are a number of scenarios in which imaging is indicated if
- There is inadequate response to medical therapy, or
- There are numerous episodes of acute bacterial sinusitis in a year, or
- There is a clinical suspicion of intracranial or intraorbital complications, or
- The patient is immunocompromised
- Major symptoms: facial pain/pressure, facial congestion/fullness, nasal obstruction/blockage, nasal discharge, hyposmia/anosmia, purulence in the nasal cavity on examination and fever 5
- Minor symptoms: headache, halitosis, fatigue, dental pain, cough and ear pain/pressure/fullness 5
- Symptoms in children are more non-specific with cough and nasal discharge being the most common presentations. Facial pain and headache are not usually present 6
- Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis account for the majority of acute bacterial sinusitis in adult and paediatric populations 6,7
- Mixed microorganisms cultured from intranasal swabs do not usually correlate with the pathologic source 6,7
- Specialist ENT referral is warranted in the following situations 6,8
- Suspected complications (subperiosteal, intradural, and brain abscesses)
- No response to 2nd line antibiotic therapy
- Recurrent disease ( >3 acute episodes per year)
- Use of plain radiography for diagnosis of inflammatory sinus disease is not recommended 1-4,9,21,22
ct
Coronal Computed Tomography
- Coronal CT is not a routine investigation in the diagnosis of acute bacterial sinusitis and is indicated only for non-responsive or recurrent acute sinusitis, pre-surgical planning and for evaluating suspected complications 1-4,6,8
- Coronal plane optimally displays 9,10
- The ostiomeatal unit and relationship of the brain and roof of the ethmoid sinus
- The relationship of the orbits to the paranasal sinuses
- For patients requiring sinus imaging evaluation, consensus in North America and Europe currently recommends CT in preference to plain film radiography which are insensitive and non-specific 1-4
- There have been no studies comparing CT to sinus puncture and aspiration
- CT has low specificity for diagnosis of acute sinusitis, thus clinical correlation is essential 11
- Features of acute sinusitis on CT include: mucosal thickening, presence of air/fluid levels, enhancing pockets with non-enhanced central zone (pus) and complete sinus opacification 12,13
- For anatomical evaluation including pre-surgical planning, a non-contrast scan is adequate
- If complications are suspected, then the scan is usually performed before and after administration of contrast
- Multidetector CT enables fast scan times, and may reduce the need for sedation in young children
- Low-dose CT protocols can effectively reduce the radiation dose without significantly affecting diagnostic quality 14,15
mri
Magnetic Resonance Imaging
- For intracranial complications of acute sinusitis, MRI is more accurate than CT and is considered by some to be the initial diagnostic modality of choice 16,17
- MRI and MR Venography (MRV) are more sensitive than CT for the diagnosis of cavernous sinus thrombosis 18,19
- Limitations: expensive, not available at all centres, long scan times 20
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- McAlister WH, Strain JD, Cohen HL, et al. The American College of Radiology: ACR appropriateness criteria: sinusitis - child. 2012 [cited 2014 December 8]. (Guidelines). View the reference
- Fokkens W, Lund V, Bachert C, et al. EEACI Position paper on rhinosinusistis and nasal polyps: executive summary. Allergy. 2005:60:583-601. (Guidelines)
- European Academy of Allergology and Clinical Immunology. European position paper on rhinosinusitis and nasal polyps. Rhinology. 2005;18:S1-87. (Review article)
- Slavin RG, Spector SL, Bernstein IL, et al. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol. 2005;116:S13-47. (Review article)
- Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. 1997;117(3):S1-S7. (Review article)
- Brook I, Gooch WM 3rd, Reiner SA, et al. Medical management of acute bacterial Sinusitis. Ann Otol Rhinol Laryngol. 2000;109:1-17. (Clinical decision rule)
- Evans KL. Diagnosis and management of sinusitis. BMJ. 1994;309:1415-22. (Review article)
- Low DE, Desrosiers M, McSherry J. A practical guide for the diagnosis and treatment of acute sinusitis. CMAJ. 1997;156(6S):S1-14. (Review article)
- Yousem DM. Imaging of sinonasal inflammatory disease. Radiology. 1993;188:303-14. (Review article)
- Zinreich SJ. Rhinosinusitis: radiologic diagnosis. Otolaryngol Head Neck Surg. 1997:117(3):S27-S34. (Review article)
- Gwaltney JM, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med. 1994;330:25-30. (Level IV evidence)
- Lindbaek M, Johnsen U, Kaastad E, et al. CT Findings in general practice patients with suspected acute sinusitis. Acta Radiologica. 1996;37:708-13. (Level IV evidence)
- Eustis HS, Mafee MF, Walton C, Mondonca J. MR imaging and CT of orbital infections and complications in acute rhinosinusitis. Radiol Clin North Am. 1998;36:1165-83. (Review article)
- Tack D, Widelec J, De Maertelaer V, Bailly J-M, Delcour C, Gevenois PA. Comparison between low-dose and standard-dose multidetector CT in patients with suspected chronic sinusitis. AJR Am J Roentgenol. 2003;181:939-44. (Level III evidence)
- Hagtvedt T, Aalokken TM, Notthellen J, Kolbenstvedt A. A new low-dose CT examination compared with standard-dose CT in the diagnosis of acute sinusitis. Eur Radiol. 2003;13:976-80. (Level III evidence)
- Younis RT, Anand VK, Davidson B. The role of computed tomography and magnetic resonance imaging in patients with sinusitis with complications. Laryngoscope. 2002;112:224-9. (Level IV evidence)
- Hahnel S, Ertl_Wagner B, Tasman A-J, Forsting M, Jansen O. Relative value of MR imaging as compared with CT in the diagnosis of inflammatory paranasal sinus disease. Radiology. 1999;210:171-6. (Level IV evidence)
- Lee SK, Terbrugge KG. Cerebral venous thrombosis in adults: the role of imaging evaluation and management. Neuroimag Clin N Am. 2003;13:139-152. (Review article)
- Tsai FY, Wang AM, Matovich VB, et al. MR staging of acute dural sinus thrombosis: correlation with venous pressure measurements and implications for treatment and prognosis. AJNR Am J Neuroradiol. 1995;16:1021-9. (Level III evidence)
- McAlister WH, Kronemer K. Imaging of sinusitis in children. Pediatr Infect Dis J. 1999;18:1019-20. (Review article)
- Konen E, Faibel M, Kleinbaum Y, et al. The value of the occipitomental (waters') view in diagnosis of sinusitis: a comparative study with computed tomography. Clin Radiol. 2000;55:856-60. (Level II/III evidence)
- Davidson TM, Brahme FJ, Gallagher ME. Radiographic
evaluation for nasal dysfunction: computed tomography versus plain films.
Head and Neck. 1989;11:405-9. (Level III evidence)
Information for Consumers
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Contrast Medium (Gadolinium versus Iodine) Iodine-Containing Contrast Medium Magnetic Resonance Imaging (MRI) Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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