Authors' objectives

To assess the performance of diagnostic tests and the effects of antibiotics and ancillary treatments in the management of community-acquired acute bacterial rhinosinusitis in children and adults.

Searching

MEDLINE was searched from 1966 to May 1998 for articles published in English; the search terms were reported. Excerpta Medica and Abstracts from the Interscience Conference on Antimicrobial Agents and Chemotherapy (American Society for Microbiology, 1993-1997) were also searched. In addition, the references from all identified studies and review articles were checked, and experts in the field were contacted. Further MEDLINE searches for relevant foreign language studies were also conducted.

Study selection

Assessment of study quality

Diagnosis: the studies were assessed according to specification of the reference standard and index tests, and blinding of the interpreters to additional clinical information and the other test results. Verification bias was avoided by excluding studies where some patients did not undergo all of the tests being compared.

Treatment: the studies were assessed according to the methods of randomisation, blinding, specification of criteria for the diagnosis of sinusitis, use of cointerventions (decongestants), the robustness of the assessment of clinical outcomes, and the reporting of withdrawals and losses to follow-up.

Two reviewers independently assessed study quality. Any disagreements were resolved through discussion with a third reviewer.

Data extraction

Two reviewers independently extracted the data. Any disagreements were resolved through discussion with a third reviewer.

Methods of synthesis

Results of the review

Fourteen diagnostic accuracy studies (n=1,651) and 29 RCTs (n=4,708) were included in the meta-analyses.

A summary of the main results are reported in the following section. For a more detailed analysis of the results, readers are referred to the main report and the related publications (see Other Publications of Related Interest nos.1-2).

The overall methodological quality and reporting of both the diagnostic accuracy studies and RCTs was poor.

Diagnosis.

A meta-analysis of 6 studies indicated that sinus radiography had a moderate sensitivity and specificity,73% (95% CI: 60, 83) and 80% (95% CI: 71, 87), respectively, when compared with the reference standard of sinus puncture for the diagnosis of acute bacterial rhinosinusitis. The results of studies comparing the accuracy of ultrasonography with puncture or sinus radiography were inconclusive in determining the accuracy of ultrasonography. There was some evidence that a clinical diagnosis made on the presence of three or four symptoms (purulent rhinorrhea with unilateral predominance, local pain with unilateral predominance, bilateral purulent rhinorrhea, and the presence of pus in the nasal cavity) may have a similar diagnostic accuracy to that of sinus radiography.

Treatment.

Treatment with antibiotics was significantly more effective than treatment with placebo (risk ratio 0.54, 95% confidence interval: 0.37, 0.79). Treatment with amoxicillin or folate inhibitors was as effective as treatment with newer and more expensive antibiotics. There were no significant differences in the number of withdrawals due to side-effects in the trials of amoxicillin compared with the trials of other antibiotics.

Cost information

Yes. Initial symptomatic treatment was the most cost-effective strategy up to a prevalence of 25%, with the use of clinical criteria for diagnosis being the most cost-effective strategy for a prevalence of 25 to 83%. Use of antibiotic treatment with either amoxicillin or a folate inhibitor was only cost-effective above a prevalence of 83%. Sinus radiography as an initial management strategy for uncomplicated patients was not cost-effective at any prevalence.

Authors' conclusions

Where the prevalence of bacterial infection in patients presenting with uncomplicated symptoms of acute rhinosinusitis was low to moderate, such as in primary care, initial symptomatic treatment or the use of clinical criteria to guide treatment was the most cost-effective strategy. If antibiotics are indicated, amoxicillin or a folate inhibitor should be initially considered, as should the severity of the symptoms.

CRD commentary

The review questions were broad but reasonably defined in terms of the interventions, participants, outcomes and study designs. A limited number of sources were searched for potentially relevant studies, although both foreign language and unpublished studies were sought. This means that some potentially relevant studies might have been missed. Studies were selected by only one reviewer, and no efforts were made to minimise bias and errors in this process. The data extraction and quality assessment were undertaken using more rigorous methods to minimise bias in the review process. The quality of the included studies was adequately assessed and details of the included studies were tabulated, thus enabling the reader to assess whether the authors' results and conclusions are consistent with the evidence presented. The use of meta-analyses to combine the studies appeared appropriate, and differences between the studies were adequately addressed. Overall, the authors' conclusions are consistent with the evidence reviewed and are likely to be reliable.

Implications of the review for practice and research

Practice: The authors stated that where the prevalence of bacterial infection in patients presenting with uncomplicated symptoms of acute rhinosinusitis is low, initial symptomatic treatment or the use of clinical criteria to guide treatment is the most cost-effective strategy. They also stated that if antibiotics are indicated, amoxicillin or a folate inhibitor should initially be considered.

Research: The authors stated that future studies should use more rigorous diagnostic standards and clinical outcome measures. The optimal duration of treatment, the role of patient preferences in clinical decision-making, and the emergence of antibiotic resistance also need to be addressed.

Funding

Agency for Health Care Policy and Research, contract number 290-97-0019.

Bibliographic details

Lau J, Zucker D, Engels E A, Balk E, Barza M, Terrin N, Devine D, Chew P, Lang T A, Liu D. Diagnosis and treatment of acute bacterial rhinosinusitis. Rockville, MD, USA: Agency for Health Care Policy and Research. Evidence Report/Technology Assessment; 9. 1999. [PMC free article: PMC4780986] [PubMed: 11925970]

Original Paper URL

http://www.ahrq.gov/clinic/epcsums/sinussum.htm

Other publications of related interest

1. Benninger MS, Sedory Holzer SE, Lau J. Diagnosis and treatment of uncomplicated acute bacterial rhinosinusitis: summary of the Agency for Health Care Policy and Research evidence-based report. Otolaryngol Head Neck Surg 2000;122:1-7. 2. Engels EA, Terrin N, Barza M, Lau J. Meta-analysis of diagnostic tests for acute sinusitis. J Clin Epidemiol 2000;53:852-62.

These additional published commentaries may also be of interest. Willett LR. Review: diagnostic tests for bacterial rhinosinusitis have moderate accuracy; antibiotics reduce clinical failures. Evid Based Med 2000;5:125. Diagnosing acute sinusitis. Bandolier 2001;8:5.

Indexing Status

Subject indexing assigned by CRD

MeSH

Acute Disease; Amoxicillin /therapeutic use; Anti-Bacterial Agents /therapeutic use; Bacterial Infections /diagnosis /therapy; Evidence-Based Medicine; Rhinitis /diagnosis /therapy; Sinusitis /diagnosis /therapy

AccessionNumber

12000008347

Database entry date

31/05/2006

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.