the pediatric infectious disease journal publish ahead of ... · the pediatric infectious disease...

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

The Pediatric Infectious Disease Journal Publish Ahead of Print DOI: 10.1097/INF.0b013e31829bb2c2

Signs and Symptoms that Differentiate Acute Sinusitis from Viral Upper Respiratory Tract

Infection

Nader Shaikh, MD, MPH1, Alejandro Hoberman, MD1, Diana H. Kearney, RN, CCRC1,

D. Kathleen Colborn, BS1, Marcia Kurs-Lasky, MS3, Jong H. Jeong, PhD3, Mary Ann

Haralam, CRNP1, A’Delbert Bowen, MD4, Lynda L. Flom, MD4, and Ellen R. Wald,

MD2

1University of Pittsburgh School of Medicine, Division of General Academic Pediatrics

2University of Wisconsin School of Medicine and Public Health

3University of Pittsburgh Graduate School of Public Health, Biostatistics

4Children’s Hospital of Pittsburgh, Division of Pediatric Radiology

Corresponding Author: Nader Shaikh, MD, MPH

Children’s Hospital of Pittsburgh

General Academic Pediatrics

4401 Penn Avenue Pittsburgh, PA 15224

412-692-8111 (phone) 412-692-8516 (fax) [email protected]

Keywords: Pediatrics, Patient-reported outcome, symptoms

Abbreviated title: Signs and Symptoms of Acute Sinusitis

Running Head: Acute Sinusitis

Conflicts of Interest: None

Source of Funding: Dr. Shaikh was supported by a Grant (1R21AI076677) from the National

Institutes of Health (NIAID). This grant benefited from University of Pittsburgh CTSI

(NIH/NCRR/CTSA Grant UL1 RR024153).

ACCEPTEDPhDPhD33, Mary, Mary

, and Ellen R. Wald, and Ellen R. Wald

General Academic PediaGeneral Academic Pedi

blic Health lic Health

blic Health, Biostatisticsblic Health, Biostatisti

n of Pediatric Radiologyn of Pediatric R

ader Shaikh, MD, MPH der Shaikh, MD, MP

gh

rics cs

Pittsburgh, PA 15224 Pittsburgh, PA 15224

(phone) 412-692phone) 4

rds: Pediatrics, Patiendiatrics, Patien

bbreviated title: viated title: Sign

ing Head: Head Acu

f InIn


ABSTRACT

Objective: Differentiating acute bacterial sinusitis from viral upper respiratory tract infection (URI) is

challenging; 20% to 40% of children diagnosed with acute sinusitis based on clinical criteria likely have an

uncomplicated URI. The objective of this study was to determine which signs and symptoms could be used to

identify the subgroup of children who meet current clinical criteria for sinusitis but who nevertheless have a

viral URI.

Methods: We obtained sinus radiographs in consecutive children meeting a priori clinical criteria for acute

sinusitis. We considered the subgroup of children with completely normal sinus radiographs to have an

uncomplicated URI despite meeting the clinical diagnostic criteria for sinusitis. We examined the utility of

signs and symptoms in identifying children with URI.

Results: Of 258 children enrolled, 54 (20.9%) children had completely normal radiographs. The absence of

green nasal discharge, the absence of disturbed sleep, and mild symptoms were associated with a diagnosis of

URI. No physical exam findings were particularly helpful in distinguishing between children with normal vs.

abnormal radiographs.

Conclusions: Among children meeting current criteria for the diagnosis of acute sinusitis, those with mild

symptoms are significantly more likely to have a URI than those with severe symptoms. In addition to

assessing overall severity of symptoms, practitioners should ask about sleep disturbance and green nasal

discharge when assessing children with suspected sinusitis; their absence favors a diagnosis of URI. ACCEPTEDneve

ing ng a prioria priori clinical criteria clinical criteri

y normal sinus radiographsy normal sinus radiograph

criteria for sinusitis. We excriteria for sinusitis. We ex

9%) children had complete9%) children had c

f disturbed sleep, and milddisturbed sleep, and mild

gs were particularly helpfugs were particularly helpfu

Among children meeting ong children mee

ms are significantly more lms are significantly more l

sessing overall severity of g overall severity

rge when assessiwhen a


ACCEPTED


ACCEPTEDD


ACCEPTED

Cop

yrig

ht ©

201

3 Li

ppin

cott

Will

iam

s &

Wilk

ins.

Una

utho

rized

repr

oduc

tion

of th

is a

rticl

e is

pro

hibi

ted.

Tab

le 2

. A

ccur

acy

of s

ympt

oms

in th

e di

agno

sis

of u

pper

res

pira

tory

trac

t inf

ectio

n (U

RI)

, and

pro

babi

lity

of U

RI

assu

min

g a

pre-

test

pro

babi

lity

of 4

0%.

Find

ings

that

are

bot

h cl

inic

ally

and

sta

tistic

ally

sig

nifi

cant

are

bol

ded.

Sym

ptom

s

Dia

gnos

is a

L

ikel

ihoo

d ra

tio

in p

redi

ctin

g U

RI

b

Pro

babi

lity

of U

RI

Lik

ely

UR

I (n

=54)

L

ikel

y si

nusi

tis

(n=2

04)

P

osit

ive

likel

ihoo

d

rati

o (C

I)

Neg

ativ

e lik

elih

ood

rati

o (C

I)

If

sym

ptom

pr

esen

t (C

I)

If s

ympt

om

abse

nt (C

I)

In t

he p

ast 2

4 ho

urs

Fe

ver

19

(35

.2)

99 (

48.5

) 0.

73 (

0.49

- 1

.07)

1.

26 (

0.99

- 1

.60)

32

.6%

(24

.7 -

41.

6)

45.6

% (

39.8

- 5

1.6)

Hea

dach

e

29 (

53.7

) 8

3 (4

0.7)

1.

32 (

0.98

- 1

.78)

0.

78 (

0.57

- 1

.06)

46

.8%

(39

.5 -

54.

2)

34.2

% (

27.6

- 4

1.5)

Gre

en n

asal

dis

char

ge

24

(44

.4)

146

(71.

6)

0.62

(0.

46 -

0.8

5)

1.95

(1.

41 -

2.7

0)

29.3

% (

23.3

- 3

6.1)

56

.6%

(48

.5 -

64.3

)

Tir

ed

42

(77

.8)

160

(78.

4)

0.99

(0.

85 -

1.1

6)

1.03

(0.

59 -

1.8

1)

39.8

% (

36.0

- 4

3.7)

40

.7%

(28

.1 -

54.

7)

Irri

tabl

e (b

ad m

ood)

36 (

66.7

) 15

1 (7

4.0)

0.

90 (

0.73

- 1

.11)

1.

28 (

0.82

- 2

.00)

37

.5%

(32

.8 -

42.

4)

46.1

% (

35.5

– 5

7.1)

Sinc

e th

e on

set o

f ill

ness

Bad

bre

ath

31

(57

.4)

108

(52.

9)

1.08

(0.

83 -

1.4

1)

0.91

(0.

64 -

1.2

7)

42.0

% (

35.7

- 4

8.5)

37

.6%

(30

.0 -

45.

9)

Feve

r

22 (

40.7

) 10

8 (5

2.9)

0.

77 (

0.54

- 1

.09)

1.

26 (

0.96

- 1

.64)

33

.9%

(26

.6 -

42.

1)

45.6

% (

39.2

- 5

2.2)

Hea

dach

e b

26

(51

.0)

88

(46.

3)

1.10

(0.

81 -

1.5

0)

0.91

(0.

67 –

1.2

4)

42.3

% (

35.0

- 5

0.0)

37

.8%

(30

.9 -

45.

3)

Nig

httim

e co

ugh

47 (

87.0

) 18

7 (9

1.7)

0.

95 (

0.85

- 1

.06)

1.

56 (

0.68

– 3

.56)

38

.8%

(36

.2 -

41.

4)

50.9

% (

31.2

- 7

0.3)

Day

time

coug

h

47

(87

.0)

193

(94.

6)

0.92

(0.

83 -

1.0

2)

2.40

(0.

98 -

5.9

1)

38.0

% (

35.5

- 4

0.6)

61

.6%

(39

.5 -

79.

7)

Eat

ing

less

28 (

51.9

) 11

7 (5

7.4)

0.

90 (

0.68

- 1

.20)

1.

13 (

0.82

- 1

.55)

37

.6%

(31

.2 -

44.

4)

42.9

% (

35.4

- 5

0.9)

Play

ing

less

21 (

38.9

) 9

8 (4

8.0)

0.

81 (

0.56

- 1

.16)

1.

18 (

0.92

- 1

.51)

35

.1%

(27

.3 -

43.

7)

43.9

% (

37.9

- 5

0.2)

Tir

ed

38

(70

.4)

156

(76.

5)

0.92

(0.

76 -

1.1

1)

1.26

(0.

78 -

2.0

3)

38.0

% (

33.7

- 4

2.6)

45

.6%

(34

.2 -

57.

6)

Stuf

fy n

ose

46

(85

.2)

190

(93.

1)

0.91

(0.

81 -

1.0

3)

2.16

(0.

96 -

4.8

8)

37.9

% (

35.2

- 4

0.7)

59

.0%

(38

.9 -

76.

5)

Dis

turb

ed s

leep

32 (

59.3

) 16

2 (7

9.4)

0.

75 (

0.59

- 0

.94)

1.

98 (

1.30

- 3

.01)

33

.2%

(28

.3 -

38.

6)

56.9

% (

46.4

- 66

.7)

Snee

zing

mor

e th

an u

sual

32 (

59.3

) 13

5 (6

6.2)

0.

90 (

0.70

- 1

.14)

1.

20 (

0.83

- 1

.75)

37

.4%

(31

.9 -

43.

2)

44.5

% (

35.6

- 5

3.9)

Itch

y ey

es

22

(40

.7)

70

(34.

3)

1.19

(0.

82 -

1.7

2)

0.90

(0.

71 -

1.1

5)

44.2

% (

35.3

- 5

3.5)

37

.6%

(32

.1 -

43.

4)

Itch

y no

se b

23

(42

.6)

87

(42.

9)

0.99

(0.

70 -

1.4

1)

1.00

(0.

78 -

1.3

0)

39.9

% (

31.9

- 4

8.4)

40

.1%

(34

.1 -

46.

5)

Tee

th/J

aw p

ain

b

5 (9

.8)

33

(17.

4)

0.56

(0.

23 -

1.3

7)

1.09

(0.

98 –

1.2

2)

27.3

% (

13.4

– 4

7.8)

42

.1%

(39

.4 -

44.

9)

ACCEPTEDR

I as

sum

I as

sum

ing

UR

I ng

UR

b EDEDEDEDEDga

tive

like

lihoo

d ga

tive

like

liho

rati

o (C

I)

rati

o (C

I)

If

If EDED07

) 1.

26 (

0.99

- 1

.60)

7)

1.26

(0.

99 -

1.6

0)

- 1.

78)

0.78

(0.

57 -

178

) 0.

78 (

0.57

- 1

46 -

0.8

5)

1.95

(1.

4146

- 0

.85)

1.

95 (

1.4

9 (0

.85

- 1.

16)

1.03

(0

(0.8

5 -

1.16

) 1.

03 (

0.90

(0.

73 -

1.1

1)

1.2

0.90

(0.

73 -

1.1

1)

1.08

(0.

83 -

1.4

1)

1.08

(0.

83 -

1.4

1)

.9)

0.77

(0.

54 -

1.0

9)

0.77

(0.

54 -

1.

(46.

3)

1.10

(0.

81 -

(46.

3)

1.10

(0.

81

187

(91.

7)

0.95

(0

(91

.7)

0.95

(0

193

(94.

6)

0.92

193

(94.

6)

0

11

7 (5

7.4)

11

7 (5

7.4)

8.9)

9

8 (4

8.0)

)

98

(48.

0

8 (7

0.4)

15

6 (7

6.5)

)

156

(76.

46 (

85.2

) 19

0 (9

346

(85

.2)

190

(93

32 (

59.3

) 16

232

(59

.3)

32 (

59.3

) 32

(59

.3)

22 (

40.7

) 2

(40.

3 (4

2.6)

(42.

6

Cop

yrig

ht ©

201

3 Li

ppin

cott

Will

iam

s &

Wilk

ins.

Una

utho

rized

repr

oduc

tion

of th

is a

rticl

e is

pro

hibi

ted.

Faci

al s

wel

ling

10

(18

.5)

53

(26.

0)

0.71

(0.

39 –

2.3

2))

1.10

(0.

95 –

1.2

8)

32.2

% (

20.6

– 4

6.5)

42

.3%

(38

.7 –

56.

0)

Face

pai

n b

4

(7.9

) 4

0 (2

1.0)

0.

37 (

0.14

- 0

.99)

1.

17 (

1.05

– 1

.30)

19

.9%

(8.

52 -

39.8

) 43

.8%

(41

.1 -

46.

5)

Asy

mm

etri

c fa

ce p

ain

b

1 (2

.0)

14

(7.7

) 0.

26 (

0.04

- 1

.93)

1.

06 (

1.00

- 1

.12)

14

.8%

(2.

28 –

56.

3)

41.4

% (

40.1

– 4

2.9)

CI

= 9

5% c

onfi

denc

e in

terv

al

a N

umbe

r (p

erce

nt o

f ch

ildr

en)

b N

ot a

ll 25

8 ch

ildre

n pr

ovid

ed d

ata

for

thes

e fi

ndin

gs

ACCEPTED19

12)

14.8

%12

) 14

.8% DDDDD

Cop

yrig

ht ©

201

3 Li

ppin

cott

Will

iam

s &

Wilk

ins.

Una

utho

rized

repr

oduc

tion

of th

is a

rticl

e is

pro

hibi

ted.

T

able

3. A

ccur

acy

of s

igns

in th

e di

agno

sis

of u

pper

res

pira

tory

trac

t inf

ecti

on (

UR

I), a

nd p

roba

bilit

y of

UR

I as

sum

ing

a pr

e-te

st p

roba

bilit

y of

40%

Sign

s

Dia

gnos

is a

L

ikel

ihoo

d ra

tios

in p

redi

ctin

g U

RI

b

Pro

babi

lity

of U

RI

Lik

ely

UR

I (n

=54)

L

ikel

y si

nusi

tis

(n=2

04)

P

osit

ive

likel

ihoo

d ra

tio

(CI)

N

egat

ive

likel

ihoo

d ra

tio

(CI)

If s

ympt

om

pres

ent

(CI)

If

sym

ptom

ab

sent

(CI)

M

easu

red

tem

pera

ture

>38

° C

b

2 (3

.7)

7 (3

.4)

1.07

(0.

23 -

5.0

0)

1.00

(0.

94 -

1.0

6)

41.6

% (

13.2

- 7

6.9)

39

.9%

(38

.5 -

41.

4)

Blu

ish

turb

inat

es b

7

(13

.0)

48 (

23.9

) 0.

54 (

0.26

- 1

.13)

1.

14 (

1.01

- 1

.30)

26

.6%

(14

.8 -

43.

0)

43.3

% (

40.1

- 4

6.4)

Alle

rgic

shi

ners

20 (

37.0

) 10

8 (5

2.9)

0.

70 (

0.48

- 1

.01)

1.

34 (

1.04

- 1

.72)

31

.8%

(24

.3 -

40.

3)

47.1

% (

41.0

. - 5

3.4)

Tra

nsve

rse

nasa

l cre

ase

6

(11

.1)

26 (

12.7

) 0.

87 (

0.38

- 2

.01)

1.

02 (

0.92

- 1

.13)

36

.8%

(20

.1 -

57.

3)

40.4

% (

37.9

- 4

3.1)

Post

-nas

al d

isch

arge

vis

ible

in p

hary

nx b

12

(22

.2)

60 (

30.9

) 0.

72 (

0.42

- 1

.23)

1.

13 (

0.95

- 1

.34)

32

.4%

(21

.8 -

45.

2)

42.9

% (

38.8

- 4

7.1)

Faci

al s

wel

ling

(ei

ther

sid

e)

7

(13

.0)

51 (

25.0

) 0.

52 (

0.25

- 1

.08)

1.

16 (

1.02

- 1

.32)

25

.7%

(14

.3 -

41.

8)

43.6

% (

40.5

- 4

6.8)

Eit

her

max

illar

y si

nus

tend

er to

per

cuss

ion

5 (

9.3)

27

(13

.2)

0.70

(0.

28 -

1.7

3)

1.05

(0.

95 -

1.1

6)

31.8

% (

15.9

- 5

3.6)

41

.1%

(38

.7 -

43.

5)

Eit

her

max

illar

y si

nus

tend

er to

pre

ssur

e

13 (

24.1

) 48

(23

.5)

1.02

(0.

60 -

1.7

5)

0.99

(0.

84 -

1.1

7)

40.6

% (

28.6

- 5

3.8)

39

.8%

(35

.9 -

43.

9)

Eit

her

fron

tal s

inus

tend

er to

per

cuss

ion

c

5 (

16.1

) 21

(23

.1)

0.70

(0.

20 –

1.7

0)

1.09

(0.

90 -

1.32

) 31

.8%

(16

.1 –

53.

1)

42.1

% (

37.5

– 4

6.8)

Eit

her

fron

tal s

inus

tend

er to

pre

ssur

e c

15

(48

.4)

23 (

25.3

) 1.

91 (

1.15

– 3

.18)

0.

69 (

0.48

– 0

.99)

56

.1%

(43

.5 –

67.

9)

31.5

% (

24.3

– 3

9.8)

Eit

her

infe

rior

turb

inat

e sw

olle

n

31 (

57.4

) 13

2 (6

4.7)

0.

89 (

0.69

- 1

.14)

1.

21 (

0.84

- 1

.73)

37

.2%

(31

.5 -

43.

2)

44.6

% (

35.9

- 5

3.6)

Eit

her

infe

rior

turb

inat

e er

ythe

mat

ous

21

(38

.9)

98 (

48.0

) 0.

81 (

0.56

- 1

.16)

1.

18 (

0.92

- 1

.51)

35

.1%

(27

.3 -

43.

7)

43.9

% (

37.9

- 5

0.2)

Pus

in n

ose

21

(38

.9)

128

(62.

7)

0.62

(0.

44 -

0.8

8)

1.64

(1.

24 -

2.1

6)

29.2

% (

22.5

- 3

7.0)

52

.2%

(45

.3 -

59.

1)

Pus

in m

iddl

e m

eatu

s

9 (

16.7

) 42

(20

.6)

0.81

(0.

42 -

1.5

6)

1.05

(0.

91 -

1.2

0)

35.1

% (

21.9

- 5

0.9)

41

.2%

(37

.9 -

44.

5)

Phar

ynge

al c

obbl

esto

ning

b

5 (

9.3)

22

(10

.9)

0.85

(0.

34 -

2.1

3)

1.02

(0.

92 -

1.1

2)

36.1

% (

18.3

- 5

8.7)

40

.5%

(38

.1 -

42.

8)

CI

= 9

5% c

onfi

denc

e in

terv

al

a N

umbe

r (p

erce

nt o

f ch

ildr

en)

b N

ot a

ll 25

8 ch

ildre

n pr

ovid

ed d

ata

for

thes

e fi

ndin

gs

c O

nly

chil

dren

gre

ater

than

or

equa

l to

72 m

onth

s of

age

(i.e

., th

ose

wit

h de

velo

ped

fron

tal s

inus

es)

wer

e in

clud

ed in

this

ana

lysi

s

ACCEPTEDg

a pr

ng U

RI

g U

RI

bb

DDDDDiv

e lik

elih

ood

ve li

kelih

ora

tio

(CI)

ra

tio

(CI)

If

sy

If pre

pr DD1.

00 (

0.94

- 1

.06)

41

.61.

00 (

0.94

- 1

.06)

41

.6

1.14

(1.

01 -

1.3

0)

1.14

(1.

01 -

1.3

0)

.01)

1.

34 (

1.04

- 1

.72)

01

) 1.

34 (

1.04

- 1

.72)

- 2

.01)

1.

02 (

0.92

- 1

.-

2.01

) 1.

02 (

0.92

- 1

0.42

- 1

.23)

1.

13 (

0.95

2 -

1.23

) 1.

13 (

0.95

52 (

0.25

- 1

.08)

1.

16 (

12

(0.2

5 -

1.08

) 1.

16

0.70

(0.

28 -

1.7

3)

1.0

0.70

(0.

28 -

1.7

3)

1.0

1.02

(0.

60 -

1.7

5)

1.02

(0.

60 -

1)

0.70

(0.

20 –

1.7

0)1)

0.

70 (

0.20

–

(25.

3)

1.91

(1.

15 –

325

.3)

1.91

(1.

15 –

3

132

(64.

7)

0.89

(0.

6913

2 (6

4.7)

0.

89 (

0.69

98 (

48.0

) 0.

81 (

98 (

48.0

) 0.

81 (

9)

128

(62.

7)

0.6

128

(62.

7)

0.

16.7

) 42

(20

.6)

6.7)

42

(20

.6)

5 (

9.3)

22

(10

.9)

5 (

9.3)

22

(10

.9)

CCCCCCe

find

ings

s2

mon

ths

of a

ge (

i.e.,

thos

e w

2 m

onth

s of

age

(i.e

., th

ose

w


ACCEPTEDTETETE


ACCEPTED


ECCCEACACCACCCEEPEPEPTE

ACCEPTED

the pediatric infectious disease journal publish ahead of ... · the pediatric infectious disease...

Documents