The Pediatric Infectious Disease Journal Publish Ahead of ... · The Pediatric Infectious Disease...
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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
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTEDD
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTEDTETETE
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ACCEPTED
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ECCCEACACCACCCEEPEPEPTE
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