The Common Cold in Patients with a History of Recurrent Sinusitis Increased Symptoms and Radiologic Sinusitislike Findings

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Original Research

The Common Cold in Patients with a History of Recurrent Sinusitis Increased Symptoms and Radiologic Sinusitislike Findings

J Fam Pract. 2001 January;50(1):26-31

References

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Related Resources:

Johns Hopkins Asthma & Allergy page Information on epidemiology, triggers, drug therapy and immunotherapy. Case studies and other features. www.hopkins-allergy.org/sinusitis/index.html
National Institute of Allergy and Infectious Diseases Information on NIAID research projects and opportunities, publications, as well as the agency’s Immune Tolerance Network www.niaid.nih.gov/default.htm
Common Cold Centre General information for patients www.cf.ac.uk/biosi/associates/cold/info.html

The more severe and prolonged symptoms and facial pain during common colds may cause sinusitis-prone patients to seek medical help earlier and more often than healthy patients. The knowledge of having a tendency for recurrent sinusitis episodes may further strengthen this behavior. Also, facial pain is a symptom that people do not usually regard as part of a common cold but rather as a symptom related to sinusitis. Our finding is in agreement with that of Hansen and collegues¹¹ who found that previous sinusitis was a factor that lead patients without bacterial sinusitis to seek medical help for respiratory symptoms.

Since the diagnostic reference standard (maxillary puncture with bacterial culture) is not suitable for routine use in differentiating bacterial sinusitis from viral respiratory infection, certain specific symptoms and signs have been suggested to be used for this purpose.¹² A recent study showed that clinicians tend to rely on varied historical and physical examination criteria for this purpose.¹³ Also, a history of sinus infections was strongly connected to physicians’ tendency to give a diagnosis of sinusitis.¹³

Although the role and benefits of imaging remain unclear, it is increasingly used to evaluate patients with colds.¹⁴ The majority of patients with a common cold have been shown to have widespread radiologic sinus changes that resolve spontaneously.^15-17 In our study, 65% of the sinusitis-prone patients had radiologic sinusitislike changes, which is a much higher proportion than that among the healthy controls (35%), the latter figure being in agreement with the earlier reports.¹⁷ The severe symptoms and the high frequency of radiologic sinusitislike changes during a common cold make the patients with a sinusitis history particularly susceptible to be given a diagnosis of bacterial sinusitis, leading to unnecessary prescriptions for antibiotics.

We would need an objective diagnostic test in addition to symptomatology and radiologic findings to differentiate bacterial sinusitis from viral respiratory infection in sinusitis-prone patients who seek medical help during an early phase of a respiratory infection. A pathogen-positive bacteriologic culture collected endoscopically from the middle meatus would have been useful in this respect. If this finding had been used in addition to the clinical and radiologic criteria for the diagnosis of bacterial sinusitis, the number of antimicrobial treatments in our series would have decreased from 10 to 2 in the sinusitis-prone group and from 3 to 2 in the control group. Since endoscopically collected samples are not suitable for routine use in primary care, nasopharyngeal culture is an alternative method. Nasal cultures have been considered inaccurate in the diagnosis of bacterial sinusitis, because they give false-positive results.¹⁶ However, there is evidence that a pathogen-positive nasal culture is fairly sensitive to acute bacterial maxillary sinusitis.¹⁸ In our series, compared with the endoscopically obtained culture findings from the middle meatus, the nasopharyngeal samples also gave a few false-positive results, but only in the control patients. Further studies are needed to clarify the usefulness of this method in diagnosing true bacterial sinusitis.

We do not know how many of the patients actually had bacteriological sinusitis in our series, because we did not do maxillary punctures with bacteriologic cultures. However, we think most had a viral disease at the time of the first examination, because bacterial sinusitis usually follows viral respiratory infection after 5 to 7 days. The study patients had symptoms for an average of 3 days. Secondly, only 5 patients (10%), 2 sinusitis-prone patients and 3 controls, had both a pathogenic bacterium isolated from the middle meatus and an air-fluid level or total opacification in any of the sinuses in the CT scan. Although the precise value of endoscopically obtained culture findings in sinus disease remains controversial¹⁶ there is increasing evidence to suggest that this method could be valuable.¹⁹ A finding of an air-fluid level or total opacification in CT scan has been shown to correlate with bacterial sinusitis,¹¹ and patients with this finding have benefited from antibiotic treatment.²⁰ The sinusitis-prone patients and the control patients were similar for all these findings.

Limitations

The patients who participated in our study were volunteers, but they were unaware of the aims of the study. The selection process was similar for the control patients and the sinusitis-prone patients. Proper symptoms were required for inclusion in both groups, which may have caused more serious cases to be selected. The patients were not recruited during the worst period of seasonal allergies (from the end of May to the beginning of August), to avoid having allergy symptoms confound the cold symptoms. Different viruses may cause different symptoms, and to avoid this bias both groups were enrolled evenly during the study period.