1 November 1992

Clinical Evaluation for Sinusitis: Making the Diagnosis by History and Physical Examination

Publication: Annals of Internal Medicine
Volume 117, Number 9


Objective: To identify the most useful clinical examination findings for the diagnosis of acute and subacute sinusitis.
Design: Prospective comparison of clinical findings with radiographs.
Setting: General medicine clinics at a university-affiliated Veterans Affairs Medical Center.
Patients: Two hundred forty-seven consecutive adult men with rhinorrhea (51%), facial pain (22%), or self-suspected sinusitis (27%) (median age, 50 years; median duration of symptoms, 11.5 days).
Measurements: Patients were examined by a principal investigator (86%) or by a staff general internist, internal medicine resident (postgraduate year 2 or 3), or physician assistant, all blinded to radiographic results. All examiners recorded the presence or absence of 16 historical items, 5 physical examination items, and the clinical impression for sinusitis (high, intermediate, or low probability). The criterion standard was paranasal sinus radiographs (4 views), which were interpreted by radiologists blinded to clinical findings.
Results: Thirty-eight percent of patients meeting entrance criteria had sinusitis. Sensitivity, specificity, and likelihood ratios were measured for clinical items. Logistic regression analysis showed five independent predictors of sinusitis: maxillary toothache (odds ratio, 2.9), transillumination (odds ratio, 2.7), poor response to nasal decongestants or antihistamines (odds ratio, 2.4), colored nasal discharge reported by the patient (odds ratio, 2.2), or mucopurulence seen during examination (odds ratio, 2.9). The overall clinical impression was more accurate than any single finding: high probability (likelihood ratio, 4.7), intermediate (likelihood ratio, 1.4), low probability (likelihood ratio, 0.4).
Conclusions: General internists, focusing on five clinical findings and their overall clinical impression, can effectively stratify male patients with sinus symptoms as having a high, intermediate, or low probability of sinusitis.

Get full access to this article

View all available purchase options and get full access to this article.


Norrby R. Clinical aspects on bacterial infections in the upper respiratory tract. Scand J Infect Dis. 1983;(Suppl)39:14-8.
Hamory BSande MSydnor ASeale D, and Gwaltney J. Etiology and antimicrobial therapy of acute maxillary sinusitis. Journal of Infect Dis. 1979;139:197-202.
Axelsson AChidekel NGrebelius N, and Jensen C. Treatment of acute maxillary sinusitis. A comparison of four different methods. Acta Otolaryngol (Stockh). 1970;70:71-6.
Evans FSydnor JMoore WMoore GManwaring J, and Brill A. Sinusitis of the maxillary antrum. N Engl J Med. 1975;293:735-9.
Wald EChiponis D, and Ledesma-Medina J. Comparative effectiveness of amoxicillin and amoxicillin-clavulanate potassium in acute paranasal sinus infections in children: a double-blind, placebo-controlled trial. Pediatrics. 1986;77:795-800.
Meyers B. Bacterial sinusitis. J Fam Pract. 1984;18:117-8, 123-7.
Ramsey P and Weymuller E. Complications of bacterial infection of the ears, paranasal sinuses, and oropharynx in adults. Emerg Med Clin North Am. 1985;3:143-60.
Yarington C. Sinusitis as an emergency. Otolaryngol Clin North Am. 1979;12:447-54.
Axelsson A and Runze U. Symptoms and signs of acute maxillary sinusitis. ORL J Otorhinolaryngol. Relat Spec. 1976;38:298-308.
Bates B. A Guide to Physical Examination and History Taking. 5th edition. Philadelphia: J.B. Lippincott Co.; 1991:189.
Simon HB. Approach to the patient with sinusitis. In: Goroll AH, May LA, Mulley AG Jr; eds. Primary Care Medicine. 2nd edition. Philadelphia: J.B. Lippincott Co.; 1987:883-5.
Ballinger P. Merrill's Atlas of Radiographic Positions and Radiologic Procedures. 7th edition. St. Louis: Mosby Year Book;1991: 364.
Axelsson AGrebelius NChidekel N, and Jensen C. The correlation between the radiological examination and the irrigation findings in maxillary sinusitis. Acta Otolaryngol (Stockh). 1970;69:302-6.
Axelsson A and Runze U. Comparison of subjective and radiological findings during the course of acute maxillary sinusitis. Ann Otol Rhinol Laryngol. 1983;92:75-7.
Williams JRoberts LDistell B, and Simel D. Diagnosing sinusitis by x-ray: comparing a single waters view to 4-view paranasal sinus radiographs. J Gen Intern Med. 1992;6:[In press].
Cohen J. A Coefficient of agreement for nominal scales. Educ and Psychological Measurement. 1960;20:37-46.
Landis J and Koch G. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159-74.
Fleiss J. The analysis of data from matched samples. In: Statistical Methods for Rates and Proportions. 2nd edition. New York: John Wiley & Sons; 1981:112-35.
Sackett DHaynes R, and Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine. 2nd edition. Boston: Little, Brown and Co.; 1991.
Simel DFeussner JDeLong E, and Matchar D. Intermediate, indeterminate, and uninterpretable diagnostic test results. Med Decis Making. 1987;7:107-14.
Durrelman S and Simon R. Flexible regression models with cubic splines. Stat Med. 1989;8:551-61.
Harrell F. The LOGIST procedure. In: SAS/STAT User's Guide, Release 6.04. Cary, North Carolina: SAS Institute, Inc.; 1990:175-230.
Hosmer D and Lemeshow S. Applied Logistic Regression. New York: John Wiley & Sons, Inc.; 1989:82.
Wasson JSox HNeff R, and Goldman L. Clinical prediction rules. Applications and methodological standards. N Engl J Med. 1985; 313:793-9.
Efron B and Tibshirani R. Statistical data analysis in the computer age. Science. 1991;253:390-5.
Hanley J and McNeil B. The meaning and use of the area under a receiver operation characteristic (ROC) curve. Radiology. 1982;143: 29-36.
Axelsson A and Jensen C. The roentgenologic demonstration of sinusitis. Am J Roentgenol Radium Ther Nucl Med. 1974;122:621-7.
Sackett D. A Primer on the precision and accuracy of the clinical examination. JAMA. 1992;267:2638-44.
Gleckman R. Acute bacterial sinusitis. Hospital Pract (Off Ed). 1986;21:92, 97, 100-2.
Begg C. Biases in the assessment of diagnostic tests. Stat Med. 1987;6:411-23.
Havas TMotbey J, and Gullane P. Prevalence of incidental abnormalities on computed tomographic scans of the paranasal sinuses. Arch Otolaryngol Head Neck Surg. 1988;114:856-9.
Simel DSamsa G, and Matchar D. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol. 1991;44:763-70.

Information & Authors


Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 117Number 91 November 1992
Pages: 705 - 710


Published in issue: 1 November 1992
Published online: 1 December 2008




John W. Williams Jr, MD, MHS
David L. Simel, MD, MHS
From Audie L. Murphy Veterans Hospital and the University of Texas Health Science Center, San Antonio, Texas; and Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, North Carolina. For current author addresses, see end of text.

Metrics & Citations



If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.


Download article citation data for:
John W. Williams, David L. Simel, LeRoy Roberts, et al. Clinical Evaluation for Sinusitis: Making the Diagnosis by History and Physical Examination. Ann Intern Med.1992;117:705-710. doi:10.7326/0003-4819-117-9-705

View More

Get Access

Login Options:

You will be redirected to to sign-in to Annals to complete your purchase.

Create your Free Account

You will be redirected to to create an account that will provide access to Annals.

View options


View PDF/ePub

Related in ACP Journals







Copy the content Link

Share on social media