Pynnonen MA, Terrell JE. Conditions That Masquerade as Chronic RhinosinusitisA Medical Record Review. Arch Otolaryngol Head Neck Surg. 2006;132(7):748-751. doi:10.1001/archotol.132.7.748
Copyright 2006 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2006
To identify conditions that are commonly mistaken for chronic rhinosinusitis (CRS). The hypothesis was that many patients referred to a rhinology clinic with a presumptive diagnosis of CRS do not have CRS.
Retrospective, observational design study of adult patients referred for evaluation of CRS-like symptoms. The expert opinion of the rhinologist was the diagnostic standard.
Tertiary care rhinology clinic.
A consecutive sample of 186 patients referred to the University of Michigan Health Systems' Department of Otolaryngology–Head and Neck Surgery between April 1998 and June 2000 for evaluation of CRS-like symptoms.
Main Outcome Measures
For each patient, a history was obtained and a physical examination was performed, including nasal endoscopy and, when indicated, computed tomographic evaluation of the sinuses. Each patient's diagnosis at referral, CRS, was compared with the final diagnosis made by the rhinologist. The final diagnoses were collected and analyzed using descriptive statistics.
Of 186 patients, 112 (60%) had CRS and 74 (40%) did not. The most common diagnoses among the patients who did not have CRS were allergic rhinitis (n = 37), laryngitis associated with reflux (n = 21), head or facial pain (n = 18), and nonallergic rhinitis (n = 23). Many patients had more than 1 diagnosis.
Among a tertiary care population, common medical disorders, including rhinitis, laryngitis associated with reflux, and headache disorders, may simulate CRS. Heightened awareness of these conditions may improve diagnostic accuracy in patients with CRS-like symptoms.
The public's perception of the symptoms of sinusitis is often incorrect and contributes to sinusitis being reported as one of the most common chronic conditions in the United States. Thirty-five million persons reported having sinusitis in 2001, and diagnoses of acute and chronic sinusitis resulted in $3.39 billion in direct health care expenditures in 1996.1,2
Sinusitis, both the acute and chronic forms, is difficult to diagnose clinically. The clinical manifestations of acute bacterial rhinosinusitis (ABRS) must be differentiated from those of viral upper respiratory tract infection (URTI). Although ABRS is usually diagnosed clinically, sinus culture is the criterion standard for diagnosis. Acute bacterial rhinosinusitis is usually treated with antibiotic agents, whereas viral URTI is treated symptomatically with analgesic and decongestant agents.
Like ABRS, chronic rhinosinusitis (CRS) is also difficult to diagnose clinically. Unlike ABRS, however, there is no criterion standard for the diagnosis of CRS.3- 5 Rather, the diagnosis relies on integration of the historical, physical, and sometimes radiographic findings. Substantial clinical judgment is often required.
Evaluation of CRS-like symptoms is further complicated by the lengthy differential diagnosis. Whereas the differential diagnosis for acute sinusitis-like symptoms is chiefly limited to ABRS and viral URTI, the differential diagnosis for CRS-like symptoms is broad, encompassing various conditions that may present with the symptoms of CRS, such as facial pressure, sinus congestion, nasal obstruction, discharge, and hyposmia.
Two recent studies examined patients referred to rhinology clinics with headache or facial pain and a presumed diagnosis of CRS. One study found a 58% incidence of migraine6 and the other found a 99% incidence of various conditions with head pain without sinusitis.7 These findings suggest that, among patients referred to rhinology clinics with presumed CRS, undiagnosed headache may be masquerading as CRS. The frequency with which conditions other than headache mimic CRS has not been reported.
Our hypothesis was that a substantial proportion of patients referred to a tertiary care rhinology clinic for evaluation of CRS-like symptoms have conditions other than CRS. The objective of this study was to identify conditions that simulate CRS and to report the frequency of these alternate diagnoses in this population.
Medical charts for patients referred to an adult tertiary care rhinology clinic for evaluation of CRS-like symptoms were reviewed. Patients referred to the Michigan Sinus Center between April 1998 and June 2000 for evaluation of CRS-like symptoms were eligible. One hundred eighty-six consecutive patients for whom medical records were available for review were included in the study.
For each patient, a history was obtained and a physical examination was performed, including complete head and neck examination and nasal endoscopy, by the attending physician. Previous computed tomographic (CT) images were reviewed if available. If the history or findings at physical examination suggested possible CRS and a previous CT scan was unavailable or findings were inconclusive, a CT scan was obtained before a final diagnosis was made. For most patients, the final diagnosis was made at the end of the first visit, although some patients required more than 1 evaluation before a final diagnosis could be made. A medical chart review was performed.
Our definition of CRS included all types listed in the Rhinosinusitis Task Force guidelines.5 The standard for the diagnosis of CRS was the expert opinion of the rhinologist, which was based on history and findings at physical examination and CT scan review. A history consistent with the diagnosis of CRS was based on the Rhinosinusitis Task Force guidelines. However, in all cases, the diagnosis of CRS was subsequently confirmed at nasal endoscopy, sinus CT scanning, or both.3 Physical examination findings deemed consistent with but not necessarily diagnostic of CRS included purulent discharge, polyposis, edema, and inflammation in the middle meatus.6 Computed tomographic findings consistent with a diagnosis of CRS included moderate to severe sinus mucosal thickening or severe sinus polyposis, as with demineralization of ethmoid trabeculae or the accumulation of highly attenuating secretions. Findings on CT scans that had been obtained during an acute URTI were often considered equivocal, and a repeat CT scan was typically obtained after a 3- to 4-week course of therapy with broad-spectrum antibiotic agents and nasal steroid spray. The subsequent CT scan was used to confirm or to exclude the diagnosis of CRS.
Patients who had symptoms of possible CRS but lacked endoscopic or CT evidence of chronic mucosal inflammation were determined not to have CRS and an alternative diagnosis was made. Patients with incidental sinus abnormalities noted on the CT scan but without symptoms of CRS were determined not to have CRS.
Diagnoses other than CRS were made as follows. Headache was diagnosed on the basis of established diagnostic criteria.8 Allergic rhinitis was diagnosed by history, physical examination, and often supplemental allergy testing.9 Nonallergic rhinitis included diagnoses of idiopathic vasomotor rhinitis10 and rhinitis medicamentosa,10 as well as postnasal drip.11 Postnasal drip was diagnosed when no cause of the symptom (eg, CRS, allergic rhinitis, or anatomical obstruction) could be identified. Bacterial rhinitis was diagnosed in patients with chronic purulent nasal discharge but without evidence of sinus disease clinically or on CT scans. Many of these patients had sicca symptoms or dryness and crusting of the nasal cavity, and many noted improvement with saline solution rinses alone. Diagnosis of laryngitis associated with reflux was based on clinical history, usually with throat symptoms, as well as anatomical examination of the larynx or documentation of symptomatic response to medications.12 Anatomical obstruction included septal deviation or spurs, valve collapse, and other more unusual anatomical deformities. Olfactory dysfunction was diagnosed when no other cause for the olfactory disturbance was found. Similarly, cough was diagnosed when no underlying cause for the cough could be identified. Depression or somatization disorder was diagnosed on the basis of clinical findings, typically in conjunction with careful review of other medical records.
One hundred eighty-six patients were referred for evaluation of CRS-like symptoms. One hundred twelve patients (60%) were given a diagnosis of CRS, and 74 (40%) had 1 or more conditions other than CRS, or alternate diagnoses. There were 31 men (42%) and 43 women (58%), with an age range of 22 to 75 years (mean age, 43 years).
Among the 74 patients with alternate diagnoses, allergic rhinitis was the most common (n = 36 [49%]), followed by nonallergic rhinitis (n = 22 [30%]) (Table). Laryngitis associated with reflux was diagnosed in 21 patients (28%), and head or facial pain, including tension headache, migraine headache, and temporomandibular dysfunction, was diagnosed in 14 patients (19%). Multiple diagnoses were common, with an average of 1.6 diagnoses per patient. Eight patients (11%) had diagnoses of both pain and rhinitis, 8 patients had more than 1 form of rhinitis, and 3 patients had a diagnosis of more than 1 kind of pain (data not shown).
The purpose of this study was to identify conditions that simulate CRS and to describe the frequency of these alternate diagnoses in this population. Among this cohort of patients referred to a tertiary care rhinology clinic for evaluation of presumed CRS, 40% had diagnoses other than CRS. The most common diagnoses in this group were various forms of rhinitis, as well as laryngitis associated with reflux, headache, and facial pain.
These data suggest that CRS-like symptoms provide a diagnostic challenge. This point is further strengthened by 2 anecdotal observations. We have observed that most patients with alternate diagnoses had been prescribed a multitude of medications, including nasal steroid sprays, antihistamines, and often several courses of antibiotic therapy. We have also observed that many patients were referred with a diagnosis of presumed CRS despite a normal sinus CT scan. These findings support the contention that CRS-like symptoms are difficult for referring physicians to diagnose and treat.
CRS-like symptoms are difficult to evaluate for 2 reasons. First, the symptoms of CRS are nonspecific. It is difficult for patients and physicians to differentiate symptoms due to CRS from symptoms attributable to a disorder that mimics CRS. Second, there is no widely accepted “gold standard” for the diagnosis of CRS. The current diagnostic standard of continuous symptoms of 12 weeks' duration in conjunction with evidence of inflammation is imperfect. Just as the symptoms of CRS are nonspecific, so are some CT abnormalities. These 2 factors make the diagnosis of CRS difficult and debatable in many cases.
While the matter of what constitutes a diagnosis of CRS will not be settled here, we have an additional observation that greatly facilitates evaluation of the patient whose symptoms are not due to CRS, that is, patients who report CRS-like symptoms but who have normal sinus CT scans. In our experience, most such patients report 1 or more symptoms related to chronic sinus drainage or chronic sinus headache. We find that focusing the patient evaluation on the headache symptom and the mucous symptoms often elucidates the conditions that underlie the CRS-like symptoms.
The retrospective design of this study may have resulted in underestimation of the number of diagnoses in each patient. The diagnoses in the medical record captured only the most prominent symptoms or previously undiagnosed conditions that contributed to the patient's or referring physician's perception of chronic sinus problems. Previously diagnosed conditions were not necessarily itemized in the medical record unless they contributed to the diagnostic confusion or the perception of chronic sinus problems. As a result, common conditions such as cough, hyposmia, allergic rhinitis, and migraine headache may be underrepresented in our results.
Another potential weakness of this study is related to the interpretation of sinus CT scans. Previous studies have demonstrated a 27% to 42% incidence of paranasal sinus abnormalities among the general population.13- 15 The high incidence of mucosal abnormalities in patients without symptoms of sinusitis requires that sinus CT scans be correlated with the patient's history to avoid treating clinically insignificant findings. While some may argue that such findings are not incidental but represent a false-negative clinical diagnosis, we take the opposite view and consider such CT findings to be falsely positive. Most patients with asymptomatic mucosal abnormalities on sinus CT scans do not have clinically significant CRS. While we acknowledge the occasional patients with diffuse severe polyposis who have few or no symptoms, in our experience most sinus CT scans that we deem false positive reflect minimal disease, such as minimal mucosal inflammation in 1 or 2 sinuses, an isolated mucous retention cyst, or abnormalities that reflect an acute process such as viral URTI.
We conclude that among adults referred to a tertiary care rhinology clinic, rhinitis, laryngitis associated with reflux, headache, and facial pain may simulate CRS. Heightened awareness of these conditions may improve the diagnostic accuracy of CRS-like symptoms, and these alternate diagnoses should be considered in the differential diagnosis in every patient with CRS-like symptoms.
Common head and neck conditions such as rhinitis, laryngitis associated with reflux, and head or facial pain disorders may exhibit CRS-like symptoms and should be included in the differential diagnosis in patients with such symptoms. Heightened awareness of these conditions is particularly important when evaluating patients with symptoms of presumed recurrent rhinosinusitis or CRS that do not respond to medical treatment. Sinus CT scans or otolaryngology consultation can be instrumental in discerning the underlying diagnoses and refining the therapeutic plan.
Correspondence: Melissa A. Pynnonen, MD, Department of Otolaryngology, University of Michigan Health System, 1904 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0312 (email@example.com).
Submitted for Publication: September 19, 2005; final revision received March 1, 2006; accepted March 17, 2006.
Financial Disclosure: None reported.