Waters View Sinus X-Ray Useful for Evaluating Chronic Cough in Kids

Fran Lowry

November 19, 2010

November 19, 2010 (Phoenix, Arizona) — An occipitomental sinus x-ray, also called a Waters view sinus x-ray, which looks at just the maxillary view of the sinus cavity, is an effective way to evaluate what is causing chronic cough in children.

"A Waters view sinus x-ray is quick, it's easy to get, you don't have to sedate children to do it, and it provides useful information," Nevin W. Wilson, MD, professor of pediatrics at the University of Nevada School of Medicine in Reno, told Medscape Medical News.

He presented his experience with the technique here at the American College of Allergy, Asthma & Immunology 2010 Annual Scientific Meeting.

Data evaluating the utility of a Waters view sinus x-ray in the diagnosis of chronic cough in children were sparse, Dr. Wilson said, and there were no data on the accuracy of interpretation of a film by a pediatric allergist-immunologist, as opposed to a radiologist.

He and his team evaluated 110 children 3 to 18 years of age who had chronic cough lasting for at least 3 weeks. The majority of the children had a cough that lasted 12 weeks or more and had been seen by their regular physicians. Many of the children had received a course of antibiotics.

Nearly 70% of the children had an abnormal Waters view sinus x-ray.

"Our team's finding that 68.2% of the children had a positive Waters view film was similar to the radiologist's finding, which was that 67.3% were positive," Dr. Wilson noted.

"Chronic sinusitis as a cause of chronic cough in children is something that everybody should be thinking about," Dr. Wilson said. "We changed the mind of our pulmonologist in the process of doing this study. She tended to diminish the role of sinusitis as a cause of chronic cough. She didn't think it was as common as we did."

The point of doing a Waters view sinus x-ray is to eliminate the need for a computed tomography (CT) scan as much as possible, Dr. Wilson added.

The technique is also helpful in differentiating children who do not need antibiotics from those who do.

"We took the treatment of those children who had a negative sinus x-ray in a completely different direction. We treated them for asthma, for reflux, we evaluated them for other causes, as opposed to putting everybody on antibiotics, although the truth is that most of them had already been put on antibiotics by their primary care doctor before we saw them," he said.

Despite its advantages, the technique has some limits, Dr. Wilson pointed out. "The younger the child, the harder it is to get them to sit still to do it, and that can be a limiting factor. Sometimes the sinuses are really small and hard to read, and you have to be used to reading Waters view films to get good results, so I'm certainly not advocating it as an obvious alternative to CT scan. That's clearly the preferred way, but particularly in this day, when there is a lot of concern about the amount of radiation in a CT scan, it is still better than guessing based on clinical findings."

Plus, it is relatively easy, even in a small hospital, to get a Waters view sinus x-ray, he said. "All the children have to do is hold still long enough, tilt their head back a little, and have the X-ray done."

Charles J. Siegel, MD, clinical associate professor at the University of Missouri–Kansas City School of Medicine, and moderator of the session, told Medscape Medical News that he was very impressed with the technique.

"I thought this was a very interesting study because in clinical practice, we are constantly faced with children with chronic cough. We're always in a dilemma about treating or not treating with antibiotics, and of course in today's world, you want to minimize these medications as much as possible, so we are always looking for objective criteria," he said.

In addition, children are very difficult to x-ray, Dr. Siegel said. "If you try to do a limited CT scan, it is hard to get it through managed care, and kids just don't hold still for that. Even a full sinus series is difficult to do. The child won't sit still and parents worry about radiation. I think this has the potential to bear tremendous fruit. This is something I will probably take home and implement in practice."

Dr. Wilson and Dr. Siegel have disclosed no relevant financial relationships.

American College of Allergy, Asthma & Immunology (ACAAI) 2010 Annual Scientific Meeting: Abstract 36. Presented November 15, 2010.

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