Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis

Mark H. Ebell, MD, MS; Brian McKay, MPH; Ariella Dale, PhD; Ryan Guilbault, MPH; Yokabed Ermias, MPH


Ann Fam Med. 2019;17(2):164-172. 

In This Article

Abstract and Introduction


Purpose: To evaluate the accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis (ARS).

Methods: We searched Medline to identify studies of outpatients with clinically suspected ARS and sufficient data reported to calculate the sensitivity and specificity. Of 1,649 studies initially identified, 17 met our inclusion criteria. Acute rhinosinusitis was diagnosed by any valid reference standard, whereas acute bacterial rhinosinusitis (ABRS) was diagnosed by purulence on antral puncture or positive bacterial culture. We used bivariate meta-analysis to calculate summary estimates of test accuracy.

Results: Among patients with clinically suspected ARS, the prevalence of imaging confirmed ARS is 51% and ABRS is 31%. Clinical findings that best rule in ARS are purulent secretions in the middle meatus (positive likelihood ratio [LR+] 3.2) and the overall clinical impression (LR+ 3.0). The findings that best rule out ARS are the overall clinical impression (negative likelihood ratio [LR−] 0.37), normal transillumination (LR− 0.55), the absence of preceding respiratory tract infection (LR− 0.48), any nasal discharge (LR− 0.49), and purulent nasal discharge (LR− 0.54). Based on limited data, the overall clinical impression (LR+ 3.8, LR− 0.34), cacosmia (fetid odor on the breath) (LR+ 4.3, LR− 0.86) and pain in the teeth (LR+ 2.0, LR− 0.77) are the best predictors of ABRS. While several clinical decision rules have been proposed, none have been prospectively validated.

Conclusions: Among patients with clinically suspected ARS, only about one-third have ABRS. The overall clinical impression, cacosmia, and pain in the teeth are the best predictors of ABRS. Clinical decision rules, including those incorporating C-reactive protein, and use of urine dipsticks are promising, but require prospective validation.


Acute rhinosinusitis (ARS) is defined as inflammation of the paranasal sinuses, most often the maxillary sinuses, that is caused by viruses or bacteria and has a duration of less than 6 weeks.[1] Acute rhinosinusitis is a common outpatient infection, responsible for over 3 million outpatient visits annually in the United States; the symptoms overlap considerably with that of other upper respiratory tract infections, making accurate diagnosis challenging.[2] While 75% of patients with ARS receive an antibiotic, and it is the most common reason for outpatient prescription of antibiotics,[2,3] only about one-third with sinus symptoms have a confirmed bacterial pathogen when sinus fluid is cultured.[4,5]

Helping physicians more accurately identify which patients with clinically suspected sinusitis actually have acute bacterial rhinosinusitis (ABRS) could reduce harm from inappropriate antibiotic use. A systematic review found a 5% absolute increase in the rate of cure with antibiotics for clinically diagnosed ARS, compared with an 11% increase in rate of cure with imaging-diagnosed ARS; more accurate clinical diagnosis could identify the patients most likely to benefit from antibiotics.[6] Previous systematic reviews of the clinical diagnosis of ARS are all more than 15 years old and did not use modern analytic techniques such as bivariate meta-analysis.[7–10] The goal of the current study is therefore to perform a comprehensive meta-analysis of the clinical diagnosis of ARS and ABRS.