THIS EVIDENCE REPORT IS OUTDATED AND IS NO LONGER VIEWED AS GUIDANCE FOR CURRENT MEDICAL PRACTICE. IT IS MAINTAINED FOR ARCHIVAL PURPOSES ONLY.

Evidence Report/Technology Assessment

Number 9, Supplement

Prepared for:
Agency for Healthcare Research and Quality

U.S. Department of Health and Human Services
2101 East Jefferson Street
Rockville, MD 20852

Contract No. 290-97-0019

Prepared by:

New England Medical Center, Boston, MA
Joseph Lau, M.D.
Principal Investigator
John P. Ioannidis, M.D.
Ellen R. Wald, M.D.

AHRQ Publication No. 01-E005

October 2000

The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments.

To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the nation. The reports undergo peer review prior to their release.

AHRQ expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the health care system as a whole by providing important information to help improve health care quality.

We welcome written comments on this evidence report. They may be sent to: Director, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, 6010 Executive Blvd., Suite 300, Rockville, MD 20852.

Douglas B. Kamerow, M.D.	John M. Eisenberg, M.D.
Director, Center for Practice and Technology Assessment	Director
Agency for Healthcare Research and Quality	Agency for Healthcare Research and Quality

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Health Care Policy and Research or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

Objectives. This report evaluates and analyzes the existing evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children.

Search Strategy. Human studies of sinusitis were identified using MEDLINE (from 1966 to March 1999), technical experts, and bibliographies.

Selection Criteria. A systematic review and meta-analysis considered all pertinent studies that included at least 10 children younger than 18 years of age with symptoms of uncomplicated acute bacterial rhinosinusitis of less than 30 days duration. Only diagnostic studies that compared two or more tests were used. Both randomized and nonrandomized controlled trials were included to assess treatment efficacy.

Analysis. The analysis focused on clinical improvement rates for intervention studies of antibiotics or ancillary measures and the concordance of diagnostic tests, expressed as likelihood ratios.

Main Results. Of 1,857 citations reviewed, the authors identified 21 qualifying studies, compared with 450 reports on complications of acute sinusitis and 233 nonsystematic reviews of the subject, which did not qualify for inclusion. The qualifying studies included five randomized trials and eight case series on antibiotic therapy, three randomized trials on ancillary treatments, and eight studies with information on diagnostic tests (including three of the therapeutic trials). Definitions and inclusion criteria were heterogeneous across studies. The pooled clinical improvement rate with antibiotics was 87.6 percent (177/202) in randomized trials and 92.2 percent (318/345) in nonrandomized studies (p = 0.08). The respective improvement rates without antibiotics were 60 percent and 80 percent. Improvement rates were significantly higher in nonrandomized studies (odds ratio, 1.79; 95 percent confidence interval [CI], 1.05-3.04). Data on ancillary measures were sparse and heterogeneous. In studies with both clinical and plain film radiography, the pooled rate of abnormal radiographic findings against a clinical diagnosis of sinusitis was 73.2 percent (596/814; range 55.4 percent to 96 percent among studies). There was poor concordance between clinical criteria, plain film radiography, ultrasonography, computed tomography, and fluid on aspiration in all available paired assessments; all positive likelihood ratios were < 4.0, and all negative likelihood ratios were > 0.2.

Conclusions. High-quality evidence for acute uncomplicated sinusitis in children is very limited. Diagnostic modalities show poor concordance, and treatment options are based on inadequate data. More evidence is needed for this very common condition.

This document is in the public domain and may be used and reprinted without permission.

Suggested citation: Lau J, Ioannidis JP, Wald ER. Diagnosis and treatment of uncomplicated acute sinusitis in children. Evidence report/technology assessment no. 9, supplement (contract 290-97-0019 to New England Medical Center). AHRQ publication no. 01-E005. Rockville, MD: Agency for Healthcare Research and Quality. October 2000.