BRIEF REPORT: A Red Streak in the Lateral Recess of the Oropharynx Predicts

Acute Sinusitis

Colin Thomas, MD, MPH, 1 Vitali Aizin, MD 2 ~Division of General Internal Medicine and Geriatrics, VA San Diego Healthcare, San Diego, CA, USA; 2Department of Medicine, University of California San Diego, School of Medicine, San Diego, CA, USA.

OBJECTIVE: To evaluate the oropharyngeal red streak sign for diag- nosing acute sinusitis.

DESIGN.. Exploratory cohort study.

SETTING: A Veterans Affairs medical center urgent care center.

PARTICIPANTS: Sixty consecutive subjects presenting with nasal symptoms lasting 4 weeks or less.

MEASUREMENTS AND MAIN RF~ULTS: Each subject underwent a structured history and physical examination, followed by a sinus com- puted tomography {CT) scan. Acute sinusitis was defined by an air-fluid level or opactfication of 1 or more sinuses on CT imaging. Twenty-seven subjects were diagnosed with sinusitis. A localized red streak in the lat- eral recess of the oropharynx was associated with sinusitis, with a pos- itive likelihood ratio (LR+) and 95% confidence interval (CI) of 2.11 (1.23, 3.63) and a negative likelihood ratio (LR-) and 95% CI of 0.44 (0.24, 0.83). Opacity on maxillary or frontal sinus transillumination was also associated with sinusitis (LR+ of 1.89; CI 1.03, 3.32 and LR of 0.56; CI 0.32.0.96}. Symptom duration > 10 days was associated with acute sinusitis with an LR+ of 1.89 (1,06, 3.59). A history of facial pain (LR+ of 0.59; CI 0.39. 0.90 and LR- of 2.85; CI 1.27, 6.41) and the finding of sinus percussion tenderness (LR+ of 0.22; CI 0,05, 0.90 and LR- of 1.88; CI 1.17, 3.03) were inversely associated with sinusitis.

CONCLUSIONS: The oropharyngeal red streak may be an accurate physical sign for diagnosing acute sinusitis. This sign should be includ- ed in future studies of clinical diagnostic criteria for acute sinusitis.

KEY WORDS: sinusitis; physical examination; signs; symptoms; sensitivity; specificity. DOI: 10.1111/j. 1525-1497.2006.00498.x J GEN INTERN MED 2006; 21:986-988.

T he National Center for Heal th Sta t i s t ics e s t i m a t e s t h a t

over 30 million phys i c i an visi ts occur a n n u a l l y for evalu-

a t ing acu te u p p e r respi ra tory infections, a n d a n addi t ional

28 million visi ts are m a d e for chronic s inus i t i s a n d allergic

rhinit is . ~ In clinical practice, s i nus i t i s is m o s t often d iagnosed

by h is tory a n d phys ica l examina t ion ; yet, the s y m p t o m s a n d

s igns of s inus i t i s , viral u p p e r respi ra tory infection, a n d allergic

rhini t is often overlap. Conf i rmatory radiographic t e s t s for

s inus i t i s are expensive, inconvenient , a n d u s e d pr imari ly to

evalua te the ex ten t of s i n u s d i sease in pa t i en t s who are can-

d ida tes for surg ica l intervention. 2 A few clinical f n d i n g s have

emerged from s t u d i e s of acu te s inus i t i s . However, s o me of

t hese f indings have limited utility b e c a u s e they are inconven-

ient to perform, like t r ans i l lumina t ion , or are in f requen t find-

ings with limited sensit ivity, like maxi l lary toothache . Others ,

like cough with p u r u l e n t s p u t u m , are nonspecif ic . 3'4 Identify-

ing addi t ional h is tory or phys ica l e x a m f indings t h a t can dis-

None o f the authors have any conflicts o f interest to declare. Address correspondence and requests for reprints to Dr Thomas:

VA San Diego Healthcare, 111N, San Diego, CA 92161 (e-mail: colin.

thomas@reed, va.gov).

986

t i n g u i s h be tween acu te s i n u s i t i s a n d o ther n a s a l condi t ions

would be use fu l to the pract ic ing clinician.

Highly organized mucoci l ia ry d ra inage f rom the s i n u s e s

a n d n a s a l m u c o s a r e su l t s in collection of n a s a l sec re t ions in

the lateral recess of the oropharynx . 5 M u c o p u r u l e n t d ra inage

c a n s o m e t i m e s be visual ized on e x a m i n i n g the pos ter ior

pha rynx ; however, even w h e n the secre t ions are absen t ,

o ropharyngea l red s t r e a k s are often s e e n on the m u c o s a . 6

The d iagnos t ic a c c u r a c y of th i s f inding for a c u t e s i n u s i t i s

h a s not been evaluated . B e c a u s e p r imary care providers c an

readily detect the o ropharyngea l red s t reak, it is a very prac-

tical clinical s ign to evaluate . The objective of th i s s t u d y w a s to

character ize the d iagnos t ic a c c u r a c y of the o ropha ryngea l red

s t r eak for acu te s inus i t i s .

METHODS Consecut ive s u b j e c t s were recrui ted from the VA San Diego

Heal thcare Sy s t e m {VASDHS) u r g e n t care center. The ins t i tu -

t ion 's h u m a n s u b j e c t s commi t t ee approved the s t u d y protocol.

Dur ing the r e c r u i t me n t period be tween December 15, 2000

a n d Februa ry 28, 2001, the inves t iga tors reviewed the pre-

s e n t i n g s y m p t o m s recorded by the tr iage n u r s e for pa t i en t s

wai t ing to be seen in the u r g e n t care center. Sub jec t s were

cons idered for inc lus ion if t hey were p r e s e n t i n g wi th symp-

t o m s of n a s a l d ischarge , n a s a l conges t ion or obs t ruc t ion , fa-

cial pain, or se l f - suspec ted s inus i t i s . Sub jec t s were exc luded

for s y m p t o m s p r e s e n t greater t h a n 4-weeks dura t ion , ant ibi-

otic u s e wi th in the p a s t m o n t h , p r e s e n t a t i o n for eva lua t ion of

mul t ip le medical problems, p regnancy , a n d inabil i ty to posi-

t ion their h e a d for coronal CT imaging. Sub jec t s were recrui ted

in the order they p r e s e n t e d to the u r g e n t care cen te r to a max -

i m u m of 2 to 3 per day b a s e d on availability of the CT scanner .

Data Collection A s t r u c t u r e d eva lua t ion of each s t u d y subjec t , inc lud ing 12

h is tory a n d 10 phys ica l examina t ion f indings (online appen-

dix), w a s comple ted by a t ra ined, 4 t h - y e a r medical s t u d e n t

a n d verified by a n in te rna l medic ine a t t end ing p h y s i c i an or

per formed directly by a n in te rna l medic ine a t t end ing phys i -

cian. T r a n s i l l u m i n a t i o n of the maxi l la ry a n d frontal s i n u s e s

w a s per formed in a d a r k e n e d e x a m room u s i n g a F ino f fTrans -

i l lumina tor (product # 4 1 1 0 0 Welch Allyn ~"', Chicago, IL)

following s t a n d a r d me t h o d s . 7 A second a t t e n d i n g phys i c i an

independen t ly per formed s i n u s t r a n s i l l u m i n a t i o n a n d evalu-

a ted the p re sence of a red s t r eak in the lateral r eces s of the

o r o p h a r y n x (Fig. 1). The f indings of the s econd e x a m i n e r were

Manuscript received October 18, 2005

Initial editorial decision December 21, 2005

Final acceptance March 28, 2006

]GIM Thomas and Aizin, Red S treak Predicts Acute Sinusit is 987

i

FIGURE 1. A localized red streak in the lateral recess of the oro- pharynx (white arrow).

used only to est imate interrater reliability. Smell was a s se s sed

us ing the alcohol sniff test, s a technique where an alcohol pad

is slowly raised toward the na res while the pat ient b rea thes

normally, with eyes closed, and identifies when the smell of

alcohol is detected. Coronal CT images of the s inuses were

performed for all s tudy par t ic ipants within 90 minutes after

completing the s t ruc tured history and physical examination. A

neuroradiologist , bl inded to the clinical Findings, interpreted

the CT images. Acute s inusi t is was de termined to be p resen t if

1 or more s inuses conta ined an air-fluid level or was com-

pletely opaeified. Because s inus mucosal thickening is com- monly seen on CT scan in viral upper respiratory infections, 9

this finding was not considered to be diagnostic for acute sinusit is .

Statistical Analysis

Concordance between the principal examiners for transil lumi-

nat ion and the oropharyngeal red s t reak was es t imated with

the K statistic. The accuracy of history and physical exam find-

ings compared with the reference s t andard CT scan was esti-

mated by sensitivity, specificity, and LR+ and LR - . lo We also

calculated 95% confidence intervals (CI) for these tes t charac-

teristics. Sample size was es t imated assuming a sensitivity of 0.67 and a specificity of 0.67 for the oropharyngeal red streak. This would yield a positive likelihood ratio (LR+) of 1.94 and

would require 19 subjects each with and without s inusi t is to produce a confidence interval tha t would not overlap 1. A recru i tment target of 50 to 70 subjects was set for the study.

RESULTS Patient Characteristics

Seventy-three subjects were screened for s tudy participation.

Three refused consen t because of time const ra ints and 10

withdrew before completing their CT scan. Sixty subjects

(6 women and 54 men) completed the s tudy and were includ- ed in the analysis. Subjects ranged in age from 25 to 83 years,

with a mean ± SD age of 51 :k 12.6 years. Symptoms were

p resen t for a mean ± SD of 12 ! 7.8 days and a median (interquartile range) of 7 days (6 to 21 days). Twenty-seven

subjects were diagnosed with acute sinusitis: 10 with air-fluid

levels, 8 with s inus opacity, and 9 with both.

Diagnostic Accuracy of Clinical Findings

Frequency sensitivity, specificity, and likelihood ratios for the

history and physical examinat ion findings with diagnosis of

acute s inusi t is by CT scan are shown in Table 1. A red s t reak

in the lateral recess of the oropharynx was seen in 30 pat ients and was associa ted with acute s inusi t is on CT scan with an

LR+ of 2.11 (1.23, 3.63) and a negative likelihood ratio (LR- )

of 0.44 (0.24, 0.83). Opacity of a frontal or maxillary s inus on

t ransi l luminat ion was also associated with acute s inusi t is with an LR+ of 1.89 {1.03, 3.32) and an L R - of 0,56 (0.32,

0.86). The presence of facial pain or percuss ion t ende rnes s

was inversely associa ted with acute s inusi t is with an LR+

of 0.59 (0.39, 0.90), an L R - of 1.88 (1.17, 3.03), and an

LR+ of 0.42 (0.21, 0.86), L R - of 1.88 (1.17, 3.03), respective- ly. Symptom durat ion > 10 days was associa ted with acute

s inusi t is with an LR+ of 1.89 (1.06, 3.59). In ter- ra ter agree-

Table I . Frequency, Sensitivity, Specificity, and Likelihood Ratios for Clinical Findings in Acute Sinusitis

Frequency Sensitivity Specificity LR+ (95% CI) LR - (95% Cl)

History Duration of symptoms (> 10 d) Pain in face Purulent nasal secretions Cough exacerbated when supine Sneezing Post nasal drip Cough with purulent sputum Impaired smell Nasal obstruction Fever

Physical examination Oropharyngeal red streak Sinus tenderness Transillumination Abnormal alcohol sniff test Purulent nasal secretions Otitis media

25 0.71 0.62 1.89 (1.06,3.39) 0.46 (0.14,1.51) 40 0,48 0.18 0.59 (0.39,0.90) 2.85 (1.27,6.41} 33 0.67 0.55 1.47 (0.93,2.32) 0.61 (0.33,1.13) 52 0.81 0.09 0.90 (0.73,1.11) 2.04 (0.53,7.76) 30 0.44 0.45 0.81 (0.48,1.38) 1.22 (0.74,2.02) 47 0.74 0.18 0.91 {0.69,1.19} 1.43 (0.54,3.74) 22 0.33 0.61 0.85 (0.43,1.67) 1,1O (0.75.1.6 I) 32 0.52 0.45 0.95 (0.59.1.53) 1.06 (0.62,1.82) 45 0.74 0.24 0,98 (0.73,1.31) 1.07 (0.44,2.57) 31 0.52 0.48 1.01 (0.62,1.69] 0.99 (0.59,1.68}

30 0.70 0.67 2.11 (1.23,3.63) 0.44 (0.24.0.83) 27 0.26 0.39 0.43 (0.21,0.86] 1.88 (1.17,3.03) 28 0.63 0.67 1.89 (1.08,3.32) 0.56 (0.32,0.96) 30 0.59 0.58 1.40 (0.84,2.32) 0.71 (0.41,1.22) 12 0.22 0.82 1.22 (0.44,3.36) 0.95 (0.73,1.23) 2 0.04 0.97 1.22 (0.08,18.64) 0.99 (0.90.1.09l

LR+, positive likelihood ratio; LR- , negative likelihood ratio; CI, confidence interval.

988 Thomas and Aizin, Red Streak Predicts Acute Sinusitis JGIM

m e n t for the red s t r eak a n d s i n u s t r ans i l l umina t ion w a s found

to be grea ter t h a n expected by chance , with ~ scores of 0.7 a n d

0.8, respectively.

DISCUSSION

In th i s exploratory cohort s tudy , the oropharyngea l red s t r eak

w a s assoc ia ted wi th a c u t e s i n u s i t i s detected by CT scan . Th i s

phys ica l f inding h a s not b e e n s tud ied previously. The red

s t r e a k is s imple to evaluate , requi res no special equ ipmen t ,

a n d w a s reproducible be tween i n d e p e n d e n t examine r s . T r a n s -

i l lumina t ion of the s i n u s e s w a s assoc ia ted with acu te s inus i -

tis, conf i rming prev ious s tud ies . 3'4 In c o n t r a s t to a prior

s tudy , 4 a h i s to ry of facial pa in a n d s i n u s p e r c u s s i o n t ender -

n e s s were a s soc ia t ed with the a b s e n c e of acu te s inus i t i s .

Methodological differences be tween the s t u d i e s m a y a c c o u n t

for the differences observed. In the prior s tudy , the a u t h o r s

u s e d pla in r ad iography a s the cri terion s t a n d a r d a n d accepted

the less specific f inding of m u c o s a l th icken ing as a d iagnost ic

of acu te s inus i t i s . Additionally, they eva lua ted 4 different his-

torical f indings related to cranio-facial pain, inc lud ing maxil-

lary toothache, h e a d a c h e facial pain, a n d painful chewing. We

found it difficult for pa t i en t s to reliably d i s t i ngu i sh be tween

t h e s e different types of facial pain, so we elected to evalua te a

single f inding of facial pain.

S i n u s CT s c a n was selected as the reference s t a n d a r d for

th is s t u d y b e c a u s e it was available, noninvasive, a n d accepta-

ble to pa t ien ts p resen t ing with relatively mild n a s a l complaints .

Al though some author i t ies 3 s ta te tha t s i n u s p u n c t u r e a n d

aspi ra t ion is the "most accurate" reference s t andard , the tech-

n ique is variably defined in the literature, s a m p l e s only the

maxil lary s inus , a n d is no t well accepted by pat ients . The

pat ient popula t ion was typical of a Veterans Affairs medical

center, being s o m e w h a t older a n d predominant ly male, l imiting

the generalizabili ty of t hese f indings. The s t u d y w a s powered to

eva lua te a single e x a m finding with super ior pe r fo rmance

charac ter i s t ics ; therefore, n o n a s s o c i a t i o n s m u s t be in terpre t -

ed wi th caut ion.

The clinical d iagnos is of acu te bacter ia l s i n u s i t i s cont in-

u e s to be a challenge. Addit ional s t u d i e s are needed to define

the opt imal clinical d iagnost ic cri teria or a predic t ion rule. The

f ind ings from th i s s t u d y s u g g e s t t h a t the o ropha ryngea l red

s t r eak s h o u l d be inc luded in fu tu re s t u d i e s eva lua t ing clinical

d iagnost ic criteria for acu te s inus i t i s .

This study is the result of work supported with resources and the use of facilities at the VA San Diego Healthcare System.

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