Diagnosis and Management of Asymptomatic Sinusitis

Introduction to Asymptomatic Sinusitis

• The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines recommend that radiographic imaging is unnecessary for patients who already meet clinical diagnostic criteria for acute bacterial rhinosinusitis, emphasizing the importance of interpreting imaging findings in conjunction with clinical findings 1

Special Considerations

• Immunocompromised patients are at higher risk for invasive fungal sinusitis and may require closer monitoring 2
• Clinical correlation is necessary to avoid overdiagnosis, as radiographic abnormalities alone are insufficient for diagnosis of sinusitis requiring treatment, according to the AAO-HNS guidelines 1

General Principles

• Asymptomatic sinusitis found on CT scans should not be treated, as it represents a normal variant, with 87% of young adults recovering from a cold, 68% of symptomatic children with upper respiratory infections, and 42% of healthy children showing significant maxillary sinus abnormalities on imaging, and 3-40% of asymptomatic adults having abnormalities on sinus CT scans 3, 4
• The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the European Position Paper on Rhinosinusitis (EPOS) guidelines recommend interpreting imaging findings in conjunction with clinical findings, reducing unnecessary testing, and the American College of Radiology recommends multiplanar CT as the preferred imaging modality for patients with chronic rhinosinusitis 2, 5, 3, 4
• Treating based on imaging findings without clinical correlation may lead to unnecessary antibiotic use, and CT findings should always be interpreted in conjunction with clinical and endoscopic findings, with intravenous contrast generally not needed for routine evaluation 3, 4, 2
• Multiplanar CT offers several advantages, including excellent anatomic bony detail, bone detail and soft-tissue imaging capabilities, low-dose protocols, and coronal, axial, and sagittal plane visualization, making it valuable for preoperative planning for endoscopic surgery and objective confirmation in cases of chronic rhinosinusitis, and can identify important anatomical variations that may contribute to chronic rhinosinusitis, such as Onodi cells 4

3, 4