EVALUATION OF THE PATIENT WITH SORE THROAT, EARACHE, AND SINUSITIS: AN EVIDENCE BASED APPROACH

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EVIDENCE BASED EMERGENCY MEDICINE: EVALUATION AND DIAGNOSTIC TESTING

0733-8627/99 $8.00

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EVALUATION OF THE PATIENT WITH SORE THROAT, EARACHE, AND SINUSITIS: AN EVIDENCE BASED APPROACH Mary H. Stewart, MD, Jonathan E. Siff, MD, and Rita K. Cydulka, MD

SCOPE OF THE PROBLEM

Sore throat ranks as one of the top ten presenting complaints to emergency departments (ED) in the United States.", lZ5 Although lifethreatening entities, such as epiglottitis, parapharyngeal abscess, peritonsillar abscess, and retropharyngeal abscess, all may present as sore throat and must be considered in the differential diagnosis of sore throat, these life threats are rare and the commonest cause of sort throat is acute 133 pharyngiti~.'~~, Acute pharyngitis is an inflammation of the oropharynx usually secondary to infectious agents, of which there is a wide range of infectious agents.38Most of these organisms produce a self-limited infection with no significant sequelae; however, oropharyngeal infection with Streptococcus pyogenes or Group A beta hemolytic Streptococcus (GABHS) may have significant sequelae if untreated and therefore should be considered in every patient presenting with acute pharyngiti~.'~ Approximately 5% to 15% of adult cases of acute pharyngitis and up to 50% of all pediatric cases of acute pharyngitis may be caused by GABHS.53 From the Case Western Reserve University School of Medicine, Department of Emergency Medicine; Metro Health Medical Center, Cleveland, Ohio (MHS, JES, RKC); and the Emergency Department, Allen Memorial Hospital, Oberlin, Ohio (MHS)

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA

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VOLUME 17 NLJMBER 1 FEBRUARY 1999

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The identification and treatment of GABHS pharyngitis is important for several reasons. First, treatment promotes the resolution of symptoms, resulting in fewer lost days of school or work.s0,88, 98, Io2 Second, early treatment shortens the duration of infectivity, reducing the spread of this highly contagious ba~terium.”~ Third, treatment within 9 days of infection prevents the development of acute rheumatic fever (ARF).28 Finally, treatment decreases the incidence of suppurative complications of GABHS infection, such as peritonsillar abscess and retropharyngeal abs~ess.~, EVALUATION OF EXISTING LITERATURE Literature Search Methods

Studies and articles for review were initially compiled by searching the MEDLINE database from January 1966 through July 1997. Only English language publications were searched. Search terms included pharyngitis, strep, sore throat, streptococcal pharyngitis, group A streptococcus, and Streptococcus pyogenes. The reference sections of each article were subsequently reviewed and additional articles identified. In addition, several textbook chapters were evaluated. Inclusion and Exclusion Criteria

Diagnostic tests evaluated were those that could be used reliably in the ED setting for the identification of group A streptococcal pharyngitis. Studies evaluating rapid streptococcal identification methods, as well as clinical diagnosis and culture methods, were considered for inclusion. Summary of Search Results

Search methods resulted in 124 articles for review. Studies that evaluated clinical, culture, and rapid diagnostic tests for GABHS were included, with a particular focus on ED and outpatient settings. Thirtytwo articles were excluded because of inadequate presentation of data, invalid statistical evaluation, and lack of applicability to the topics of interest. A total of 92 articles were evaluated by two reviewers (JES and RKC). Studies were evaluated for use of culture and ”rapid strep” methods, presence or absence of blinding, study population location and prevalence of GABHS by the chosen ”gold standard” for that study. Statistical results, including sensitivity, specificity, positive predictive value, and negative predictive value for each study, were evaluated or calculated when possible from presented data. The methodologic quality of each article meeting inclusion criteria was evaluated. Most of the articles (85) retained were well-designed, nonrandomized, clinical stud-

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ies (level 11). The remaining seven articles evaluated were descriptive studies, cases series or reports, or expert committee recommendations (level 111). EVALUATION AND PRESENTATION OF DIAGNOSTIC TESTING EVIDENCE Historical Information

Before the 1950s, acute pharyngitis was often diagnosed, sometimes treated, and often ignored. It was not until the link between acute rheumatic fever and GABHS infection was made that interest in the accurate and timely diagnosis of GABHS pharyngitis began to Diagnosis initially was made clinically. After the link with ARF was made, culture use became widespread. Serum titers have been used to track certain at-risk patients, but because of the 4- to 6-week course involved they have no place in the immediate diagnosis and treatment of acute pharyngitis." In the early 1980s the first rapid tests appeared, allowing same-day diagnosis. Currently, most practitioners use some combination of rapid testing and culture to diagnose GABHS. HISTORY AND PHYSICAL EXAMINATION

Patients with GABHS may present with a wide variety of complaints and clinical findings. The typical patient is a young child, 5 to 11 years of age, who presents with the relatively acute onset of fever and sore throat. A history of streptococcal exposure within the last week may be obtained. A variety of symptoms may accompany the fever and sore throat, including headache, nausea and vomiting, malaise, dysphagia, and abdominal pain.116The associated abdominal pain may be significant and suggest a surgical cause for the patient's pain and fever. Cough and rhinorrhea are usually absent in GABHS-infected patients. The physical examination may demonstrate edema and erythema of the tonsils and other pharyngeal structures. A nonadherent pharyngeal exudate may also be present. Other intraoral findings may include palatal petechiae, red swollen uvula, and raised hemorrhagic areas with yellow exudative centers ("doughnut" lesions). Extraoral findings can include anterior cervical lymphadenopathy, fever, and a scarlatiniform rash that initially has a sandpaper-like feel and often progresses to exfoliation.", lo3,116 In an effort to diagnose GABHS more accurately on clinical grounds, several scoring systems have been developed. An early system by Breese14 looked at six signs and symptoms (fever > 100.4"F, sore throat, cough, headache, abnormal pharynx, and abnormal cervical glands), as well as patient age, white blood cell count, and season to predict the presence of GABHS. Centor developed a system looking at the presence or absence of four clinical variables: 1) history of fever, 2)

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anterior cervical adenopathy, 3) tonsillar exudate and 4) absence of cough.22These and other clinically based prediction systems have generated negative predictive values (NPV) of 38% to 88% and positive 42, lo3, predictive values (PPV) of 39% to 59%.34, CULTURE

Microbiologic culture continues to be the standard for diagnosis of GABHS in most laboratories and clinical practices.”, 16, 34 Originally, cultures were performed on 5% sheep blood agar plates (SBA) and incubated aerobically. These techniques continue to be widely used, especially in office practice^.'^, 133 After incubation, the presence of GABHS is confirmed using the Bacitracin disk test or with antigen detection tests in the laboratory. Cultures are then semiquantitatively evaluated for colony counts with 1+ representing fewer than 10 colonies and 4 + representing colonies numbering from 50 to 100 or too numerous to count. Cultures are considered positive if any growth of GABHS is identified. Methods such as anaerobic incubation, the use of streptococcal selective media that inhibit the growth of normal oral flora, and broth-enhanced culture have all been used to enhance 129 A number of studies have compared these methculture results.106, ods.’, 35, 94, Io6, ’15, 129 In general, anaerobic incubation was found to en94, lo6, Anaerobic technique is more timehance culture consuming and expensive, however, raising the question of whether the increased return is worth the additional time and expense, especially in office laboratories.”, 44, Io6 Analysis of selective media studies yield both positive and negative results. Mirrett and Welch each revealed increased yields of GABHS using selective media techniques, whereas Roddey, Dykstra, and Anhalt did not.’, 35, lo7 Broth-enhanced culture, although used as the gold standard in many studies, has not been shown to be advantageous over other culture techniques.’ “Rapid Strep” Tests

The inaccuracy of clinical diagnosis and the 24- to 48-hour delay associated with culture prompted the development of rapid tests for Streptococcus pyogenes. This allowed the identification of patients requiring treatment before leaving the office or ED. The first group of tests were based on antigens with fluorescent tags. These tests took up to several hours and required experienced microbiology personnel and specialized equipment. These techniques are still widely used in laboratories for the differentiation of GABHS from other beta-hemolytic streptococci but are not practical for the outpatient setting.“,44 The first generation of tests suitable for the outpatient setting are based on latex agglutination methods. The method begins with isolation of streptococcal cell wall antigen by either acid or enzyme extraction.

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The extracted antigen is then mixed on a slide that holds latex particles. These latex particles are impregnated with GABHS antibody. The combined antigen and latex particles are then mixed for 10 to 60 minutes. The slide is then read for the presence or absence of agglutination. Agglutination will occur when GABHS antigen in present in the extracted sample and attaches to the antibody-impregnated latex particles. This method requires several steps to perform and involves a great deal of subjective interpretation of the presence and significance of agglutination. The results of a number of studies on several commercially available latex agglutination tests are summarized in Table 1. Most of the reviewed studies were in the outpatient or ED setting and involved a mixture of pediatric and adult patients. The studies reviewed showed a median sensitivity of 80.1% and median specificity of 96.5%. The second generation of quick streptococcal tests designed for office use are based on enzyme-linked immunosorbent assays (ELISA). These tests also extract streptococcal wall antigen by means of acid or enzyme extraction. The antigen extracted is then placed on a medium impregnated with Group A streptococcal antibody. Group A streptococcal anti-immunoglobulins (anti-GAS) are then added. If GABHS antigen is present in the extract, it will bind to the media. The anti-GAS will then attach to the antigen-antibody complex. The entire complex is then rendered visible by the addition of the chromagen that reacts with the complex to change the color.6,30, 135 These tests also involve multiple steps; however, they have less subjectivity involved in the interpretation and may be more appropriate for office laboratories. The results of studies involving several ELISA-based products are summarized in Table 2. These studies, performed in a variety of clinical settings and on a mixture of adult and pediatric patients, yield a median sensitivity of 78% and median specificity of 97%. Optical immunoassay (OIA) is a newer technique for rapid streptococcal detection. OIA is based on the fact that when antigen binds an antibody attached to a reflecting surface, the reflection of light is changed and this binding can be viewed directly as a color change.48The results of studies evaluating the OIA method are shown in Table 3. The OIA studies overall performed better than did agglutination or ELISA methods, yielding a median sensitivity of 91.4% and median specificity of 95.4%. Several other methods of rapid streptococcal identification are currently available. These include liposome immunoassay, nucleic acid probes, two-color latex suspensions, and immunochromatographic techniques. The available studies evaluating these products is summarized in Table 4. These various techniques give a wide range of performance characteristics, with sensitivities ranging from 65.4 to 96.9%. THE CARRIER STATE

Many patients who have negative rapid streptococcal tests but positive backup cultures (false-negatives) have only 1 culture growth.44,133 Text continued on page 164

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No.

Population Location Standard

Culturette 10-Minute Group A Strep ID system (Marion Scientific) Miceika et al, 1985 813 U ED/OPT SBA Campos and Charilaou, 1985 415 P OPT SSA Reichwein et al, 1986 404 M TSA Hoffman and Henrichsen, 1987 468 M OPT HBA Fujikawa and Ohkuni, 1986 210 P OPT SBA Yamada et al, 1986 96 A OPT TSA Gerber et al, 1984 339 P OPT TSA Gerber et al, 1986 313 M Office TSA Mackenzie, Li, Chan, 1988 P ED SBA Test by: lab staff 308 Test by: ED MD 60 Test by: ED RN 116 Test by: resident 92 Marsh et al, 1986 420 P SBA Wiedermann et al, 1991 2401 P Office SBA DuBois et al, 1986 93 M ED SBA Roddey et al, 1986 512 P Office Gas Pack

Study

Culturette 10-Minute Group A Streptococcus ID system (Marion Scientific)

Table 1. LATEX AGGLUTINATION-BASED RAPID STREPTOCOCCAL TESTS

U N U Y

Blind

99 76 93 92 95.5

80 72 69 58 75 90 76 72 13.2 30 31 43 25.5 34 23 39

94 98

92.8 99.6 91.6 98 96 100 99 96

SP

92.4 62 83.7 73 93.4 80.6 83 88

SN

11.3 36.1 19.1 42 29 32.3 31.8 82

Prevalence

95

85

97 86 87 74

93

97 99 89 57 81 85

99 82.2 95.6 84 90.5

NPV

62 98.9 72 96 97.3

PPV

Statistics

96.7 80 96

43.7 28 24.6

U U Y 79.47 80.10 10.80 58 to 96.7

64.4

25.1

Y

83 80.2

28 19.1

U Y

95.36 96.50 5.37 76 to 100

98.7

97.9 90

96.5

99 100

88.65 96.00 13.40 57 to 100

96

97.7

86.1

98 100

90.43 91.75 7.02 74 to 99

98.7

97.4

89

94 94.5

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric subjects. Location: ED = emergency department; OFT = outpatient clinic; Office = private office; Hosp = hospital service. Standard - the 'gold standard' used to compare with the rapid test SBA = sheep blood agar; SSA = staphylococcal selective agar; THB = Todd-Hewitt broth-enhanced culture; TSA = trypticase soy agar; HBA = horse blood agar; Gas Pack = Gas Pack anaerobic kit. Blind = were culture readers blinded to the results of the rapid test: yes, no, or unclear. SN = sensitivity; SP = specificity; PPV = positive predictive value; NPV = negative predictive value.

MEAN MEDIAN STD. DEV. RANGE

Group A Strep Direct Antigen Identification Test (Difco Labs) Venezia et al, 1985 P ED/OPT TSA Reichwein et al, 1986 404 M TSA Detect-A-Strep (Antibodies, Inc.) Campos and Charilaou, 1985 P OPT SSA PathoDx Strep A Kit (Diagnostic Products Corporation) Granato et al, 1986 414 P Office TSA DuBois et al, 1986 54 M ED SBA Strep A Direct Swab Test (Pharmacia Diagnostic) Araj and Majeed, 1986 207 M OPT TSA

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.

No. Population

Location

Event Test StriD StreD A [Boehrinaer Mannheim) Savoia et al, 1944 510 P Direct Strep A EIA (Hoffmann-La Roche) Egger et al, 1990 293 P HOSP Hoffmann, 1990 413 M Office CARD Strep A Test (Pacific Biotech) Manasse, 1989 539 U ED TestPack Strep A Assay (Abbott) Heiter and Bourbeau, 1995 597 M ED/OPT 970 M Anhalt et al, 1992 ED/OP/OF 808 M Heiter and Bourbeau, 1993 ED/OPT Laubscher et al, 1995 454 P OPT Schwabe et al, 1987 365 U OPT Carey et al, 1991 154 M OPT 286 P Egger et al, 1990 Hosp ED/OPT Bourbeau et al, 1993 1017 M 640 M Hoffmann, 1990 Office Hosp/OPT Yu et al, 1988 648 U Kellogg et al, 1987 1616 M U Roe et al, 1995 500 P OPT/ED Kellogg et al, 1987 358 P OPT Dobkin and Shulman, 1987 221 P HOSP

Study

35 22 26.6 25.9 27.4 22 17.8 23.2 27 19.8 18.3 30.2 31.3 31

Y Y Y Y U U U U Y U Y Y Y Y

THB SBA/SSA/THB THB SBA SBA SBA SBA THB HBA THB SBA THB SBA SBA

79.4 68 76.3 89.9 90 79.4 60.8 69 79 77 73.3 82 74.8 95.6

100 99 99.7 95.8 97.4 93.3 98.3 99 98 98 94.8 96 95.6 96.7

98.7

76.1

26.3

U

TSA

93.2 63

64.4 79

20.1 27

U Y

SBA HBA

92.4

SP

86.3

SN

92.1 96.4 96.3 77.1 92

98.8 88.3 92.8 94.1 88.6

94.1 93 89.9 98

90

100

75.9 90 87.9 92.9

92

91.2

97.8

NPV

95.6

70.3

63.6

PPV

Statistics

14.3

Prevalence

U

Blind

HBA

Standard

Table 2. ENZYME-LINKED IMMUNOSORBENT ASSAY-BASED RAPID STREP TESTS

SBA/TSA SBA

Hosp

Office

Office HBA U TSA OPT SBA (Hygeia Sciences, Inc.) Office SBA 19.7 37

N

27

Y U

27 17.5 24

Y U U

78.79 78.00 8.88 60.8 to 95.6

73.8

87.8

88

73 92.1 76

86.1

67.9

94.2 98

85.9

96.8

98.3 93

87.35 94.99 92.58 90.00 93.00 97.05 11.18 5.24 7.37 63 to 100 3.6 to 100 7.1 to 98.3

93.1

89.9

92

98 98.9 99

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric subjects. Location: ED = emergency department; OPT = outpatient clinic; office = private office; Hosp = hospital service. Standard - the 'gold standard' used to compare with the rapid test: SBA = sheep blood agar; SA = staphylococcal selective agar; THB = Todd-Hewitt broth-enhanced culture; TSA = trypticase soy agar; HBA = horse blood agar. Blind = were culture readers blinded to the results of the rapid test: yes, no, or unclear. SN = sensitivity; SP = specificity; PPV = positive predictive value; NPV = negative predictive value.

MEAN MEDIAN STD. DEV. RANGE

Tandem ICON Strep A (Hybritech) Hoffmann, 1990 511 M Pate1 et al, 1987 1016 M Stillstrom et al, 1991 246 M First Response Strep Throat Screening Test Buchta, 1989 249 P Visuwell Strep A EIA Drulak et al, 1991 417 M SUDS Group A Strep (MUREX) Yuckienuz et al, 1988 341 P

N

m

CI

No.

Office ED/OPT ED/OPT Hosp Hosp OPT OPT Office OPT OPT/ED OPT Office

Location

SBA THB

THB THB THB THB THB THB TSA THB THB THB SBA

Standard

Y

Y Y

U

Y

U U U U

Y Y Y

Blind

47.6 30.7 35 24 11.6 12 23.8 34.3 17.9 30.2 24 41

Prevalence

92.57 95.40 9.51 62 to 98.8

89.07 91.40 7.35 77 to 98.9

=

95.6 94.1

93 94.8 95.4 95.6 98.4 62 94 98.8 95.7 89 97

SP

91.4 90.4

84 91.5 92.3 97.4 98.9 77 96 94.8 84.2 83 77

SN

95.24 95.00 1.90 93 to 99

94.6 94.1

96.5 93 93

95 99

96.2 95.8

NPV

Todd-Hewitt broth-enhanced

79.17 87.00 22.09 22 to 91.5

93 90.4

81 77 87

22 82

88.6 91.5

PPV

Statistics

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric subjects. Locution: ED = emergency department; OPT = outpatient clinic; OFFICE = private office; HOSP = hospital service Stundurd - the "gold standard used to compare with the rapid test: SBA = sheep blood agar; SSA = staphylococcal selective agar; THB culture; TSA = trypticase soy agar; HBA = horse blood agar. Blind = were culture readers blinded to the results of the rapid test: yes, no or unclear. SN = sensitivity; SP = specificity; PPV = positive predictive value; NPV = negative predictive value.

MEAN MEDIAN STD. DEV. RANGE

P M M M M M P P P P M P

Population

Strep A Optical lrnmunoassay (Biostar) Gerber et al, 1997 2113 Heiter and Bourbeau, 1995 801 597 Harbeck et al, 1993 475 800 Hart et al, 1997 263 Harris et al, 1995 519 Fries 1955 505 Daly et al, 1994 424 Roe et al, 1995 500 Schlager et al, 1996 262 Roddey et al, 1995 301

Study

Table 3. REVIEW OF OPTICAL IMMUNOASSAY STUDIES

W

Q\

c1

Y Y

THB THB

ED/OPT ED/OPT

=

27

Y

HBA

Office

26.6 23.9

36.2

N

SBA or SSA

Office

93.5 92.4

82

99 99.8

88

60.7 92

96.9 93.8 97.5 99 84 77.8

60.5

PPV

97.8 97.7

87

93.4 96.7 89.3 93 96 99.4 99.2 88.7 97

87.3

NPV

Todd-Hewitt broth-enhanced

99.7 99.6

83

97.4

83

91 59

U

TSA

Office

96.9

85.4 98

67.3 88

25.1 20

99.4 99.7 99.1 99 97 96.3

84.7

SP

Y

Y

72.1 60 75 84 81 95.5

65.4

SN

TSA HBA SBA OR SSA SBA OR SSA SSA OR TSA SBA

20 7.8 32.1 32.3 18 12

26.3

Prevalence

Statistics

OPT ED/OPT Office Office OPT Hosp

U Y U U

U

Y

Blind

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric subjects. Location: ED = emergency department; OPT = outpatient clinic; Office = private office; Hosp = hospital service. Standard - the 'gold standard' used to compare with the rapid test: SBA = sheep blood agar; SSA = staphylococcal selective agar; THB culture; TSA = trypticase soy agar; HBA = horse blood agar. Blind = were culture readers blinded to the results of the rapid test: yes, no, or unclear. SN = sensitivity; SP = specificity; PPV = positive predictive value; NPV = negative predictive value.

324 320 Gerber et al, 1984 263 P Jonckheer et al, 1986 1907 P Joslyn et al, 1995 182 M 614 M Reed et al, 1990 806 M Berkowitz et al, 1985 1044 M Q Test Strep (Becton Dickinson) Gerber et al, 1990 228 P lmmunochromatography Concise Strep A (Hybritech) Erlich et al, 1993 351 P Two-Color Latex Suspension Reveal Colour Strep A (Wellcome) Hoffmann, 1990 407 M Nucleic Acid Probe Gen-Probe Group A Streptococcus Direct Test Heiter and Bourb'eau, 1993 808 M 1103 M

644

TSA/SSA TSA

Liposome lmmunoassay Directigen 1-2-3 Group A Strep Test (BBL Microbiology Systems) Huck et al, 1989 924 M Office Moyer et al, 1990 M OPT

Population

Standard

No.

Location

Study

Table 4. ALTERNATIVE RAPID STREPTOCOCCAL TEST METHODS SUMMARIZED

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The presence of a carrier state is often put forth as the explanation for these results.", 45 Many authors exclude patients with only 1 culture growth and thus demonstrate markedly improved sensitivities and negative predictive values.8,30, 33, 45, 47, 89, 91, 99, 135 Gerber has shown however, that up to 45% of patients with false-negative rapid streptococcus tests have significant streptococcal antibody response, suggesting true infection and risk for streptococcal complication^.^^

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RECOMMENDATIONS FOR DIAGNOSTIC TESTING

Several studies have been performed to evaluate different strategies for the evaluation and treatment of suspected GABHS in the outpatient or ED settingz1,59,83 When the high pretest probability of GABHS is taken into account, all of these studies concluded that patients with positive rapid test results should be treated without confirmatory culture. The rapid streptococcal tests have specificities commonly in the 95% to 100% range. Specificity is defined here as the percentage of people without a disease who have a negative test result. Therefore, if the rapid test is positive it is likely that the patient has GABHS and can be treated on that basis alone. All of these studies recommend confirmatory culture in patients with negative rapid streptococcal tests owing to the poor sensitivity of rapid streptococcal tests. Sensitivity is defined here as the percentage of people with a disease (GABHS) who have a positive test result (positive rapid strep screen). As discussed above, the sensitivities of the available tests varies widely, with many tests having sensitivities of 80% to 90%. This means that 10% to 20% of patients with GABHS will have a negative rapid streptococcal test result and be incorrectly diagnosed without the use of confirmatory culture. The American Heart Association recommends treatment of patients with rapid streptococcal test results and confirmatory culture, with 48 hours of incubation, in patients with negative rapid tests.25The Infectious Diseases Society practice guideline for Group A streptococcal pharyngitis also suggests treatment of patients with positive rapid test results and confirmatory culture for those patients with negative rapid studies." PRACTICAL CONSIDERATIONS AND FUTURE RESEARCH CONSIDERATIONS

Several studies have been performed to evaluate the cost-benefit ratios for various treatment strategies for GABHS. Centor et a1 considered treatment strategies based on the presence of clinical variables. If three of the four Centor variables (given earlier) were present in an adult or a Breese score of greater than 28 was found in a child, this was considered a high pretest probability for GABHS, and Centor et a1 recommended treatment without further testing. In patients without high pretest probability, rapid testing or pharyngeal Gram's stain was

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suggested. Patients with positive Gram’s stain or positive rapid tests were treated and the remaining patients had cultures performed.21 Hedges and Lowe evaluated four treatment options: 1)treat all patients, 2) treat only patients with positive cultures, 3) treat patients with a positive screening test result, and 4) treat all patients with positive screening tests, and culture the remaining patients. The researchers took into account the costs of rheumatic fever because poor follow-up care. They found that patients with high probability clinical criteria or a positive rapid test should be treated, and all other patients cultured and treatment withheld pending culture results.59Lieu et a1 used decision analysis to determine the appropriate use of culture and rapid testing in patients with a sore throat. They concluded that all patients with a sore throat should have a rapid test, independent of the clinical picture. Patients with positive rapid test results were treated and the remainder cultured, with treatment held pending culture results.83 The wide availability of rapid streptococcal detection tests and public awareness of their existence often leads to patients’ expectations of testing and antibiotics for every sore throat, regardless of the clinical suspicion or presentation. This may lead to the additional expense of extra testing and unnecessary use of antibiotics in patients without the aforementioned indications. The resurgence of rheumatic fever over the last decade increases the medicolegal risk of a missed GABHS diagnosis and treatment.24,M, lz3 This additional medicolegal risk and continued patient expectations, even in this day of increasing public awareness of antibiotic resistance, will continue to make the widespread use of rapid streptococcal testing and treatment commonplace. Considerations for future research include advancing current methods to provide a testing method with sensitivity and specificity equal to or better than culture. Also, further study and consideration of home streptococcal testing (for which a kit already exists) should be undertaken to determine if home diagnosis and treatment of patients without the additional expense of an office visit is truly cost effective and safe for the patient.17 CONCLUSION

In summary, acute pharyngitis is a common problem treated by the emergency physician. Current diagnostic strategies recommended by the American Heart Association and the Infectious Diseases Society are for rapid streptococcal testing, with all negative test results backed up by culture. These authors recommend the following strategy for emergency physicians based on this review of the literature: Patients with appropriate epidemiologic, historic, and physical examination characteristics should have rapid screens performed. Those patients with a positive test result may be treated for GABHS without confirmatory culture. Patients with negative rapid tests should receive confirmatory culture. Antibiotics may be started or withheld in these patients while waiting for the results of the culture. In the ED population, however, follow-up of culture is

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often sporadic and contacting patients difficult, so that each practitioner must base his or her treatment decision on a case-by-case basis.

EARACHE

Ear pain is a common presenting symptom in both primary care and ED settings. It is seen in both adult and in pediatric populations, although certainly it is more prevalent in children. The differential diagnosis of ear pain must be considered and includes external otitis, acute otitis media (AOM), mastoiditis, tympanic membrane (TM) perforation, foreign body, and referred pain. In the pediatric population, otitis media (OM) is the most commonly diagnosed condition, second only to upper respiratory i n f e ~ t i o n It . ~is ~ estimated that over 25 million visits for AOM resulted in more than $3 billion expenditure for antibiotics and surgical treatment in 1990.97 Although OM can be a benign condition, it may be complicated by hearing loss, perforation of the TM, mastoiditis, and cholesteatoma. Meningitis, brain abscess, venous sinus thrombosis, subdural empyema, or facial nerve injury represent severe complications of OM. This potential for complication in a prevalent condition makes an early and accurate diagnosis of otitis media necessary.

Description of the Process

A MEDLINE search for articles published between January 1975 and January 1998 was performed using the keywords ear pain, otitis media, diagnosis, tympanometry, and otoscopy. Terms were exploded as necessary and text word searches also performed. A title search produced 703 references. Titles were reviewed for clinical studies, reviews, or articles concerning diagnosis. From this list, abstracts were reviewed and case reports and letters were excluded. The remaining articles were reviewed in their entirety. Manual review of reference lists and textbooks led to an additional group of articles, from which data tables were generated. The articles were reviewed against the literature classification in the definitions in the box. There were no level I articles, eight level I1 articles, and 29 level 111 articles. There were no randomized controlled studies in this group. The presence of fluid on myringotomy is clearly the key to the determination of middle ear effusion; however, this is not easily performed in the outpatient or ED setting and is rarely performed for diagnostic purposes. The studies reviewed using this finding as a gold standard, or a cohort of preoperative patients, produces a skewed population. The remaining studies in this group were primarily prospective screening studies using various gold standards.

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Quality of Evidence Level I

Evidence from well-designed randomized controlled trials or evidence obtained from well-designed meta-analysis of randomized controlled trials Level II Evidence obtained from well-designed clinical studies, such as controlled trials without randomization, case control studies, cohort studies, time series, or uncontrolled prospective studies Level Ill Evidence obtained from descriptive studies, case series or case reports, studies using nonrandomized, historical controls, or reports of expert opinion or expert committees

Diagnostic Testing Evidence

Historically, the diagnosis of OM has been based on physical examination of the TM, which reflects pathology of the middle ear, signs easily indicating otitis media include bulging, diffusely red, opaque, or nonmobile TM. These findings are present in fewer than 50% of cases, however.78 Laboratory Tests

No laboratory tests are specific for the diagnosis of AOM.78In patients with otorrhea, aspiration of the fluid through the membrane perforation-not the external canal-can provide useful culture and sensitivity information. Nasopharyngeal cultures, conversely, do not accurately predict the bacteriology of middle ear effusionE6There may be some benefit to obtaining cultures in children with purulent pharyngitis to evaluate for streptococcal infection.78 Pneumatic Otoscopy

Acute OM is rarely found when the air drum color is normal or when mobility is completely normal on pneumatic o t o ~ c o p yAlthough .~~ decreased mobility of the TM defines AOM, other aspects of the TM must also be considered.12Outward bulging of the top contour and loss of landmarks suggest positive pressure or fluid behind the membrane. Perforation of the TM, with purulent drainage, indicates AOM. Erythema of the TM may be due to increased intravascular pressure (with crying also present) or may be present early on in the disease process and is most commonly noted when present unilaterally. To further complicate the physical examination findings, the transparency of the TM is commonly altered in children with previous episodes of otitis. Visibility also may be obscured by poor lighting or angulation of the

168

STEWART et a1

light source, thus decreased visibility of landmarks is not a reliable sign of OM. The pneumatic otoscope was first described in 1864. Although most textbooks and articles recommend the use of pneumatic otoscopy to diagnose AOM, no study has been published comparing regular otoscopy with pneumatic otoscopy. It is accepted that pneumatic otoscopy provides more accuracy because of the capability of evaluating tympanic membrane movement with the application of positive and negative pressures.12sKarma elucidated the predictive values of physical findings A bulging tympanic membrane with AOM found on myringot~my.~~ was associated with PPV of 89% and a cloudy TM with an 80% PPV. Distinctly impaired mobility of the TM was associated with a 78% PPV. In addition, the investigators evaluated the predictive value of negative findings. In a follow-up study using 11,000 visits for OM. Karma calculated the PPV for diagnosis of AOM based on tympanic membrane color, position, and mobility. Values ranging in the middle to upper 90s were obtained using combinations of cloudy color, bulging position, and impairment of mobility.73No calculations for sensitivity or specificity or performed in this study. Haughton and Pardoe compared otoscopy performed by experienced practitioners with tympanometry in a group of children referred for possible hearing loss. No calculations of sensitivity or specificity were performed. Using tympanometry as the gold standard, two of the observers’ otoscopic results were in agreement with the tympanometry, whereas the remaining three observers’ results were not. They concluded that otoscopic examination is often ~ n r e l i a b l e . ~ ~ Table 5 summarizes these studies. The calculations for sensitivity and specificity were not performed in most of these studies. PPV indicates bulging tympanic membrane, erythema, decreased mobility, and clouding are variables associated with OM. All but Karma’s study used children referred for otologic surgery because of severe disease, and thus these studies suffer from significant selection bias. Karma, conversely, used the physical examination as the gold standard for diagnosis of AOM-without other confirmatory data-raising concerns about its validity. Tympanometry

Tympanometry measures the acoustic admittance at the ear drum, which is greatly reduced when the air in the middle air is replaced by fluid. Tympanometry is easily performed in the outpatient setting. The existence of an effusion can be inferred from these measurements. Tympanometry indicates the likelihood of an effusion but is not an absolute indicator of OM.57Most studies have been done in the outpatient or preoperative setting (Table 6). The sensitivity and specificity of tympanometry in the diagnosis of AOM appears to be between 83% and 91% and 63% and 93%, respectively.

226 (515 ears)

Finitzo, 1992 Sassen, 1994

OPT OPT

Office OPT

Office

Location

Myringotomy Myringotomy

Clinical diagnosis Tympanometry

Myringotomy

Standard

Y

N

N U

N

Blind

93 74

SN

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric patients. Locution: ED = emergency department; OM = outpatient clinic/surgery. Blind = were surgeons blinded to tympanometry results: Y = yes, N = no, U = unclear. SN = sensitivity; SP = specificity; PPV = positive predictive value; NFV = negative predictive value.

P P

P P

185 ears

Karma, 1993 Hauhton, 1982

Population

P

No.

Karma, 1989

Study

Table 5. OTOSCOPY

58 60

SP

Statistics

89 80 78 65 91-99

PPV

NPV

Probability of effusion based on exam were random in 3 of 5 observers

Bulging TM Cloudy TM Decreased mobility Distinct erythema

Comments

Myringotomy Myringotomy Myringotomy Myringotomy

OPT OPT OPT OPT

P P P P

955 ears

N U N N

N

78

95 83 79 71 91 80 aver

N

Y

90 83

SN

N

Blind

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric patients Locution: ED = emergency department; OPT = outpatient clinic/surgery. Blind = were surgeons blinded to tympanometry results: Y = yes, N = no, U = unclear. SN = sensitivity; SP = specificity; PPV = positive predictive value; NPV = negative predictive value. Delay refers to time between tympanometry and myringotomy.

120 311 ears

Watters, 1997 Haughton, 1977 Williams, 1977 Ben-David, 1981

Myringotomy

ED/OPT

P

Koivunen, 1997

162

78 ears

Szucs. 1995

Myringotomy

P P

OPT

Standard

P

Location

Myringotomy Myringotomy

~

Population

OPT OPT

No.

515 ears

~~~~~

Finitzo, 1992 Sassen, 1994

Study

Table 6. TYMPANOMETRY

37

57 90 93 38 79

86 63

SP

0.71 88

85

NPV

76

PPV

Statistics

Retrospective review No delay

Not useful in uncooperative children Delay average 2.1 mo. With adenoid hypertrophy Minitympanometry Uncooperative children Delay < 2 hrs

Comments

EVALUATION OF THE PATIENT WITH SORE THROAT, EARACHE, AND SINUSITIS

171

Tympanometry should be considered an objective equivalent of pneumatic o t o s ~ o p yMoreover, .~~ it should be noted that normal tympanometry does not preclude the diagnosis of OM-or middle ear effusion-if air in the middle ear may be under normal pressure. The study by Koivunen et a1 (see Table 3) consisted of two portions; the first in the ED, and the second in a group of preoperative children. The first portion consisted of performing minitympanometry (by a nurse in the ED utilizing MicroTymp, Welch Allyn). This portion of the study primarily judged cooperation of the children in the length of time to perform the procedure. The second portion of the study was done on preoperative children; tympanometry was performed just prior to surgery and middle ear aspiration. Sensitivity and specificity were derived from the second group. This study compared the specificity and sensitivity for age groups <24 months and >24 months and there was essentially no difference. The sensitivity and specificity was much lower for the children that were uncooperative, however. The authors conclude that tympanometry is of no value in children who resist the examinati~n.~~ Although it would appear that the presence of fluid at myringotomy is the gold standard for comparison with tympanometry, there are problems with this assumption. The population examined is usually children with a strong clinical indication for myringotomy. Children with mild disease are therefore excluded. The prevalence of the disease in the population referred for surgery is 70% to 85%, which significantly alters the PPV and negative predictive value of these test^.^^,^^, 110 It is not justifiable or ethical to perform myringotomy for research purposes alone. Finally, several studies suggest that general anesthetic agents may IZo influence the test res~lts.~, Acoustic Reflectometry

Acoustic reflecfometry is an objective measure of middle ear effusion; in this test, the tip of the instrument is held firmly to the orifice of the ear canal. An airtight seal is preferred but not required. The results of reflectometry are independent of patient age, crying, cerumen, or patient cooperation. This equipment is not readily available in most EDs, however. The device directs a spectrum of sound into the ear canal, and the sound is reflected back off the TM. Whereas a normal ear absorbs sound and little is reflected back, a fluid-filled ear reflects an abnormal amount of sound. This is measured by the device (in decimals) on a scale of 0 to 10, with 0 indicating no reflection and 10 the highest measured. The "normal" cutoff, or breakpoint, varies between 4 and 6 in most studies but is not well defined. Most of the studies to date are in the pediatric outpatient population (Table 7). Babonis performed a descriptive study of children diagnosed with acute OM using pneumatic otoscopy, tympanometry, and acoustic reflectometryin an outpatient setting. The diagnoses were made by history,

107 ears 158 ears

>900 ears

Babonis, 1994 Douniadakis, 1993

Combs, 1993

P

P P

Population

OPT

OPT OPT

Location

Tympanometry

Clinical exam Tympanometry

Standard

86

79 90

86

86

N U

U

79

SN

SP

82

77

87

NPV

83

PPV

Statistics Blind

Population: I' = pediatric patients only; A = adult patients only; M = mixed adult and pediatric patients Location: ED = emergency department; OPT = outpatient clinic/surgery. Blind = were surgeons blinded to tympanometry results: Y = yes, N = no, U = unclear. SN = sensitivity; SP = specificity; I'I'V = positive predictive value; NPV = negative predictive value.

No.

Study

Table 7. ACOUSTIC REFLECTOMETRY

Descriptive study At 4.5 breakpoint (prevalence 50%) At 5.0 breakpoint (prevalence 50%) Weighted averages of 3 studies at breakpoint 2 6.0

Comments

EVALUATION OF THE PATIENT WITH SORE THROAT, EARACHE, AND SINUSITIS

173

symptoms, and diminished movement by pneumatic otoscopy. Serial tympanometry and reflectometry measurements were performed at the time of diagnosis, 3 to 5 days later, and at a 12- to 15-day follow-up. A higher incidence of abnormal tympanometry and reflectometry were noted at diagnosis than at follow up. Nevertheless, the authors concluded that both studies contributed little in cases of uncomplicated OM and increased cost without increasing cost-effecti~eness.~ Douniadakis studied children in the outpatient ENT clinic. OM was diagnosed by pneumatic otoscopy and physical examination and then confirmed using tympanometry and acoustic reflectometry. There was a 50% prevalence rate in the study population. They concluded that a breakpoint of 4.5 to 5.0 provided the best PPVs and negative predictive values for OM, with satisfactory specificity and sensitivity. Most falsenegative results occurred in children with negative middle ear pressures or children with fluid and bubbles in the middle ear. Most false-positive results occurred with the tympanic membrane scarring or stiffening. According to these authors, otoscopic observation of fluid levels or bubbles identifies OM with effusion and obviates the need for any further evaluation. The authors conclude that the acoustic reflectometer is a useful diagnostic and follow-up tool for middle ear effusion.32 Combs analyzed three studies involving more than 900 patients (see Table 4). He showed a weighted average sensitivity of 90% and specificity of 86% when diagnosing OM, using a value of six or more reflectivity. Reflectivity is proportional to the amount of the effusion. Acoustic reflectometry is very sensitive to user technique and may result in falsely low reflectivity. Acoustic reflectometry is an objective measure of middle ear effusion. It is a simple procedure, but the equipment is not routinely found in the ED. Combs reports that other studies show an increasing failure rate on audiometric testing with increasing values of reflectivity. This finding may be useful for following patients but not necessarily for diagnosis of OM in the ED setting because it requires serial examinations and follow-up care.23 In summary, acute OM is suggested by decreased tympanic membrane mobility and hearing deficits. Although there are several techniques available to assess tympanic membrane mobility, the diagnosis can almost always be confirmed by using pneumatic otoscopy. The Clinical Practice Guideline for Otitis Media with Effusion in Young Children, 1994 affirms the reliability of this device in the diagnosis of OM. These adjuncts to the diagnosis of OM discussed here are available but not necessarily easily accessible in the ED. Tympanometry and acoustic reflectometry are objective measurements that are useful in directing long-term therapy and evaluating the need for surgical intervention. Their roles in the ED is limited. There have been no studies of these diagnostic tests in the uncomplicated patient population using myringotomy. Evaluation of these techniques in the outpatient arena suggests that they are no more reliable than history, physical examination, and pneumatic otoscopy. This was perhaps summarized best by

174

STEWART et a1

Combs: ”No technology can replace the careful history and otoscopic examination by an experienced phy~ician.”’~

SINUSITIS

Sinusitis is an inflammation of the sinuses, the cause of which may be viral, bacterial, or a combination of the two; chemical irritation; or allergic. Sinusitis is frequently associated with inflammation of the nasal passages, thus rhinosinusitis may be a more precise term for this disease.70 Approximately 0.5% of upper respiratory tract infections in adults are complicated by sinusitis, which is one of the most commonly reported diseases in the United States.29Approximately 25 million patients-or 14% of the population-visit physicians’ offices every year for sinusitis.70 It is estimated that over $200 million are spent annually on prescriptive cold and sinus products; this does not include over-the-counter (OTC) medication^.^^ Direct medical costs of sinusitis reached almost $2.4 billion in 1992, making it one of the most expensive disorders experienced by the US p o p ~ l a t i o n . ~ ~ The diagnosis and treatment of sinusitis is confusing to clinicians for several reasons, one being that its presentation is similar to that of viral upper respiratory infections. An easy-to-use diagnostic test is lacking. Sinus aspiration, the gold standard in making the diagnosis of bacterial sinusitis, is rarely performed in daily clinical practice because it is technically difficult. Although most cases of sinusitis are uncomplicated, the close anatomic relationship of the sinuses to the brain and eyes render spread of infection devastating. Orbital complications include preseptal or orbital cellulitis and orbital abscess. Intracranial complications include cavernous sinus thrombosis, epidural abscess, subdural abscess, meningitis, and brain abscess. Emergent surgical referral is indicated when these complications are evident. This article focuses on the methods of diagnosis available in the outpatient and ED settings.

Description of the Process The MEDLINE database was searched for relevant articles from January 1985 to January 1998 using keywords sinusitis, diagnosis, clinical guidelines, and CT scan-sinus. A search for additional articles from the referenced lists of retrieved articles was also conducted. After exclusion of case reports and letters, the remaining articles were reviewed in their entirety. The articles were evaluated against the literature classification defined earlier (see Table 1).There was one level I article, five level I1 articles, and 23 level I11 articles. There were no randomized controlled trials, and there was one study using expectation maximization.

EVALUATION OF THE PATIENT WITH SORE THROAT, EARACHE, AND SINUSITIS

175

Physical Examination Findings

A complete history and physical examination can generally produce an appropriate diagnosis of sinusitis. For example, the patient who presents with a short history of purulent nasal drainage, pain, and obstruction may be diagnosed with acute sinusitis. Common signs and symptoms of acute sinusitis include facial or dental pain, nasal obstruction, nasal discharge, periorbital swelling, fever, and fatigue or lethargy. Several studies have evaluated the relationship of symptoms and clinical findings with the ability to diagnose sinusitis (see Table 8). A prospective study of 221 patients compared the results of the SinoNasal Outcome Test-20 (SNOT-20) with CT findings. The questionnaire included a cluster of 20 recognized symptoms on a five-point scale. The most commonly reported symptom was fatigue; 62% of the patients complained of sinus pain or pressure, most commonly over the maxillary sinuses. The CT scans were then graded according to severity; 34% were normal and 43% revealed either mucosal thickening or fluid in the maxillary sinus. Severity of symptoms did not correlate with the severity of CT findings. The authors concluded that "CT findings must be used in the context of patient and the clinical picture" and that management must be clinically based rather than radiologically based.'O Williams discovered that signs and symptoms have a low accuracy in the absence of radiographic findings of sinusitis. Although maxillary toothache showed a specificity above %YO, the sensitivity was only 18%; the other symptoms were not statistically significant. He concluded that the overall clinical impression was more accurate than any single finding.I3' Lindbaek identified symptoms and clinical findings in 201 symptomatic primary care patients. All patients had CT within 2 days of the initial diagnosis. Using multivariate analysis and logistic regression analysis, the following variables were independently associated with positive CT findings. These included double sickening (i.e., two phases in the illness history), purulent rhinorrhea, erythrocyte sedimentation rate (ESR) >10 mm, and purulent secretion in the cavum nasi. The presence of at least three of these four variables conferred a sensitivity of 66% and a specificity 81% in predicting sinusitis.84 DeBock et a1 demonstrated that the maximal likelihood estimates of sensitivities and specificities could be obtained by means of the expectation maximization algorithm in the case of acute maxillary sinusitis. This is a useful algorithm when there is a lack of an external standard. Studies were selected in which information regarding the relationship between a diagnostic test and a clinical condition could be quantified. Because the different studies are independent of one another, the total likelihood is the product of the likelihoods of each study. In the expectation step, the disease status of the patient is "reconstructed" by summing up the individual studies. The maximization step then calculates the maximal likelihood estimates from this "reconstructed" disease state and

201

Lindbaek et al, 1996

M U M A

M

M

Population

OPT OPT OPT OPT

OPT

OPT

Location

US Antral aspir. Antral aspir. x-ray

CT

CT

Standard

U U U Y

Y

Y

Blind

44 18 45

SN

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric patients. Location: ED = emergency department; OPT = outpatient clinic/surgery. Blind = were surgeons blinded to tympanometry results: Y = yes, N = no, U = unclear. SN = sensitivity; SP = specificity; PPV = positive predictive value; NPV = negative predictive value.

Williams, 1992

441 115 90 247

221

Bhattacharyya et al, 1997

DeBock, 1994

No.

Study

Table 8. SIGNS AND SYMPTOMS

52 34 93 65

SP

PPV

Statistics NPV

No statistically significant relationship Logistic regression analysis identified 4 factors (see text) Expectation Maximization of multiple studies Van Duijn, 1992 Berg & Carenfelt, 1988 Berg & Carenfelt, 1985 Colored nasal discharge Cough/sneeze Maxillary toothache Sinus tenderness

Comments

EVALUATION OF THE PATIENT WITH SORE THROAT, EARACHE, AND SINUSITIS

177

data. Using this model, a sensitivity of 58% and specificity of 88% in diagnosing sinusitis by clinical examination were derived. This compares with 100% sensitivity and specificity for antral aspiration. Explicit criteria determined that a positive clinical examination-clinical examination was considered positive if the clinician said it was positive-was comparable to positive x-ray or ultrasound in accuracy of diagnosis, but a negative x-ray was superior to a negative clinical examination or negative ultrasound in ruling out sinusitis. A positive antral aspiration (i.e., any fluid obtained on aspiration) reveals better diagnostic performance than positive clinical exam, ultrasonography, or r a d i ~ g r a p h y . ~ ~ Diagnostic Testing

Radiography Radiography has been a frequently used method of diagnosis of sinusitis. Plain films have been shown to both under- and overdiagnose sinus soft tissue changes, and up to a 75% discrepancy has been reported when radiography is compared with coronal CT in the pediatric population.81 Josephson showed false-negative rates as high as 40% when compared with CT.67Plain radiographs are less expensive than some other forms of imaging, are widely available, and rarely require sedation in the pediatric patient. Plain films are of limited value for imaging paranasal sinuses, particularly the ethmoid sinuses and osteomeatal complex.105Mucosal thickening implies inflammation or at least edema of the mucosa, but in the absence of opacification or air fluid levels, does not necessarily imply infection.lZ6 Sinus x-ray films are less sensitive than sinus CT scans for demonstration of radiographic changes consistent with acute sinusitis (Table 9).18* 27, 43, 74, lo9 Ros evaluated the use of a single Water’s view compared to a three-view x-ray series in pediatric patients and concluded that it is sufficient in evaluation of suspected sinusitis and children. They did not compare the single view to CT findings. Ultrasonography A-mode ultrasonography offers a relatively simple, painless, and noninvasive evaluation of the patient with suspected sinusitis. If the sinus cavity is partially or totally filled with secretions, ultrasound waves are conducted to the posterior wall of the sinus and back again to the probe, resulting in an echo on the screen. Minor mucosal thickening may not be detected. The lack of comparison of ultrasonography with a gold standard imaging study makes evaluation of this technique difficUlt.27,31,l05,115 According to explicit criteria studied by deBock et al, the diagnostic value of a positive ultrasound test is comparable to that of radiography;

OPT

OPT

M

M

P

70

91

35

52

DeBock, 1994 (Janner et al, 1982) Katz, 1995

Ros, 1995

OPT

OPT

X-ray series

MRI

Antral aspir.

CT

CT

Standard

Y

Y

U

Y

57 62

Y

89*

99

48

67

SN

Blind

~~~

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric patients. Location: ED = emergency department; OPT = outptient clinic/surgery. Blind = were surgeons blinded to tympanometry results: Y = yes, N = no, U = unclear. SN = sensitivity; SP = specificity; PPV = positive predictive value; NPV = negative predictive value.

P

ED

Garcia, 1994

A

30

Burke, 1994

Location

No.

Population

Study

Table 9. RADIOGRAPHY

SP

83"

75

88 88 75 10 0

~

PPV

Statistics NPV

Agreement: M N + x-ray + = 67% MRI+ x-ray+ = 33% MRI- x-ray+ = 0% *for Water's view only

Radiologist 1 Radiologist 2 ED Physician 1 ED Physician 2 CT 100% X-ray Frontal 20% cases Ethmoid 54% cases Sphenoid 0% cases Maxillary 75% cases Expectation Maximization

Comments

EVALUATION OF THE PATIENT WITH SORE THROAT, EARACHE, AND SINUSITIS

179

however, a negative radiograph is more specific than a negative ultraOverall, it appears that ultrasound lacks the sensitivity and specificity to be diagnostic (Table 10). Limited CT

The commonly prescribed CT examination for evaluation of the sinuses is a series of contiguous and direct coronal slices through the paranasal sinuses. Although the delineation of the anatomy is important for preoperative evaluation, limited imaging sufficient to detect inflammatory disease without providing full detail is useful for nonoperative 49 The limited CT scan includes management of sinusitis (Table ll).43, four noncontiguous 5-mm slices, with one slice each through the frontal sinus, the anterior ethmoid and maxillary sinuses, posterior ethmoid and maxillary sinuses, and sphenoid sinus. This technique is less expensive, provides less radiation exposure, and is easier to schedule than fullsinus CT examination. Recent reviews indicate that cost of limited CT lZ6 and plain radiography are eq~ivalent.~~, Computed Tomography

CT has become the gold standard for sinus imaging.67,70, 137 It offers excellent visualization of the paranasal sinuses and osteomeatal complex. The CT radiologic signs of acute sinusitis are 1) fluid level in one or more sinuses, 2) total opacification in one or more sinuses, or 3 ) mucosal thickening of 5 mm or more in the maxillary, frontal, or sphenoid sinuses. Lindbaek found much variation in CT findings in patients with similar symptoms and clinical findings who were diagnosed clinically 85 Sixty-three percent of patients studied had radiowith acute sinusitis.84, logic signs of sinusitis, whereas 24% of those diagnosed clinically with acute sinusitis had negative CT images.84,85 CT is not specific for the clinical diagnosis of sinusitis because the soft tissue changes seen in imaging do not necessarily correlate with major signs and symptoms of sinusitis.52,81 Bacterial sinusitis cannot be distinguished from viral infection on either CT or plain radiographs. Mucosal thickening has been noted in asymptomatic subjects as well as 81, 84, 85 It is recommended that the CT in subjects with a common scan be used within the context of the patient’s clinical picture. Limitations of the Evidence

The criteria for diagnosis of sinusitis vary largely; there is no gold standard. Although antral aspiration has been suggested as a gold standard, it does not consider disease outside of the maxillary sinus. The procedure is painful and rarely performed clinically, except in the complicated or immunocompromised patient. Aspiration of the affected

A

A

Population

X-ray

X-ray

OPT

OPT

Standard

Location

Y

Y

Blind

83 aver 44-58

SN

88 aver 55-61

SP PPV

Statistics

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric patients. Location: ED = emergency department; OPT = outpatient clinic/surgery. Blind = were surgeons blinded to tympanometry results: Y = yes, N = no, U = unclear. SN = sensitivity; SP = specificity; PPV = positive predictive value; NPV = negative predictive value.

Shapiro, 1986

75

25

Dobson, 1996

DeBock, 1994

No.

Study

Table 10. ULTRASOUND

NPV

X-ray US Agreement abn 22 22 100% nl 28 22 79% Expectation Maximization of five studies Ranges dependent on criteria used to consider an x-ray normal

Comments

44 49

Goodman, 1995 Garcia, 1994

Location

OPT OPT

Population

A P

Full CT Full CT

Standard

SN 93

Blind

Y Y

SN = sensitivity; SP

= specificity; PPV = positive predictive value; NPV = negative predictive value.

Population: P = pediatric patients only; A = adult patients only; M = mixed adult and pediatric patients. Location: ED = emergency department; OPT = outptient clinic/surgery. Blind = were surgeons blinded to tympanometry results: Y = yes, N = no, U = unclear.

No.

Study

Table 11. LIMITED CT SCAN

89

SP

PPV

Statistics

NPV

88% overall concordance

Comments

182

STEWART et a1

sinus is not justifiable in the uncomplicated patient or solely for research findings. Essentially all of the diagnostic adjuncts discussed in this section used CT scan as the gold standard. The lack of specificity of the CT scan implies even worse performance by the adjuncts. Based on these studies, therefore, no imaging studies are recommended for the routine diagnosis of uncomplicated sinusitis presenting to the ED.52 References 1. Anhalt J, Heiter B, Naumovitz D, et a1 Comparison of three methods for detection of Group A streptococci in throat swabs. J Clin Microbiol 302135-2138, 1992 2. Araj G, Majeed H: Evaluation of a two-minute strep A direct swab test (SADST) on patients with pharyngitis at a primary care clinic. J Hyg Camb 97133-138, 1986 3. Badgett T, Hesterberg L: Management of Group A streptococcus pharyngitis with a second generation rapid strep screen: Strep A OIA. Microbial Drug Resistance 2~371-376,1996 4. Babonis T Progression of tympanometry and acoustic reflectometry. Clin Pediatr 33:593400, 1994 5. Ben-David J, Podoshin L, Fradis M, et al: Tympanometry and audiometry in diagnosis of middle ear effusions. Ear, Nose, Throat J 60(3):120-123, 1981 6. Benjamini E, Leskowitz S Antigen-antibody interactions. In Immunology: A Short Course, ed 2. New York, Wiley-Liss, 1991 7. Bennike T, Brochner-Mortensen K, Kjaer E, et al: Penicillin therapy in acute tonsillitis, phlegmonous tonsillitis, and ulcerative tonsillitis. Acta Med Scand 139:253-274, 1951 8. Berkowitz C, Anthony B, Kaplan E, et al: Cooperative study of latex agglutination to identify Group A streptococcal antigen on throat swabs in patients with acute pharyngitis. J Pediatr 10789-92, 1985 9. Bess FH, Harrington B, Bluestone CD, et al: Summary reports on national-international conferences, Part 1. 87288-292, 1978 10. Bhattacharyya T, Piccinillo J, Wippold F: Relationship between patient-based description of sinusitis and paranasal sinus CT findings. Arch Otolaryngol Head Neck Surg 123:1189-1192, 1997 11. Bisno A, Gerber M, Gwaltney J, et al: Diagnosis and management of Group A streptococcal pharyngitis: A practice guideline. Clin Infect Dis 25:574-583, 1997 12. Bluestone CD, Stoal SE, Scheet M D Pediatric Otolaryngology, ed 2. Philadelphia, WB Saunders, 1990 13. Bourbeau P, Heiter B, Anhalt J, et al: Comparison of direct specimen testing utilizing TestPack A with testing of specimens following a two-hour broth enrichment. Diagn Microbiol Infect Dis 1793-96, 1993 14. Breese 8:A simple scorecard for the tentative diagnosis of streptococcal pharyngitis. Am J Dis Child 131:514-517, 1977 15. Breese B: Beta hemolytic streptococcus: Its bacteriologic culture and character. Am J Dis Child 132:502-508, 1978 16. Breese B, Disney F: The accuracy of diagnosis of beta streptococcal infections on clinical grounds. J Pediatr 44:670473, 1954 17. Buchta R Use of a rapid strep test (First Response) by parents for detection of streptococcal pharyngitis. Pediatr Infect Dis J 8:829-833, 1989 18. Burke TF, Guertler AT, Timmons JH. Comparison of sinus x-ray with CT in acute sinusitis. Acad Emerg Med 1(3):235-239, 1994 19. Campos J, Charilaou C: Evaluation of Detect-A-Strep and the culturette ten-minute strep ID kits for detection of Group A streptococcal antigen in oropharyngeal swabs from children. J Clin Microbiol22145-148, 1985 20. Carey R, Tilyard M, Morris R, et al: Evaluation of a rapid diagnostic test for Group A Beta-haemolytic streptococcus in general practice. NZ Med J 104:401403, 1991

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21. Centor R, Meier F, Dalton H: Throat cultures and rapid tests for diagnosis of Group A streptococcal pharyngitis in adults. In Sox H (ed): Common Diagnostic Tests: Use and Interpretation, ed 2. Philadelphia, American College of Physicians, 1990 22. Centor R, Witherspoon J, Dalton H, et al: The diagnosis of strep throat in the emergency room. Med Decision Making 1:239-246, 1981 23. Combs JT The diagnosis of otitis media: New techniques. Ped Infect Dis J 13:10491046, 1994 24. Congeni 8, Rizzo C, Congeni J, et al: Outbreak of acute rheumatic fever in northeast Ohio. J Pediatr 111:176-179, 1987 25. Dajani A, Taubert K, Ferrieri P, et a1 Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: A statement for health professionals. Committee on Rheumatic Fever, Endocarditis, and Kawasaki disease of the council on cardiovascular disease in the young: The American Heart Association. Pediatrics 96:758-764, 1995 26. Daly J, Korgenski E, Munson A, et a1 Optical immunoassay for streptococcal pharyngitis: Evaluation of accuracy with routine and mucoid strains associated with acute rheumatic fever outbreak in the intermountain area of the United States. J Clin Microbiol 32:531-532, 1994 27. DeBock GH, et a1 Sensitivity and Specificity of Diagnostic Tests in Acute Maxillary Sinusitis. J Clin Epidemiol471343-52, 1994 28. Denny F, Wannamaker L, Brink W, et a1 Prevention of rheumatic fever: Treatment of the preceding streptococcic infection. JAMA 143:151-153, 1950 29. Diaz IA, Bamberger DM: Acute sinusitis. Semin Resp Inf 10:14-20, 1995 30. Dobkin D, Shulman S: Evaluation of an ELISA for Group A streptococcal antigen for diagnosis of pharyngitis. J Pediatr 110:566-569, 1987 31. Dobson MJ, Fields J, Woodford T Comparison of ultrasound and plain radiographs in diagnosis of maxillary sinusitis. 51:170-172, 1996 32. Douniadakis DE, Nickolopoulus TP, Tsakanikos MD, et a1 Evaluation of acoustic reflectometry in detecting otitis media in children. Br J Audio1 27409414, 1993 33. Drulak M, Bartholomew W, LaScolea L, et a1 Evaluation of the modified Visuwell Strep-A enzyme immunoassay for detection of Group A streptococcus from throat swabs. Diagn Microbiol Infect Dis 14:281-285, 1991 34. DuBois D, Ray V, Nelson B, et al: Rapid diagnosis of Group A strep pharyngitis in the emergency department. Ann Emerg Med 15:157-159, 1986 35. Dykstra M, McLaughlin J, Bartlett R Comparison of media and techniques for detection of Group A streptococci in throat swab specimens. J Clin Microbiol 9:236238, 1979 36. Egger P, Siegrist C, Strautmann G, et al: Evaluation of two ELISA tests for the rapid detection of Group A streptococci. Eur J Pediatr 149:256-258, 1990 37. Erlich T, Schwartz, Wientzen, et al: Comparison of an immunochromatographic method for rapid identification of Group A streptococcal antigen with culture method. Arch Fam Med 293664369, 1993 38. Evans A, Dick E: Acute pharyngitis and tonsillitis in University of Wisconsin students. JAMA 190~699-708,1964 39. Finitzo T, Friel-Patti S, Chinn K, et al: Tympanometry and otoscopy prior to myringotomy: Issues in diagnosis of OM. Int J Pediatr Otorhinolaryngol 24101-110, 1992 40. Fries S: Diagnosis of Group A streptococcal pharyngitis in a private clinic: Comparative evaluation of an optical immunoassay method and culture. J Pediatr 126:933936, 1995 41. Fujikawa S, Ohkuni M: A new latex agglutination test for rapid diagnosis of Group A streptococci. Jpn Circ J 501251-1252, 1986 42. Funamura J, Berkowitz C: Applicability of a scoring system in the diagnosis of streptococcal pharyngitis. Clin Pediatr 22:622-626, 1983 43. Garcia DP, Corbett ML, Eberly SM, et al: Radiographic imaging studies in pediatric chronic sinusitis: 1. J Allergy Clin Immunol 94:523-530, 1994 44. Gerber M: Comparison of throat cultures and rapid strep tests for diagnosis of streptococcal pharyngitis. Pediatr Infect Dis J 8520-824, 1989 45. Gerber M, Randolph M, Chanatry J, et al: Antigen detection test for streptococcal

184

46. 47. 48. 49. SO.

51. 52. 53. 54.

55. 56.

57.

58. 59. 60. 61. 62. 63. 64. 65. 66. 67.

STEWART et a1

pharyngitis: Evaluation of sensitivity with respect to true infections. J Pediatr 108:654658, 1986 Gerber M, Randolph M, DeMeo K: Liposome immunoassay for rapid identification of Group A streptococci directly from throat swabs. J Clin Microbiol281463-1464, 1990 Gerber M, Spadaccini L, Wright L, et al: Latex agglutination tests for rapid identification of Group A streptococci directly from throat swabs. J Pediatr 105702-705, 1984 Gerber M, Tanz R, Kabat W, et al: Optical immunoassay test for Group A 8-hemolytic streptococcal pharyngitis: An office-based, multicenter investigation. JAMA 277899903, 1997 Goodman GM, Martin DS, Klein J, et al: Comparison of screening coronal CT vs. full CT for evaluation of patients with Presumptive Sinusitis. Ann Allergy Asthma Immuno1 74:178-182, 199.5 Granato P, Giachetti-Powers L, Murfitt K, et al: Comparative evaluation of PathoDx Strep A Test and culture for the detection of Group A streptococci in pharyngeal specimens. Diagn Microbiol Infect Dis 5293-298, 1986 Gupta R, Rattan A, Prakash K, et al: Immunodiagnosis of Group A streptococci by latex agglutination assays with monoclonal or monospecific polyvalent antibodies. Indian J Med Res 9725-31, 1993 Gwaltney JM: Acute community-acquired sinusitis. Clin Infect Dis 23:1209-1223,1996 Gwaltney JM: Pharyngitis. In Mandell G, Bennett J, Dolin R (eds): Principles and practice of infectious diseases, ed 4. New York, Churchill-Livingstone, 1995, pp 566572 Harbeck R, Teague J, Crossen G, et al: Novel, rapid optical immunoassay technique for detection of Group A streptococci from pharyngeal specimens: Comparison with standard culture methods. J Clin Microbiol31:839-844, 1993 Harris R, Paine D, Wittler R, et al: Impact on empiric treatment of Group A streptococcal pharyngitis using an optical immunoassay. Clin Pediatr 34:122-127, 1995 Hart A, Buck L, Morgan S, et a1 A comparison of the BioStar Strep A OIA rapid antigen Assay, Group A selective strep agar (SSA), and Todd-Hewitt broth cultures for the detection of Group A streptococcus in an outpatient family practice setting. Diagn Microbiol Infect Dis 29:139-145, 197 Haughton PM, Pardoe K A comparison of otoscopy and tympanometry in the Diagnosis of Middle Ear Effusions. Clin Phys Physiol Meas 3:213-220, 1982 Haughton PM: Validity of tympanometry for middle ear effusions. Arch Otolaryng 103:505-513, 1977 Hedges J, Lowe R Streptococcal pharyngitis in the emergency department: Analysis of therapeutic strategies. Am J Emerg Med 4107-115, 1986 Heiter B, Bourbeau P: Comparison of the Gen-Probe Group A streptococcus direct test with culture and a rapid streptococcal antigen detection assay for diagnosis of streptococcal pharyngitis. J Clin Microbiol31:2070-2073, 1993 Heiter B, Bourbeau P:Comparison of two rapid streptococcal antigen detection assays with culture for diagnosis of streptococcal pharyngitis. J Clin Microbiol 33:14081410, 1995 Hoffman S Detection of Group A streptococcal antigen from throat swabs with five diagnostic kits in general practice. Diagn Microbiol Infect Dis 13:209-215, 1990 Hoffman S, Henrichsen J: Detection of Group A streptococcal antigen from throat swabs by use of a latex agglutination test kit in general practice. Acta Pathol Microbiol Immunol Scand Sect B 9589-94, 1987 Hosier D, Craenen J, Teske D, et al: Resurgence of acute rheumatic fever. Am J Dis Child 141~730-733,1987 Huck W, Reed B, French T, et al: Comparison of the directigen 1-2-3 Group A strep test with culture for detection of Group A beta-hemolytic streptococci. J Clin Microbiol 271715-1718, 1989 Jonckheer T, Goossens H, De Donder M, et al: Evaluation of the direct detection of Group A Beta-hemolytic streptococcal antigen in a pediatric population: Comparison with the traditional culture technique. Eur J EpidemiolZ205-207, 1986 Josephson GD, Gross C W Diagnosis and management of acute and chronic sinusitis. Compr Ther 23:708-714, 1997

EVALUATION OF THE PATIENT WITH SORE THROAT, EARACHE, AND SINUSITIS

185

68. Joslyn S, Hoekstra G, Sutherland J: Rapid antigen detection testing in diagnosing Group A Beta-hemolytic streptococcal pharyngitis. Journal of the American Board of Family Practice 8:177-182, 1995 69. Jung TT, Rhee CK: Otolarynglogic approach to the diagnosis and management of otitis media. Otolaryngol Clin North Am 244:931-945, 1991 70. Kaliner MA, Osquthorpe JD, Fireman P, et a1 Sinusitis: Bench to bedside: 111. J Aller Clin Immunol99:5829-5848, 1997 71. Kaplan E, Top F, Dudding B, et al: Diagnosis of streptococcal pharyngitis: Differentiation of active infection from the carrier state in the symptomatic child. J Infect Dis 123:49&501, 1971 72. Karma PH, Penttila MA, Sipila MM, et al: Otoscopic diagnosis of middle ear effusion in acute and non-acute OM: Int J Pediatr Otolaryngol 173749, 1989 73. Karma PH, Sipila MM, Kataja MD, et a1 Pneumatic otoscopy and OM: The value of different TM findings and their combinations. In Kim DJ, Bluestone CD, Klein JO, et a1 (eds): Recent Advances in OM, Proceedings of the Fifth International Symposium. Burlington, Ontario, December, 1993, pp 41-55 74. Katz RM, Friedman S, Diament M, et a1 Comparison of imaging techniques in patients with chronic sinusitis. Aller Proc 16:123-127, 1995 75. Kayaba H, Tamura H, Fujiwara Y: Evaluation of the therapy for streptococcal pharyngitis using Abbott Test Pack Strep A. Acta Paediatrica Japonica 38:s-11, 1996 76. Kellogg J, Bankert D, Levisky J: Comparison of the Testpack Strep A Enzyme Immunoassay System with anaerobically incubated cultures for detection of Group A streptococci from oropharyngeal swabs. Am J Clin Pathol88:631-634, 1987 77. Kellogg J, Landis R, Nussbaum A, et al: Performance of an enzyme immunoassay test and anaerobic culture for detection of Group A streptococci in a pediatric practice versus a hospital laboratory. J Pediatr 111:18-21, 1987 78. Kempthorne J, Giebink GS: Pediatric approach to diagnosis and management of otitis media. Otolaryngol Clin North Am 24:905-929, 1991 79. Koivunen P, Albo 0, Ubari M, et al: Minitympanometry in detecting middle ear fluid. J Pediatr 13L419-422, 1997 80. Krober MS, Bass JW, Michels GN: Streptococcal pharyngitis: Placebo-controlled double-blind evaluation of clinical response to penicillin therapy. JAMA 253 9:12711274, 1985 81. Kronemer KA, McAlister WH: Sinusitis and its imaging in the pediatric population. Pediatr Radiol 27837-846, 1997 82. Laubscher B, van Melle G, Dreyfuss N, et al: Evaluation of a new immunological test kit for rapid detection of Group A streptococci: The Abbot Testpack Strep A Plus. J Clin Microbiol 33:260-261, 1995 83. Lieu T, Fleisher G, Schwartz J: Cost-effectiveness of rapid latex agglutination testing and throat culture for streptococcal pharyngitis. Pediatrics 85:246-256, 1990 84. Lindbaek M, Hjortdahl P, Johnsen ULH: Use of symptoms, signs, blood tests to diagnose sinusitis: Comparison with CT. Fam Med 28:183-188, 1996 85. Lindbaek M, et al: CT findings in general pediatric patients and suspected acute sinusitis. Acta Radiol 37708-713, 1996 86. Long SS, Henretig FM, Teter MJ, et al: Nasopharyngeal flora and AOM. Infect Immunol41:987,1983 87. Low DE, Desrsiers M, et a1 A practical guide for the diagnosis and treatment of acute sinusitis. CMAJ 157 6(suppl):51-14, 1997 88. Lowe R, Hedges J: Early treatment of streptococcal pharyngitis. Ann Emerg Med 1 3 4 4 U 8 , 1984 89. Mackenzie A, Li M, Chan F: Evaluation of a kit for rapid detection of Group A streptococci in a pediatric emergency department. CMAJ 138:917-919, 1988 90. Manasse R Evaluation of the Pacific Biotech CARDS STREP A Test for detecting Group A streptococci from cases of pharyngitis. J Clin Mcirobiol 271657-1658, 1989 91. Marsh W, Quirk B, Gururaj V Clinical experience with the use of Culturette Brand 10-Minute Group A Strep ID kit in the early diagnosis of streptococcal pharyngitis [letter]. Clin Pediatr 25:55, 1986

186

STEWART et a1

92. Meland E, Digranes A, Skjaerven R Assessment of clinical features predicting streptococcal pharyngitis. Scand J Infect Dis 25:177-183, 1993 93. Miceika B, Vitous A, Thompson K Detection of Group A streptococcal antigen directly from throat swabs with a ten-minute latex agglutination test. J Clin Microbiol 21:467469, 1985 94. Mirrett S, Monahan J, Reller LB: Comparative evaluation of medium and atmosphere of incubation for isolation of streptococcus pyogenes. Diagn Microbiol Infect Dis 6~217-221,1987 95. Moyer N, Quinn P, Showalter C: Evaluation of the Directigen 1,2,3 Group A Strep Test for diagnosis of streptococcal pharyngitis. J Clin Microbiol 28:1661-1663, 1990 96. Nadler H: Rapid detection of Group A streptococci. Diagn Clin Testing 273941, 1989 97. National Center for Health Statistics: Office Visits for OM US, 1975-1990. Advance Data From Vital and Health Statistic, No. 214. Hyattsville, MD, Public Health Science; 1992, DHHS Pub. 6 NO.92-1250 98. Nelson JD: The effect of penicillin therapy on the symptoms and signs of streptococcal pharyngitis. Pediatr Infect Dis 3:lO-13, 1984 99. Pate1 K, Chittom A, Toshniwal R, et al: Rapid commercial test for direct detection of Group A streptococci in throat swabs. Eur J Clin Microbiol 6:193-194, 1987 100. Pichichero M Culture and antigen detection tests for streptococcal tonsillopharyngitis. AFP 45:199-205, 1992 101. Poses R, Cebul R, Collins M, et al: The accuracy of experienced physicians’ probability estimates for patients with sore throat. JAMA 254:925-929, 1985 102. Randolph M, Gerber M, DeMeo K, et al: Effect of antibiotic therapy on the clinical course of streptococcal pharyngitis. J Pediatr 106:870-875, 1985 103. Reed 8, Huck W, French T Diagnosis of Group A Beta hemolytic streptococcus using clinical scoring criteria, Directigen 1-2-3 Group A streptococcal test, and culture. Arch Intern Med 150:1727-1732, 1990 104. Reichwein B, Jungkind D, Guardiani M, et al: Comparison of two rapid latex agglutination methods for detection of Group A streptococcal pharyngitis. Am J Clin Pathol 86~529-532,1986 105. Revonta M, Blokinanis A Sinusitis: Diagnostic methods. Can Fam Phy 4019691972, 1994 106. Roddey 0, Clegg H, Clardy L, et al: Comparison of a latex agglutination test and four culture methods for identification of Group A streptococci in a pediatric office laboratory. J Pediatr 108:347-351, 1986 107. Roddey 0, Clegg H, Martin E, et al: Comparison of an optical immunoassay technique with two culture methods for the detection of Group A streptococci in a pediatric office. J Pediatr 126:931-933, 1995 108. Roe M, Kishiyama C, Davidson K, et al: Comparison of BioStar Strep A OIA optical immune assay, Abbott TestPack Plus Strep A, and culture with selective media for diagnosis of Group A streptococcal pharyngitis. J Clin Microbiol33:1551-1553, 1995 109. Ros SP, Herman BE, Azar-Kia B: Acute sinusitis in children: Is Water’s view sufficient? Pediatr Radio1 25:306-307, 1995 110. Sassen ML, Van Aarem A, Grote JJ: Validity of Tympanometry in the Diagnosis of Middle Ear Effusion. Clin Oto 19:185-189, 1994 111. Savoia D, Francesetti C, Millesimo M, et al: Evaluation of the diagnostic accuracy of a kit for the rapid detection of Group A streptococci. Microbios 77253-259, 1994 112. Schlager T, Hayden G, Woods W, et al: Optical immunoassay for rapid detection of Group A Beta hemolytic streptococci. Arch Pediatr Adolesc Med 150:245-248, 1996 113. Schwabe L, Small M, Randall E: Comparison of TestPack Strep A Test Kit with culture technique for detection of Group A streptococci. J Clin Microbiol25:309-311, 1987 114. Schwartz R, Gerber M, McCoy P: Effect of atmosphere of incubation on the isolation of Group A streptococci from throat cultures. J Lab Clin Med 106:88-92, 1985 115. Shapiro GG, Furukawa CT, Pierson WE, et al: Blinded comparison of maxillary sinus radiograph and ultrasound for diagnosis of sinusitis. J Aller Clin Immun 7759-64, 1986 116. Shulman S Streptococcal pharyngitis: Clinical and epidemiologic factors. Pediatr Infect Dis J 8:816-819, 1989

EVALUATION OF THE PATIENT WITH SORE THROAT, EARACHE, AND SINUSITIS

187

117. Snellman L, Stang H, Stang J, et al: Duration of positive throat cultures for Group A streptococci after initiation of antibiotic therapy. Pediatrics 91:1166-170, 1993 118. Stillstrom J, Schwan A, Bjorklind A: Streptococcal throat infection: Calculation of test standards and a comparison between an antigen detection test and culture. Scand J Prim Health Care 9:149-154, 1991 119. Stool SN, Maint MR, Medellin G: Diagnosing OM: A workshop. Compr Ther 22:776 781, 1996 120. Szucs E, Diegendaele R, Clement PAR Accuracy of tympanometry assessed by its sensitivity and specificity. Acta Otorh Be1 49:287-292, 1995 121. Teele DW, Klein JO, Rosner B Epidemiology of OM during the 1st 7 Years of Life in Children in Greater Boston: A Prospective Cohort Study. J Infec Dis 160:83-94, 1989 122. Toner JG, Mains B: Pneumatic otoscopy and tymp in the detection of middle ear effusion. Clin Oto 15:121-123, 1990 123. Veasy L, Wiedmeier S, Orsmond G, et al: Resurgence of acute rheumatic fever in the intermountain area of the United States. N Engl J Med 316:421427, 1987 124. Venezia R, Ryan A, Alward S, et al: Evaluation of a rapid method for the detection of streptococcal Group A antigen directly from throat swabs. J Clin Microbiol21:395398, 1985 125. Vukmir RB: Adult and pediatric pharyngitis: A review. J Emerg Med 10: 607-616,1992 126. Wagner W Changing diagnostic and treatment strategies for chronic sinusitis. Cleve Clin J Med 63:396-405, 1996 127. Watters GW, Jones JE, Freeland AP: Predictive value of tympanometry in the diagnosis of middle ear effusion. Clin Oto 22:343-345, 1997 128. Weiss JC, Yates GR, Quinn LD: AOM Making an accurate diagnosis. Am Fam Phy 53:12004, 1996 129. Welch D, Hensel D, Pickett D, et a1 Comparative evaluation of selective and nonselective culture techniques for isolation of Group A beta-hemolytic streptococci. Am J Clin Pathol95:587-590, 1991 130. Wiedermann B, Schwartz R, McCoy P: Experience with rapid latex agglutination testing for Group A streptococcal pharyngitis in a pediatric group office laboratory. J Am Board Fam Pract 4:79-82, 1991 131. Willaims JW, Simel DL, Roberts L, et a1 Clinical evaluation for sinusitis: Making the diagnosis by history and physical exam. Ann Intern Med 117705-710, 1992 132. Williams RG, Haughton PM. Tympanomatic diagnosis of middle ear effusion. J Laryngol Otol 9:959-962, 1997 133. Wolford R: Evaluation of the sore throat. In Wolfson A, Paris P (eds): Diagnostic testing in emergency medicine. Philadelphia, WB Saunders, 1996, pp 159-171 134. Yamada T, Fukazawa Y, Shiokawa Y, et al: Evaluation of direct and rapid identification of Group A streptococci from throat swabs by Culturette 10-Minute Group A Strep ID Test Kit. Jpn Circ J 50:1253-1255, 1986 135. Yu P, Germer J, Torgerson C, et al: Evaluation of TestPack Strep A for the detection of Group A streptococci in throat swabs. Mayo Clin Proc 63:33-36,1988 136. Yuckienuz S, Thorne G, Macone A, et al: Performance of a solid phase enzyme immunoassay for detection of Group A streptococci in a pediatric office laboratory as referred by a hospital laboratory. Pediatr Infect Dis J 7393-398, 1988 137. Zinreich J: imaging of inflammatory sinus disease. Otolaryngol Clin North Am 26:535-547, 1993

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