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Prospective analysis of sinus symptoms and correlation with paranasal computed tomography scan
Prospective analysis of sinus symptoms and correlation with paranasal computed tomography scan THOMAS J. KENNY, MD, JAMES DUNCAVAGE, MD, JAMES BRACIKOWSKI, MD, ALTAN YILDIRIM, MD, JOHN J. MURRAY, MD, PhD, and S. BOBO TANNER, MD, Nashville, Tennessee
OBJECTIVES: We designed a prospective study to determine whether there is a correlation between the severity of sinus symptoms and the severity of computed tomography (CT) scan evidence of rhinosinusitis. METHODS: Acute and chronic rhinosinusitis patients rated their symptoms and had a CT scan of the sinuses taken the same day. A Likert severity scale and standardized CT scoring system were used. Data were analyzed by nonparametric methods with Kendall’s rank correlation coefficient. RESULTS: The severity of 5 symptoms correlated with severity of disease on CT scan. Headache and facial pain or pressure had no correlation. CONCLUSION: The certainty of a clinical diagnosis of rhinosinusitis requiring treatment is enhanced in patients with high symptom severity scores for fatigue, sleep disturbance, nasal discharge, nasal blockage, or decreased sense of smell. Isolated headache and facial pain or pressure are less reliable predictors of CT scan findings supporting the diagnosis rhinosinusitis. (Otolaryngol Head Neck Surg 2001;125:40-3.)
The common complaints of facial pressure or pain and headache leading to treatment for rhinosinusitis by the primary medical doctor and subsequent referral to otolaryngologists has led us to search for guidelines for the evaluation and treatment of patients with sinus symptoms. The diagnosis of rhinosinusitis is said to be one based on clinical history and physical examination. Maxillary From the Department of Otolaryngology, The Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences (Drs Kenny, Duncavage, and Yildirim), and The Vanderbilt Asthma, Sinus, and Allergy Program (Drs Duncavage, Bracikowski, Murray, and Tanner), Nashville, Tennessee. Reprint requests: Thomas J. Kenny, MD, The Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences, Department of Otolaryngology, Medical Center North, Vanderbilt University Medical Center, Nashville, TN 37232-2559; e-mail, [email protected]. Copyright © 2001 by the American Academy of Otolaryngology— Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/1/116779 doi:10.1067/mhn.2001.116779 40
toothache, abnormal transillumination, poor response to decongestants, and a history or physical examination finding of purulent nasal discharge have been reported as independent predictors of rhinosinusitis.1 Otolaryngologists often obtain computed tomography (CT) scans of the paranasal sinuses to delineate the extent of paranasal sinus disease. Yet there are varying reports of both positive and negative correlation between sino-nasal symptoms and CT evidence of rhinosinusitis.2-4 CT scanning of the paranasal sinuses is now the preferred mode of imaging this complex area for the purposes of diagnosis, disease monitoring, and surgical planning. CT scan alone is neither sufficiently sensitive nor specific for use as a primary diagnostic method for rhinosinusitis as patients with abnormal sino-nasal findings have been detected when undergoing scanning for unrelated reasons.3,5 We therefore designed a prospective study to determine if there was any correlation between the severity of symptoms and CT scan evidence of rhinosinusitis. METHODS AND MATERIALS Three hundred four patients with acute or chronic rhinosinusitis seen at the Vanderbilt University Asthma, Sinus, and Allergy Program (ASAP) with symptoms of sinus disease between March and September of 1998 were prospectively analyzed to detect whether or not the severity of their symptoms correlated with CT scan evidence of rhinosinusitis. Patients were included in the study if they were symptomatic for at least 7 days before enrollment, met diagnostic criterion for rhinosinusitis as established by the Task Force on Rhinosinusitis,6 had a CT scan performed at the same visit, and agreed to complete our questionnaire. The Rhinosinusitis Outcome Measure (RSOM-31) (Piccirillo et al7) and the Rhinoconjuctivitis Quality of Life Questionnaire (Juniper and Guyatt8) are two valid and reliable clinical measures of paranasal sinus symptoms. The Vanderbilt ASAP center has adapted portions of these two reliable clinical outcome questionnaires and incorporated 7 of these questions into a standard questionnaire filled out by each patient. Patients completed our standard questionnaire and rated their symptoms from 0 (not troubled) to 6 (extremely troubled) by using a Likert severity scale (Table 1). Although these questions have not yet been validated, we feel these 7 questions are consistent with the most common symptoms that patients and primary care physicians believe to be associated with rhinosinusitis.
Otolaryngology– Head and Neck Surgery Volume 125 Number 1
KENNY et al
41
Fig 1. Data from 273 patients for the symptom “headache.” There are between 30 and 60 patients in each Likert score interval. There was no correlation between symptom “headache” and CT scan score.
Table 1. Sample of ASAP Symptom Severity Questionnaire
Symptom
Not troubled
Hardly troubled
Somewhat troubled
Moderately troubled
Quite a bit troubled
Very troubled
0
1
2
3
4
5
Extremely troubled
6
Our Likert severity scale ranges from a score of 0 to 6.
CT scans were performed on a TCT-60 AX Toshiba scanner (Nassau, Japan) at 120 kV and 150 mA with 5-mm cuts at 5-mm intervals with gantry tilt, a 2-second scan time, and in the coronal plane. CT scans were scored by using the modified Mckay-Lund classification scoring system. This system was chosen for its ease of interpretation, intraobserver and interobserver reliability, and because it has been recommended by the Task Force on Rhinosinusitis for future outcome research.9 The scans were then scored by our CT technician and overread by a staff radiologist, both of whom were blinded to the patients symptom scores. Our data was nonparametric and we therefore analyzed this with a nonparametric statistical method by ranking the patient’s individual symptom scores, sum total symptom scores, and sum symptom scores for 5 symptoms including fatigue, sleep disturbance, nasal discharge or postnasal drip, stuffy or blocked nose, and decreased sense of smell with their total CT scan score. A Kendall Rank Correlation Coefficient analysis was performed on the data by using the computer software StatView (Abacus, Inc, Berkeley, CA). A p value of less than 0.05 was considered to be statistically significant. RESULTS
Twenty-nine patients had incomplete questionnaires and 2 patients had total symptom scores of zero. After
excluding these patients, 273 patients met inclusion criterion. One hundred fifty-eight (58%) patients were female and 115 (42%) were male. The average age of our patients was 43.5 years with a range of 8 years to 82 years old. Of the 7 questions analyzed, the severity of 5 symptoms (fatigue P = 0.0054, tau (t) = 0.089; lack of a good night’s sleep P = 0.0051, t = 0.09; nasal discharge or postnasal drip P = 0.0049, t = 0.091; stuffy blocked nose P = 0.0028, t = 0.096; and decreased sense of smell P = 0.0005, t = 0.112) were found to individually correlate with severity of disease on CT scan. Interestingly, severity of headache (P = 0.8385, t= 0.007) (Fig 1) and facial pain or pressure (P = 0.439, t = 0.025) (Fig 2) had no correlation to severity of disease on CT scan. We then ranked the sum of all 7 symptoms from each patient and compared them with the rank of their CT scores and still found a statistically significant correlation between the severity of the sum of these 7 symptoms and the severity of the CT scan evidence for rhinosinusitis (P = 0.0011, t = 0.112). After deleting the scores for headache and facial pain or pressure, a comparison was made between the remaining 5 scores and the CT scan score. We found a highly significant correlation relating the severity of the sum of these 5 symp-
42
Otolaryngology– Head and Neck Surgery July 2001
KENNY et al
Fig 2. Data from 273 patients for the symptom “facial pain/pressure.” There are between 30 and 60 patients in each Likert score interval. There was no correlation between the symptom “facial pain/pressure” and CT scan score.
Fig 3. Data from 273 patients for the symptoms “fatigue, lack of a good night’s sleep, nasal discharge or postnasal drip, blocked or stuffy nose, and decreased sense of smell” are represented in this bar graph. The x axis represents the sum of these five symptom severity scores for each patient. Each patient had their score entered in the appropriate Likert interval. There were between 30 to 60 patients in each interval. The y axis represents the average CT score of the patients from each Likert score interval. These 5 symptoms were found to correlate both individually and when summed with the severity of their CT scans.
toms (fatigue, lack of a good night’s sleep, nasal discharge or postnasal drip, stuffy blocked nose, and decreased sense of smell) and the severity of the CT scan score (P = 0.0001, t = 0.129) (Fig 3).
DISCUSSION
The literature regarding correlation between sinonasal complaints and CT scan evidence of paranasal sinus disease is not in agreement. Bhattacharyya et al2
Otolaryngology– Head and Neck Surgery Volume 125 Number 1
used the Sino-Nasal Outcome Test 20 (SNOT-20), which is a shorter version of the RSOM-31 to compare patient-based symptoms with sinus CT imaging in patients referred for sinus CT. They found no correlation between the total SNOT-20 score or the individual score on the facial pain or pressure question and CT imaging evidence of rhinosinusitis.2 In a study by Flinn et al5 of patients referred for head CT scan, they state that paranasal sinus abnormalities on CT scan are common and found that 27% of patients in their study with no symptoms of rhinosinusitis had sinus opacification.5 In contrast to this, Calhoun et al3 concluded that although CT scans of patients without symptoms of sinus disease do show some incidental sinus abnormalities, the incidence of such abnormalities is significantly greater in patients with a history of “sinus-type symptoms.” Bolger et al4 found that mucosal abnormalities occurred in 153 (92.2%) of 166 patients scanned for chronic sinus complaints and in 15 (41.7%) of 36 patients scanned for non-sinus reasons. At the time of this writing, our study is the first prospective analysis that demonstrates a correlation between the severity of CT scan evidence for rhinosinusitis and the severity of the patient’s report of fatigue, sleep disturbance, nasal discharge or post nasal drip, nasal blockage, and decreased sense of smell. We also confirmed the lack of correlation between CT findings of rhinosinusitis and headache or facial pain or pressure noted by Bhattacharyya et al.2 Our data suggest that the clinical diagnosis of rhinosinusitis is enhanced by high symptom scores for symptoms other than headache or facial pain or pressure. The symptoms “headache” and “facial pain or pressure” remain an enigma. Patients who have rhinosinusitis can undeniably have one or both of these symptoms. However, these symptoms remain common complaints for both patients with a history of rhinosinusitis, sinonasal surgery, or both, and those without any demonstrable evidence for rhinosinusitis.
KENNY et al
43
CONCLUSION
Our findings suggest that the severity of selected sinus symptoms does correlate with the severity of CT imaging evidence for rhinosinusitis. Patients with more severe symptom scores are more likely to have CT imaging evidence supporting the diagnosis of rhinosinusitis. High symptom scores can improve the physician’s confidence in the diagnosis and support treatment without further imaging studies so long as clinical evidence of complications are not present. In patients with isolated headache and/or facial pain or pressure, the likelihood of rhinosinusitis is less, even if symptoms are severe. Therefore, in this group of patients, sinus CT scan should be considered before treatment to establish the diagnosis of rhinosinusitis. A number of these patients do not have rhinosinusitis. The reinforcement of the patients perception of rhinosinusitis when there is not rhinosinusitis can lead to future difficulties in managing the patients pain. REFERENCES 1. Williams JW Jr, Simel DL, Roberts L, et al. Clinical evaluation for rhinosinusitis: making the diagnosis by history and physical examination. Ann Intern Med 1992;117:705-10. 2. Bhattacharyya T, Picirillo JF, Wippold FJ 2nd. Relationship between patient-based descriptions of rhinosinusitis and paranasal sinus computed tomographic findings. Arch Otolaryngol Head Neck Surg 1997;123:1189-92. 3. Calhoun KH, Waggenspack GA, Simpson B, et al. CT evaluation of the paranasal sinuses in symptomatic and asymptomatic populations. Otolaryngol Head Neck Surg 1991;104:480-3. 4. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991;101:56-64. 5. Flinn J, Chapman ME, Wightman AJA, et al. A prospective analysis of incidental paranasal sinus abnormalities on CT head scans. Clin Otolaryngol 1994;19:287-9. 6. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolarygol Head Neck Surg 1997;117:S1-S7. 7. Piccirillo JF, Edwards D, Haiduk A, et al. Psychometric and clinimetric validity of the 31-item Rhinosinusitis Outcome Measure (RSOM-31). Am J Rhinol 1995;9:297-306. 8. Juniper E, Guyatt GH. Development and testing of a new measure of health status for clinical trials in rhinoconjunctivitis. Clinical and Experimental Allergy 1991;21:77-83. 9. Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolarygol Head Neck Surg 1997;117:S35-S40.
OBJECTIVES: We designed a prospective study to determine whether there is a correlation between the severity of sinus symptoms and the severity of computed tomography (CT) scan evidence of rhinosinusitis. METHODS: Acute and chronic rhinosinusitis patients rated their symptoms and had a CT scan of the sinuses taken the same day. A Likert severity scale and standardized CT scoring system were used. Data were analyzed by nonparametric methods with Kendall’s rank correlation coefficient. RESULTS: The severity of 5 symptoms correlated with severity of disease on CT scan. Headache and facial pain or pressure had no correlation. CONCLUSION: The certainty of a clinical diagnosis of rhinosinusitis requiring treatment is enhanced in patients with high symptom severity scores for fatigue, sleep disturbance, nasal discharge, nasal blockage, or decreased sense of smell. Isolated headache and facial pain or pressure are less reliable predictors of CT scan findings supporting the diagnosis rhinosinusitis. (Otolaryngol Head Neck Surg 2001;125:40-3.)
The common complaints of facial pressure or pain and headache leading to treatment for rhinosinusitis by the primary medical doctor and subsequent referral to otolaryngologists has led us to search for guidelines for the evaluation and treatment of patients with sinus symptoms. The diagnosis of rhinosinusitis is said to be one based on clinical history and physical examination. Maxillary From the Department of Otolaryngology, The Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences (Drs Kenny, Duncavage, and Yildirim), and The Vanderbilt Asthma, Sinus, and Allergy Program (Drs Duncavage, Bracikowski, Murray, and Tanner), Nashville, Tennessee. Reprint requests: Thomas J. Kenny, MD, The Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences, Department of Otolaryngology, Medical Center North, Vanderbilt University Medical Center, Nashville, TN 37232-2559; e-mail, [email protected]. Copyright © 2001 by the American Academy of Otolaryngology— Head and Neck Surgery Foundation, Inc. 0194-5998/2001/$35.00 + 0 23/1/116779 doi:10.1067/mhn.2001.116779 40
toothache, abnormal transillumination, poor response to decongestants, and a history or physical examination finding of purulent nasal discharge have been reported as independent predictors of rhinosinusitis.1 Otolaryngologists often obtain computed tomography (CT) scans of the paranasal sinuses to delineate the extent of paranasal sinus disease. Yet there are varying reports of both positive and negative correlation between sino-nasal symptoms and CT evidence of rhinosinusitis.2-4 CT scanning of the paranasal sinuses is now the preferred mode of imaging this complex area for the purposes of diagnosis, disease monitoring, and surgical planning. CT scan alone is neither sufficiently sensitive nor specific for use as a primary diagnostic method for rhinosinusitis as patients with abnormal sino-nasal findings have been detected when undergoing scanning for unrelated reasons.3,5 We therefore designed a prospective study to determine if there was any correlation between the severity of symptoms and CT scan evidence of rhinosinusitis. METHODS AND MATERIALS Three hundred four patients with acute or chronic rhinosinusitis seen at the Vanderbilt University Asthma, Sinus, and Allergy Program (ASAP) with symptoms of sinus disease between March and September of 1998 were prospectively analyzed to detect whether or not the severity of their symptoms correlated with CT scan evidence of rhinosinusitis. Patients were included in the study if they were symptomatic for at least 7 days before enrollment, met diagnostic criterion for rhinosinusitis as established by the Task Force on Rhinosinusitis,6 had a CT scan performed at the same visit, and agreed to complete our questionnaire. The Rhinosinusitis Outcome Measure (RSOM-31) (Piccirillo et al7) and the Rhinoconjuctivitis Quality of Life Questionnaire (Juniper and Guyatt8) are two valid and reliable clinical measures of paranasal sinus symptoms. The Vanderbilt ASAP center has adapted portions of these two reliable clinical outcome questionnaires and incorporated 7 of these questions into a standard questionnaire filled out by each patient. Patients completed our standard questionnaire and rated their symptoms from 0 (not troubled) to 6 (extremely troubled) by using a Likert severity scale (Table 1). Although these questions have not yet been validated, we feel these 7 questions are consistent with the most common symptoms that patients and primary care physicians believe to be associated with rhinosinusitis.
Otolaryngology– Head and Neck Surgery Volume 125 Number 1
KENNY et al
41
Fig 1. Data from 273 patients for the symptom “headache.” There are between 30 and 60 patients in each Likert score interval. There was no correlation between symptom “headache” and CT scan score.
Table 1. Sample of ASAP Symptom Severity Questionnaire
Symptom
Not troubled
Hardly troubled
Somewhat troubled
Moderately troubled
Quite a bit troubled
Very troubled
0
1
2
3
4
5
Extremely troubled
6
Our Likert severity scale ranges from a score of 0 to 6.
CT scans were performed on a TCT-60 AX Toshiba scanner (Nassau, Japan) at 120 kV and 150 mA with 5-mm cuts at 5-mm intervals with gantry tilt, a 2-second scan time, and in the coronal plane. CT scans were scored by using the modified Mckay-Lund classification scoring system. This system was chosen for its ease of interpretation, intraobserver and interobserver reliability, and because it has been recommended by the Task Force on Rhinosinusitis for future outcome research.9 The scans were then scored by our CT technician and overread by a staff radiologist, both of whom were blinded to the patients symptom scores. Our data was nonparametric and we therefore analyzed this with a nonparametric statistical method by ranking the patient’s individual symptom scores, sum total symptom scores, and sum symptom scores for 5 symptoms including fatigue, sleep disturbance, nasal discharge or postnasal drip, stuffy or blocked nose, and decreased sense of smell with their total CT scan score. A Kendall Rank Correlation Coefficient analysis was performed on the data by using the computer software StatView (Abacus, Inc, Berkeley, CA). A p value of less than 0.05 was considered to be statistically significant. RESULTS
Twenty-nine patients had incomplete questionnaires and 2 patients had total symptom scores of zero. After
excluding these patients, 273 patients met inclusion criterion. One hundred fifty-eight (58%) patients were female and 115 (42%) were male. The average age of our patients was 43.5 years with a range of 8 years to 82 years old. Of the 7 questions analyzed, the severity of 5 symptoms (fatigue P = 0.0054, tau (t) = 0.089; lack of a good night’s sleep P = 0.0051, t = 0.09; nasal discharge or postnasal drip P = 0.0049, t = 0.091; stuffy blocked nose P = 0.0028, t = 0.096; and decreased sense of smell P = 0.0005, t = 0.112) were found to individually correlate with severity of disease on CT scan. Interestingly, severity of headache (P = 0.8385, t= 0.007) (Fig 1) and facial pain or pressure (P = 0.439, t = 0.025) (Fig 2) had no correlation to severity of disease on CT scan. We then ranked the sum of all 7 symptoms from each patient and compared them with the rank of their CT scores and still found a statistically significant correlation between the severity of the sum of these 7 symptoms and the severity of the CT scan evidence for rhinosinusitis (P = 0.0011, t = 0.112). After deleting the scores for headache and facial pain or pressure, a comparison was made between the remaining 5 scores and the CT scan score. We found a highly significant correlation relating the severity of the sum of these 5 symp-
42
Otolaryngology– Head and Neck Surgery July 2001
KENNY et al
Fig 2. Data from 273 patients for the symptom “facial pain/pressure.” There are between 30 and 60 patients in each Likert score interval. There was no correlation between the symptom “facial pain/pressure” and CT scan score.
Fig 3. Data from 273 patients for the symptoms “fatigue, lack of a good night’s sleep, nasal discharge or postnasal drip, blocked or stuffy nose, and decreased sense of smell” are represented in this bar graph. The x axis represents the sum of these five symptom severity scores for each patient. Each patient had their score entered in the appropriate Likert interval. There were between 30 to 60 patients in each interval. The y axis represents the average CT score of the patients from each Likert score interval. These 5 symptoms were found to correlate both individually and when summed with the severity of their CT scans.
toms (fatigue, lack of a good night’s sleep, nasal discharge or postnasal drip, stuffy blocked nose, and decreased sense of smell) and the severity of the CT scan score (P = 0.0001, t = 0.129) (Fig 3).
DISCUSSION
The literature regarding correlation between sinonasal complaints and CT scan evidence of paranasal sinus disease is not in agreement. Bhattacharyya et al2
Otolaryngology– Head and Neck Surgery Volume 125 Number 1
used the Sino-Nasal Outcome Test 20 (SNOT-20), which is a shorter version of the RSOM-31 to compare patient-based symptoms with sinus CT imaging in patients referred for sinus CT. They found no correlation between the total SNOT-20 score or the individual score on the facial pain or pressure question and CT imaging evidence of rhinosinusitis.2 In a study by Flinn et al5 of patients referred for head CT scan, they state that paranasal sinus abnormalities on CT scan are common and found that 27% of patients in their study with no symptoms of rhinosinusitis had sinus opacification.5 In contrast to this, Calhoun et al3 concluded that although CT scans of patients without symptoms of sinus disease do show some incidental sinus abnormalities, the incidence of such abnormalities is significantly greater in patients with a history of “sinus-type symptoms.” Bolger et al4 found that mucosal abnormalities occurred in 153 (92.2%) of 166 patients scanned for chronic sinus complaints and in 15 (41.7%) of 36 patients scanned for non-sinus reasons. At the time of this writing, our study is the first prospective analysis that demonstrates a correlation between the severity of CT scan evidence for rhinosinusitis and the severity of the patient’s report of fatigue, sleep disturbance, nasal discharge or post nasal drip, nasal blockage, and decreased sense of smell. We also confirmed the lack of correlation between CT findings of rhinosinusitis and headache or facial pain or pressure noted by Bhattacharyya et al.2 Our data suggest that the clinical diagnosis of rhinosinusitis is enhanced by high symptom scores for symptoms other than headache or facial pain or pressure. The symptoms “headache” and “facial pain or pressure” remain an enigma. Patients who have rhinosinusitis can undeniably have one or both of these symptoms. However, these symptoms remain common complaints for both patients with a history of rhinosinusitis, sinonasal surgery, or both, and those without any demonstrable evidence for rhinosinusitis.
KENNY et al
43
CONCLUSION
Our findings suggest that the severity of selected sinus symptoms does correlate with the severity of CT imaging evidence for rhinosinusitis. Patients with more severe symptom scores are more likely to have CT imaging evidence supporting the diagnosis of rhinosinusitis. High symptom scores can improve the physician’s confidence in the diagnosis and support treatment without further imaging studies so long as clinical evidence of complications are not present. In patients with isolated headache and/or facial pain or pressure, the likelihood of rhinosinusitis is less, even if symptoms are severe. Therefore, in this group of patients, sinus CT scan should be considered before treatment to establish the diagnosis of rhinosinusitis. A number of these patients do not have rhinosinusitis. The reinforcement of the patients perception of rhinosinusitis when there is not rhinosinusitis can lead to future difficulties in managing the patients pain. REFERENCES 1. Williams JW Jr, Simel DL, Roberts L, et al. Clinical evaluation for rhinosinusitis: making the diagnosis by history and physical examination. Ann Intern Med 1992;117:705-10. 2. Bhattacharyya T, Picirillo JF, Wippold FJ 2nd. Relationship between patient-based descriptions of rhinosinusitis and paranasal sinus computed tomographic findings. Arch Otolaryngol Head Neck Surg 1997;123:1189-92. 3. Calhoun KH, Waggenspack GA, Simpson B, et al. CT evaluation of the paranasal sinuses in symptomatic and asymptomatic populations. Otolaryngol Head Neck Surg 1991;104:480-3. 4. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991;101:56-64. 5. Flinn J, Chapman ME, Wightman AJA, et al. A prospective analysis of incidental paranasal sinus abnormalities on CT head scans. Clin Otolaryngol 1994;19:287-9. 6. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolarygol Head Neck Surg 1997;117:S1-S7. 7. Piccirillo JF, Edwards D, Haiduk A, et al. Psychometric and clinimetric validity of the 31-item Rhinosinusitis Outcome Measure (RSOM-31). Am J Rhinol 1995;9:297-306. 8. Juniper E, Guyatt GH. Development and testing of a new measure of health status for clinical trials in rhinoconjunctivitis. Clinical and Experimental Allergy 1991;21:77-83. 9. Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolarygol Head Neck Surg 1997;117:S35-S40.