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Dr. James Duncavage looks at a set of sinus CT scans with April Yates, radiology technician, at the ASAP Clinic. CTs were used in the study which analyzed sinus symptoms and their correlation to findings in CT scans. (photo by Dana Johnson)

Fatigue strong indicator of sinus infection

BY: BARB CRAMER

9/22/2000 - Vanderbilt University Medical Center researchers say headache pain and pressure are not symptoms of a sinus infection, as traditional medical thought has been.

In a new study to be published this fall in the Head and Neck Surgery Journal, researchers have determined that extreme fatigue is more likely an indicator of a sinus infection.

Dr. James A. Duncavage, professor of Otolaryngology, directed the study which analyzed sinus symptoms and their correlation to findings in paranasal CT (computed tomography) scans.

“We have good science and good data here that support the fact that with sinus pain and pressure symptoms, and the absence of any findings of infection, either through increased temperature or the patient having some tenderness over the sinuses, the patients do not have sinusitis,” said Duncavage.

“This finding will ultimately change the way doctors treat patients. It will take time, but we need to get the message out to better treat patients.”

Assisting in the study were Dr. Thomas J. Kenny, chief resident in Otolaryngology; Dr. James P. Bracikowski, assistant professor of Medicine; Dr. Altan Yildirim, visiting otolaryngology professor from Turkey; Dr. John J. Murray, M.D., Ph.D., associate professor of Medicine; and Dr. S. Bobo Tanner, IV, assistant professor of Medicine.

The study is already accepted for publication in the Academy of Otolaryngology Journal.

In the study, 273 acute and chronic rhino-sinusitis patients rated their symptoms and had a CT scan of the sinuses taken the same day.

Researchers found that the severity of five symptoms correlated with the severity of disease on the CT scan, while headache and facial pain or pressure had no correlation.

Duncavage says the researchers concluded that if patients had symptoms of fatigue, sleep disturbance, nasal discharge, nasal blockage, or a decreased sense of smell, they would likely have a sinus infection.

An isolated headache and facial pain or pressure were less reliable predictors of a sinus infection.

Tradition has been that the diagnosis of rhino-sinusitis or sinus infection has been based on the patient’s history and a physical exam. Toothaches and a poor response to decongestants also have been considered predictors of a sinus infection.

This new study changes that.

“This is the first prospective analysis that demonstrates a correlation between the severity of CT scan evidence for rhino-sinusitis and the severity of patient reports of fatigue, sleep disturbance, nasal discharge or post nasal drip, nasal blockage and decreased sense of smell,” Duncavage said.

“I hope our study shows physicians that they must realize that the severity of selected sinus symptoms does correlate with the severity of CT imaging evidence for rhino-sinusitis. The high symptom scores can improve the physician’s confidence in the diagnosis and support treatment without further imaging studies.

Duncavage says he would treat these patients first with antibiotics. Then, if necessary, he would do a CT scan.

“The study should also help physicians realize that in patients with an isolated headache and/or facial pain or pressure, even if severe, sinus CT scans should be considered before sinus treatment, early on in their evaluation phase. It is very likely the headache and pain is caused by some other problem, not a sinus infection.”

Duncavage says that in chronic sinus disease, the most common symptom he has observed is that patients have fatigue.

“I have asked them, ‘Do you feel tired?’ and some of the patients will actually break into tears. They will say, ‘I have been so tired. There has got to be something wrong and nobody has been able to figure out what it is.

“After I have treated them successfully for their sinus infection, they report that they have had a major improvement in their energy level.”

Duncavage says the most common diagnosis for patients with a headache and pain or pressure is either a jaw disorder, migraine or vascular headaches or allergy-related problems.

“Many of the patients who present are fairly desperate and are seeking help, but in order to be helped they have to have the correct diagnosis. The reason they continue with the problem is that they haven’t had the correct diagnosis. It usually is not sinusitis.

“The bottom line is the sicker the patients feel as far as their pain and pressure, the less likely they are to have sinusitis. The ones that just feel blah or don’t have any energy and don’t have any pain over the involved sinuses, are more likely to have sinusitis.”

Duncavage says regardless of the diagnosis, all the patients can be helped.

“The key thing in health care is we have to have a diagnosis and then we can provide treatment.”

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