What is the treatment for a patient with extensive sinusitis on CT who is asymptomatic?

Management of Asymptomatic Sinusitis on CT

Asymptomatic sinusitis found on CT scans should not be treated as it represents a normal variant in healthy individuals and does not require intervention. 1

Prevalence and Clinical Significance

Sinus abnormalities on imaging are extremely common in asymptomatic individuals:

• 3-40% of asymptomatic adults show abnormalities on sinus CT scans 1
• 42% of healthy children demonstrate significant maxillary sinus abnormalities 1
• 97% of infants who had a cold in the 2 weeks before a head CT showed sinus abnormalities 1

A study examining CT findings across different patient groups found that only 3% of asymptomatic patients had positive sinus CT findings, compared to 64% in chronically symptomatic patients 2. This reinforces that radiographic findings without corresponding symptoms should not be considered pathological.

Evidence-Based Approach

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines explicitly state that:

1. Radiographic imaging is unnecessary for patients who already meet clinical diagnostic criteria for acute bacterial rhinosinusitis 3
2. Imaging findings must be interpreted in conjunction with clinical findings 3, 1
3. The absence of symptoms makes treatment unnecessary, regardless of CT findings 1

Why Treatment Is Not Indicated

Several important reasons support non-intervention for asymptomatic sinusitis:

• Normal variant: Mucosal thickening and sinus opacification can be normal findings, especially following recent viral upper respiratory infections 1
• Antibiotic stewardship: Treating based solely on imaging findings leads to unnecessary antibiotic use 1
• Lack of benefit: Without symptoms, there is no quality of life improvement to be gained from treatment
• Potential harm: Medications used to treat sinusitis carry risks and side effects that aren't justified without symptoms

Special Considerations

While treatment is generally not indicated, certain clinical scenarios warrant closer attention:

• Immunocompromised patients: These individuals may require closer monitoring as they are at higher risk for invasive fungal sinusitis 3
• Pre-surgical evaluation: Incidental findings may be relevant when planning unrelated surgeries, particularly those involving the skull base
• Progressive changes: If serial imaging shows worsening findings despite continued absence of symptoms, further evaluation may be appropriate

Conclusion

Radiographic abnormalities alone are insufficient for diagnosis of sinusitis requiring treatment. The AAO-HNS guidelines emphasize that clinical correlation is necessary to avoid overdiagnosis 3, 1. In the absence of symptoms, even extensive sinusitis findings on CT should be considered incidental and do not require medical or surgical intervention.