Are X-ray (X-ray) views of the sinuses required?

X-ray Views of the Sinuses Are Not Required for Diagnosis of Uncomplicated Sinusitis

X-ray views of the sinuses are not recommended for patients with suspected uncomplicated sinusitis, as imaging is unnecessary for clinical diagnosis of acute rhinosinusitis. 1 Plain radiographs have poor sensitivity and specificity compared to CT scans and do not accurately distinguish between viral and bacterial sinusitis.

Evidence Against Routine Sinus X-rays

Guidelines Recommendations

• The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) explicitly recommends that clinicians should not obtain radiographic imaging for patients with suspected uncomplicated acute rhinosinusitis 1
• Imaging should be reserved only for cases with clinically suspected complications 1
• The European Position Paper on Rhinosinusitis (EPOS) confirms that in acute rhinosinusitis, diagnosis is made on clinical grounds and CT is not recommended unless complications are suspected 1

Limitations of Plain Radiographs

• Radiography lacks specificity for identifying acute bacterial rhinosinusitis, as sinus fluid can also be seen with viral upper respiratory tract infections 1
• Plain radiographs have poor sensitivity for different sinuses:
  • 25-41% sensitivity for most sinus groups
  • 80% sensitivity for maxillary sinuses only 1
  • 51.8% sensitivity for ethmoid disease 2
• High false-positive rates (32% for maxillary sinuses, higher for other sinuses) 2
• Cannot adequately evaluate chronic sinusitis or provide surgical planning information 2

When Imaging May Be Indicated

Specific Clinical Scenarios

• Suspected complications (orbital, intracranial) 1
• Immunocompromised patients 1, 2
• Failure of appropriate medical or surgical treatment with continued symptoms and abnormal endoscopy 1
• Recurrent acute sinusitis or chronic sinusitis prior to surgical intervention 2
• Suspected neoplasia or invasive fungal rhinosinusitis 1

Preferred Imaging Modalities

• CT without contrast is the gold standard for sinus imaging when indicated 2
• MRI is preferred for suspected intracranial complications, fungal sinusitis, or to differentiate inflammatory disease from tumors 2
• If CT is unavailable and imaging is absolutely necessary, the Waters view (occipito-mental) is the most useful single plain radiograph for evaluating maxillary sinuses, with 84.2% sensitivity and 76.6% specificity 2, 3

Clinical Diagnosis of Sinusitis

The diagnosis of acute sinusitis should be based on:

• Clinical history and physical examination findings 1
• Symptoms including purulent nasal drainage, nasal obstruction, and localized sinus pain/pressure persisting without improvement for at least 10 days 1
• "Double sickening" pattern (symptoms worsen within 10 days after initial improvement) 1
• Nasal examination findings such as mucosal erythema and purulent secretions 1

Common Pitfalls to Avoid

• Ordering sinus X-rays for uncomplicated acute sinusitis, which adds cost without changing management 1, 4
• Misinterpreting radiographic findings as bacterial sinusitis when they may represent viral infection 1
• Relying on plain radiographs for evaluation of ethmoid, frontal, or sphenoid sinuses, which have very poor sensitivity 5, 3
• Failing to recognize that mucosal thickening and other sinus abnormalities can be seen in 40% of asymptomatic adults on CT 4

In summary, X-ray views of the sinuses are not required for diagnosis of uncomplicated sinusitis. Clinical criteria should be used instead, with imaging reserved for cases with suspected complications or those that fail to respond to appropriate treatment.