消除疼痛可提高成人慢性鼻-鼻窦炎临床诊断标准的特异性。
Elimination of pain improves specificity of clinical diagnostic criteria for adult chronic rhinosinusitis.
作者信息
Hirsch Scott D, Reiter Evan R, DiNardo Laurence J, Wan Wen, Schuman Theodore A
机构信息
Virginia Commonwealth University School of Medicine, Richmond, Virginia, U.S.A.
Department of Otolaryngology-Head & Neck Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, U.S.A.
出版信息
Laryngoscope. 2017 May;127(5):1011-1016. doi: 10.1002/lary.26442. Epub 2017 Jan 6.
OBJECTIVE
Determine whether the elimination of pain improves accuracy of clinical diagnostic criteria for adult chronic rhinosinusitis.
STUDY DESIGN
Retrospective cohort study.
METHODS
History, symptoms, nasal endoscopy, and computed tomography (CT) results were analyzed for 1,186 adults referred to an academic otolaryngology clinic with presumptive diagnosis of chronic rhinosinusitis. Clinical diagnosis was rendered using the 1997 Rhinosinusitis Taskforce (RSTF) Guidelines and a modified version eliminating facial pain, ear pain, dental pain, and headache.
RESULTS
Four hundred seventy-nine subjects (40%) met inclusion criteria. Among subjects positive by RSTF guidelines, 45% lacked objective evidence of sinonasal inflammation by CT, 48% by endoscopy, and 34% by either modality. Applying modified RSTF diagnostic criteria, 39% lacked sinonasal inflammation by CT, 38% by endoscopy, and 24% by either modality. Using either abnormal CT or endoscopy as the reference standard, modified diagnostic criteria yielded a statistically significant increase in specificity from 37.1% to 65.1%, with a nonsignificant decrease in sensitivity from 79.2% to 70.3%. Analysis of comorbidities revealed temporomandibular joint disorder, chronic cervical pain, depression/anxiety, and psychiatric medication use to be negatively associated with objective inflammation on CT or endoscopy.
CONCLUSION
Clinical diagnostic criteria overestimate the prevalence of chronic rhinosinusitis. Removing facial pain, ear pain, dental pain, and headache increased specificity without a concordant loss in sensitivity. Given the high prevalence of sinusitis, improved clinical diagnostic criteria may assist primary care providers in more accurately predicting the presence of inflammation, thereby reducing inappropriate antibiotic use or delayed referral for evaluation of primary headache syndromes.
LEVEL OF EVIDENCE
- Laryngoscope, 127:1011-1016, 2017.
目的
确定消除疼痛是否能提高成人慢性鼻-鼻窦炎临床诊断标准的准确性。
研究设计
回顾性队列研究。
方法
对1186名因疑似慢性鼻-鼻窦炎转诊至一所学术性耳鼻喉科诊所的成年人的病史、症状、鼻内镜检查及计算机断层扫描（CT）结果进行分析。临床诊断依据1997年鼻窦炎工作组（RSTF）指南以及一个去除面部疼痛、耳部疼痛、牙痛和头痛的修订版进行。
结果
479名受试者（40%）符合纳入标准。在RSTF指南诊断为阳性的受试者中，45%缺乏CT显示的鼻窦炎症客观证据，48%缺乏鼻内镜检查显示的证据，34%缺乏两种检查方式中任一种显示的证据。应用修订后的RSTF诊断标准，39%缺乏CT显示的鼻窦炎症，38%缺乏鼻内镜检查显示的证据，24%缺乏两种检查方式中任一种显示的证据。以CT或鼻内镜检查异常作为参考标准，修订后的诊断标准特异性从37.1%显著提高至65.1%，敏感性从79.2%降至70.3%，但差异无统计学意义。合并症分析显示，颞下颌关节紊乱、慢性颈痛、抑郁/焦虑以及使用精神科药物与CT或鼻内镜检查显示的客观炎症呈负相关。
结论
临床诊断标准高估了慢性鼻-鼻窦炎的患病率。去除面部疼痛﹑耳部疼痛﹑牙痛和头痛可提高特异性，且敏感性无相应降低。鉴于鼻窦炎的高患病率，改进后的临床诊断标准可能有助于初级保健提供者更准确地预测炎症的存在，从而减少不适当的抗生素使用或延迟对原发性头痛综合征进行评估的转诊。
证据级别
4级。《喉镜》，2017年，第127卷，第1011 - 1016页。
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