Use of sinus x ray films by general practitioners

BMJ 1994; 308 doi: http://dx.doi.org/10.1136/bmj.308.6944.1608 (Published 18 June 1994)
Cite this as: BMJ 1994;308:1608
  1. D J Hougton,
  2. F A Aitchison,
  3. L Wilkinson,
  4. J A Wilson
  1. Department of Otolaryngology, Head, and Neck Surgery, Royal Infirmary, Glasgow G31 2ER
  2. Department of Radiology, Royal Infirmary, Glasgow G31 2ER
  1. Correspondence to: Miss Wilson.
  • Accepted 3 February 1994

Recent guidelines published by the Royal College of Radiologists suggest that plain sinus radiography is not indicated in the routine management of sinusitis and should be requested only by specialists.1 This approach may be justified by the large radiation exposure (equivalent to five chest x ray procedures) and by the finding of abnormalities on x ray films of the sinus in up to half of the population.2,3 We assessed the prevailing use of sinus x ray films by general practitioners and surveyed current practice in sinus examination in radiology departments in the United Kingdom.

Methods

and results

All 694 general practitioners in Greater Glasgow were sent a postal questionnaire asking about their use and interpretation of sinus x ray films. The routine sinus x ray views used in 50 hospitals throughout the United Kingdom (19 teaching, 29 district, two paediatric) were also surveyed.

Responses were received from 584 general practitioners (84%). Of these, only 136 (23%) never requested sinus x ray films. Most of the remainder requested an estimated one to three (286) or three to five (109) annually. The table gives the indications selected by the 448 regular users from those listed. Most believed that sinus radiography was occasionally (269) or always (116) indicated when a patient was referred to an otorhinolaryngology specialist. Of the suggested findings, the four most likely to influence management were antral opacity (349), deviated nasal septum (345), frontal opacity (336), and nasal polyps (332). Sinus haziness, ethmoid mucosal thickening, and ethmoid disease were much less likely to influence management.

View this table:
TABLE I

Indications for sinus radiography according to 448 general practitioners who regularly request it

View this table:
TABLE 2

Reported rates of vulovovagnial candidiasis in women with cystic fibrosis and controls

Half of the 50 radiology departments provided general practitioners with one occipitometrial view; the rest used this with occipitofrontal (13), lateral (three), or both (eight) views. One (children's) department did not accept direct requests from general practitioners. Eight departments provided a greater number of views (up to four) for otolaryngologists than they did for general practitioners.

Comment

The excellent response to our survey indicates much interest in this subject among general practitioners, over three quarters of whom used sinus radiography. Is the investigation helpful? The commonest indication was persistent facial pain. If this is due to chronic rhinosinusitis, it is usually associated with other symptoms. Patients with recurrent attacks of acute sinusitis could have radiographs taken during remission of symptoms. In any case, the single view offered to general practitioners by half of the radiology departments surveyed shows adequately only one of the four main paranasal sinuses (the maxillary antra), whose x ray appearances differ from findings at antroscopy in over half of patients.4 The third most common indication seems to be pressure from patients, which it is hoped will be offset by invoking the guidelines.

Most general practitioners are aware of the low weight of the more nebulous findings such as mucosal thickening and haziness and rightly perceive that hard findings include deviated nasal septum and nasal polyps. Such intranasal disease is more appropriately shown by anterior rhinoscopy, which general practitioners can easily perform with an auroscope. Most otolaryngologists now find little benefit from prereferral sinus radiology; a full trial of topical nasal steroid treatment is of greater value. Although rhinologists prefer computed tomography when indicated, the examination shows a high incidence (over 40%) of abnormalities in symptom free subjects5 and entails considerable exposure to radiation (equivalent to that used in 200 chest radiographs1).

The revolution in management of nasal disease in the United Kingdom since the introduction of diagnostic and therapeutic nasendoscopy in the mid-1980s supports the implementation of the guidelines. We propose that general practitioners should no longer request sinus radiography; that they should give a full trial of topical steroid treatment to patients with chronic, non-specific rhinosinusitis; and that they should refer for specialist assessment those who fail to respond and those who are suspected of having a neoplasm, polyp, or other structural nasal abnormality.

This study was supported by an award from the Guthrie Trust of the Scottish Otolaryngological Society.

References

THIS WEEK'S POLL