The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–7, 2013
Copyright Ó 2013 Elsevier Inc.
Printed in the USA. All rights reserved
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http://dx.doi.org/10.1016/j.jemermed.2013.08.016

Original
Contributions

FINDINGS OF CHRONIC SINUSITIS ON BRAIN COMPUTED TOMOGRAPHY ARE NOT

ASSOCIATED WITH ACUTE HEADACHES

Katherine E. Kroll, MD,* Marc A. Camacho, MD, MS,† Shiva Gautam, PHD,‡ Robin B. Levenson, MD,† and
Jonathan A. Edlow, MD*
*Department of Emergency Medicine, †Department of Radiology, and ‡Department of Medicine, Beth Israel Deaconess Medical Center,
Boston, Massachusetts
Reprint Address: Jonathan A. Edlow, MD, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road,
West Clinical Center 2, Boston, MA 02215

, Abstract—Background: Headache is a common com- , Keywords—headache; sinusitis; CT scan; chronic sinus-

plaint in emergency department (ED) patients. Nearly 15%
of ED headache patients will have brain computed tomogra-
phy (CT) done. One frequent finding on these scans is
‘‘chronic sinusitis.’’ Assuming that ‘‘chronic sinusitis’’ is
the cause of the patient’s headache is a potential source of
mis-diagnosis. Study Objective: We hypothesized that CT
findings of chronic sinusitis occur with equal frequency in
patients with atraumatic headache as in control patients
with minor head injury. Methods: This is a retrospective,
single-center medical record review of consecutive dis-
charged patients who received noncontrast head CT scans
in an urban ED for either minor closed head injury or atrau-
matic headache. Each patient’s head CT radiologic report
was reviewed for findings of sinusitis and classified as chronic
sinusitis, indeterminate for sinusitis, air-fluid levels, or no
findings of sinusitis. Results: We enrolled 500 patients (234
in the atraumatic headache group, 266 in the minor head in-
jury group). The two groups were similar except that more
women were enrolled in the atraumatic headache group.
CT findings of chronic sinusitis in the atraumatic headache
group (22.2%) and the minor head injury group (17.7%;
difference 4.5%; 95% confidence interval of 2.5–11.6%).
Conclusion: Prevalence of CT findings of sinusitis in
ED patients with atraumatic headaches and mild head
injury are similar. This strongly suggests that CT findings
of chronic sinusitis in patients with atraumatic headache
may be incidental, and are rarely the cause of a patient’s
acute headache. Ó 2013 Elsevier Inc.
itis; diagnostic error
INTRODUCTION
Background
Headache is a common chief complaint among emergency
department (ED) patients (1). Whereas the majority of
these patients have benign primary headache disorders
(often tension-type and migraine), a small percentage
have more serious, secondary causes (2). Accurate distinc-
tion between these two categories is important to correctly
treat both groups.
Nearly 15% of ED patients with acute headache have
brain imaging done, usually computed tomography (CT)
of the brain (1). These scans often show findings consis-
tent with ‘‘sinusitis,’’ sometimes with the modifier
‘‘chronic.’’ In one large study, 42.5% of asymptomatic in-
dividuals had some sort of abnormality in one of the para-
nasal sinuses (3). Although patients and physicians alike
often ascribe acute headache to ‘‘sinusitis’’ or ‘‘sinus
headache,’’ these types of headaches are actually not
very common, as most ‘‘sinus headaches’’ are actually
migraine or tension-type headaches (4–8).

RECEIVED: 4 October 2012; FINAL SUBMISSION RECEIVED: 27 June 2013;

ACCEPTED: 7 August 2013

1
2 K. E. Kroll et al.
Thus, one potential cause of misdiagnosis is premature
diagnostic closure after a patient is found to have chronic
sinusitis findings on CT, then assuming that this is the
cause of the patient’s headache. The diagnosis of ‘‘sinus-
itis’’ is commonly reported in multiple studies of misdiag-
nosed subarachnoid hemorrhage; however, no causality
with respect to incidental CT findings was reported in
these studies (9–11). One specific cause of misdiagnosis
of a serious headache is incorrectly diagnosing sinusitis
in patients with headache whose brain CT scans were
reported as showing evidence of chronic sinusitis (12).
Although prior studies have recorded the incidence of
chronic sinusitis findings in asymptomatic individuals,
none has specifically compared these findings in patients
with acute headaches vs. a control group.
Goals of this Investigation
Our hypothesis was that CT findings of chronic sinusitis,
such as mucosal thickening, occur with equal frequency
in patients with atraumatic headache as in control pa-
tients. Our objective was to quantify and compare the fre-
quency of radiographic findings indicative of chronic
sinusitis in ED patients presenting with atraumatic head-
ache to those presenting with minor closed head injury.
MATERIALS AND METHODS
Study Design
We performed a retrospective, single-center descriptive
review of electronic medical records of consecutive pa-
tients who received noncontrast head CT scans in a busy
urban, tertiary care ED between October 2007 and April
2008 for reasons of either minor closed head injury or
atraumatic headache and who were subsequently dis-
charged home. Our hospital’s institutional review board
approved the study.
Setting
The study institution is an academic, tertiary care, Level I
trauma center located in Boston, Massachusetts. The
annual ED census is approximately 55,000 patients.
Selection of Participants
We collected data on patients who had a head CT scan
performed while in the ED. Noncontrast head CT scans
were ordered at the discretion of the treating teams during
each subject’s ED evaluation, which resulted in the final
ED diagnosis. The indication for each CT scan was deter-
mined by reviewing the provider order entry field. The
study group included patients with a diagnosis of atrau-
matic headache. The control group was patients with a di-
agnosis of minor head injury. We enrolled only patients
who were discharged home from the ED. We specifically
chose discharged patients as our subjects for two reasons:
1) patients with headaches thought to be due to sinusitis
would very rarely be admitted to the hospital and 2) to
avoid the potential confounder of inadvertently including
patients with more significant head trauma whose CT
scans may show mucosal changes or air fluid levels due
to acute bleeding from underlying skull fractures, rather
than mucosal changes related to chronic sinusitis.
The raw data were obtained from medical center data
management services, which queried the hospital’s elec-
tronic medical record and billing database (Casemix TSI,
Boston, MA) using a structured search designed to detect
all patients who received a CT scan for these diagnoses
during the study period. Patients were identified using
discharge International Classification of Diseases, Ninth
Revision (ICD-9) diagnosis codes (Appendix 1). For the
study group, this excluded patients with specific second-
ary etiologies of their headache (e.g., subarachnoid hem-
orrhage, idiopathic intracranial hypertension). For the
controls, this excluded patients with major head trauma
(e.g., intracranial hemorrhage, skull fractures) in whom
nonspecific sinus findings may have been due to acute
blood.
Methods of Measurement and Data Collection
We reviewed patients’ records to extract data on their
noncontrast head CT scan interpretations and specific de-
mographic information. One trained data collector (K.K.)
abstracted data from the ICD-9 code-based database as
well as from patient charts and recorded the information
onto a prespecified spreadsheet. The abstractor was an
emergency medicine resident who was not blinded to
the purpose of the study.
Key demographic variables collected about each case
included age, sex, race/ethnicity, date of visit, and trauma
mechanism. Each patient’s head CT radiologic report was
reviewed for findings consistent with sinusitis and classi-
fied into one of four mutually exclusive categories: 1)
chronic sinusitis, 2) indeterminate for sinusitis, 3) air-
fluid levels (AFLs), or 4) no findings of sinusitis. Three
investigators discussed and predetermined the sinusitis
classification criteria prior to data abstraction.
We defined chronic sinusitis as CT findings of mucosal
thickening, secretions, or opacification involving the eth-
moid, frontal, or maxillary sinuses. The indeterminate cat-
egory included CT scans with findings of polyps, polypoid
thickening, or mucous retention cysts. Any CT report with
mention of an AFL was included in the third category.
AFLs are associated with acute sinusitis and thus may re-
flect a legitimate etiology for an acute atraumatic headache.
Chronic Sinusitis Not Associated with Headaches 3

In the setting of trauma, an AFL may represent blood in the
sinuses rather than true sinusitis. The fourth category in-
cluded all CTs with no evidence of sinus disease, as well
as CTs with negligible findings such as concha bullosa,
small septae, or sphenoid sinus abnormalities.
Because radiologists may not comment on sinus find-
ings considered to be incidental or nonetiologic in the fi-
nal report of a CT scan, which would decrease the
frequency of sinus disease noted in our study and act as
a confounder, one investigator (R.L.), a board-certified
emergency radiologist, reviewed the CT images for 50
random patients (25 in the atraumatic headache group,
and 25 in the head injury group) for evidence of sinusitis,
with the aim of determining the degree of agreement be-
tween the official radiologic interpretation as compared
to her own interpretation with regard to findings of sinus-
itis. At the time of her review, she was blinded both to the
purpose of the study and to the official contemporaneous
interpretation. Consistent with routine practice, she did
know the indication for the CT scan – atraumatic head-
ache vs. head trauma. These 50 CT scans were randomly
selected using a random number generator. Inter-rater
reliability was tested using Cohen’s k statistic.
Data Analysis
Descriptive statistics, including proportions, medians,
means, SDs, and confidence intervals, are reported for
the two groups. Continuous data were summarized by
means and SDs; categorical data were summarized by
frequencies, proportions, and percentages. Point esti-
mates and 95% confidence intervals are also reported.
A p-value of < 0.05 was considered significant. Cohen’s
k statistic was used to determine inter-rater reliability.
If the k value was below 0.40, inter-rater reliability was
poor to fair; if k was between 0.41 and 0.60, moderate;
if k was between 0.61 and 0.80, substantial reliability;
and almost perfect if k was between 0.81 and 1.00.
An a priori power analysis designed to achieve at least
80% power to detect a 10% difference between the two
groups (a = 0.05) was performed, which found a mini-
mum sample size of 394 (197 patients per group). We
chose a round number greater than this to ensure that
our study was not underpowered. Statistical calculations
were performed on a Statistical Analysis Systems pack-
age (SAS version 9.2; SAS Inc, Cary, NC).
RESULTS
We enrolled 500 consecutive patients who had noncontrast
head CT scans, 234 in the nontraumatic headache group
and 266 in the minor head injury group. Table 1 summa-
rizes the baseline characteristics for the two groups.
Mean patients’ ages were similar and a majority of
subjects overall were women (64.6%) and white
(63.2%). More women were enrolled in the atraumatic
headache group (70.5%) than in the minor head injury
group (59.4%; p = 0.01). Moreover, fewer white subjects
and more black subjects were enrolled in the atraumatic
headache group than in the minor head injury group. Of
the head injury group, falls were the most common type
of traumatic injury.

Table 1. Patient Characteristics of Atraumatic Headache and Minor Head Trauma Groups

Demographic Category Total Atraumatic Headache Minor Head Injury Difference (95% CI) p-Value

Number of patients 500 234 266

Age, years, mean (6 SD) 41.5 (619.9) 42.8 (618.2) 40.4 (621.2) 2.4 ( 1.2–5.8) 0.18
Median; year 37 40 34
$60 years, n (%) 105 (21.0) 47 (20.1) 58 (21.8) 1.8 ( 0.1–0.1) 0.64
Range 16–94 18–87 16–94
Sex
Male sex, n (%) 177 (35.4) 69 (29.5) 108 (40.6) 11.1 (2.8–19.4) 0.01
Female sex, n (%) 323 (64.6) 165 (70.5) 158 (59.4) 11.1 (2.8–19.4) 0.01
Race/ethnicity
White, n (%) 316 (63.2) 137 (58.5) 179 (67.3) 8.7 (0.3–17.2) 0.04
Black, n (%) 80 (16.0) 49 (20.9) 31 (11.7) 9.3 (2.8–15.8) 0.01
Hispanic, n (%) 46 (9.2) 25 (10.7) 21 (7.9) 2.8 ( 2.3–7.9) 0.29
Asian, n (%) 24 (4.8) 8 (3.4) 16 (6.0) 2.6 ( 1.1–6.3) 0.17
Other, n (%) 34 (6.8) 15 (6.4) 19 (7.1) 0.7 ( 3.7–5.1) 0.74
Traumatic mechanism
Fall, n (%) - - 119 (44.7) - -
Motor vehicle collision, n (%) - - 55 (20.7) - -
Assault, n (%) - - 27 (10.2) - -
Pedestrian struck, n (%) - - 17 (6.4) - -
Bicyclist struck, n (%) - - 4 (1.5) - -
Sports injury, n (%) - - 14 (5.3) - -
Head injury NOS, n (%) - - 30 (11.3) - -

CI = confidence intervals; - = data not collected; NOS = Not Otherwise Specified.

4 K. E. Kroll et al.
As hypothesized, we found similar rates of CT find-
ings consistent with chronic sinusitis in the minor head
injury group (47/266; 17.7%) as in the atraumatic head-
ache group (52/234 patients; 22.2%; p = 0.20), depicted
in Table 2. The two groups were also similar in regards
to the frequency of patients falling into the CT categories
of indeterminate, negative, and air-fluid levels.
Our investigator agreed with the original radiologic
read in 92% of cases in the nontraumatic headache group
(23/25; k = 0.83) and in 80% (20/25; k = 0.41) of cases in
the head injury group, showing substantial reliability for
the nontraumatic headache but only moderate reliability
for the head injury group. Our radiologist noted findings
consistent with chronic sinusitis in one more CT scan
than was commented on the original radiology read in
the head injury group (4 vs. 3), and in two more CT scans
than the original radiology read in the headache group
(10 vs. 8).
DISCUSSION
Emergency physicians frequently order head CT scans in
patients with acute headache with the aim of ruling out
clinically significant pathology, such as intracranial hem-
orrhages, masses, or other conditions. In addition to pro-
viding information about these pathologies, CT scan
reports frequently include findings related to chronic
sinus disease. Chronic sinusitis rarely if ever causes an
acute headache, and clinicians may incorrectly diagnose
‘‘sinusitis’’ as the cause of a patient’s headache, prema-
turely stopping the diagnostic evaluation.
Given that sinus findings are inherently incidental on
scans primarily assessing for abnormalities of the brain,
the reporting of such findings (and their degree–minimal
to flagrant) is variable. Therefore, even the thinnest of soft
tissue layering over any portion of the inner wall of any of
the paranasal sinuses could be construed as being abnor-
mal. Flat-layering soft tissue is thought to represent mu-
cosal thickening; an AFL implies an intraluminal exudate
in the context of infection, or blood in the context of
trauma. Rounded soft tissue attenuation structures most
likely represent polyps or mucus-retention cysts. Depend-
ing on the clinical context, a radiologist’s report may not
Table 2. CT Scan Findings of Sinusitis
Sinusitis Classification Total Atraumatic Headache
Number of patients 500 234
Chronic sinusitis, n (%) 99 (19.8) 52 (22.2)
Indeterminate, n (%) 22 (4.4) 10 (4.3)
Air-fluid levels, n (%) 20 (4.0) 9 (3.8)
Negative for sinusitis, n (%) 359 (71.8) 163 (69.7)
CT = computed tomography; CI = confidence interval.
mention minor findings such as a very thin layer, tiny
rounded lesion, or very small-volume AFL.
Studies of both adult and pediatric populations have
found the rate of incidental sinus abnormalities on CT
scans of asymptomatic patients of approximately 30–
40% (3). Other researchers have shown that even when
a patient has both symptoms presumed to be referable to
the sinuses and a CT scan showing evidence of sinus dis-
ease, the extent of CT findings does not correlate with the
extent of a patient’s symptoms (13,14). Thus, there is little
evidence that sinus abnormalities seen on CT correlate
with symptoms. Our study adds to the current literature
on this topic by specifically comparing the frequency of
CT findings of sinusitis in an ED population of patients
with acute atraumatic headache with a control group.
We chose patients discharged home with a diagnosis of
minor head injury as the control group, reasoning that
findings consistent with chronic sinusitis on a CT scan
obtained due to head trauma would nearly always be
incidental findings. Documenting similar rates of such
findings in the both the atraumatic headache and the
minor head injury group suggests that such findings are
also incidental in headache patients.
The observed rate of chronic sinusitis findings on CT
between these two groups was similar. The slightly higher
rate of chronic sinusitis in the atraumatic headache group
than in the head injury group (22.2% vs. 17.7%) could
mean that our study was not powered to detect a difference
between these groups. However, our sample size well ex-
ceeded the number suggested by our power analysis to de-
tect a 10% difference. An alternative explanation is that
this variance reflects radiologists’ reporting of certain
findings depending on the chief complaint, or context,
for which the CT scan was performed.
There is inherent subjectivity in radiologists’ final im-
pressions. Our data suggest that radiologists more often
report findings of chronic sinusitis in headache patients
than in head trauma patients. There was better inter-
rater reliability for atraumatic headache CT scans than
for head trauma CT scans. This may reflect the influence
of the ‘‘chief complaint’’ on whether or not radiologists
mention certain findings in their final reports. This phe-
nomenon would make the true rates of chronic sinusitis
Minor Head Injury Difference (95% CI) p-Value
266
47 (17.7) 4.6 ( 2.5–11.6) 0.20
12 (4.5) 0.2 ( 3.4–3.8) 0.90
11 (4.1) 0.3 ( 3.1–3.7) 0.87
196 (73.7) 4.0 ( 3.9–11.9) 0.32
Chronic Sinusitis Not Associated with Headaches
even more similar than we observed in our two patient
groups.
Limitations
The retrospective nature of this study, and in particular,
the use of ICD-9 codes to identify patients in a hospital
billing database, may have resulted in some missed pa-
tients. We looked at only discharged patients in our study
for the reasons described above; thus, this study’s conclu-
sions would not generalize to patients who were admitted.
Additionally, the data abstractor was not blinded to the
purpose of the study, which may introduce bias into the
data extraction process. We attempted to limit this poten-
tial bias by clearly defining each category of CT findings
prior to data abstraction so there was little room for sub-
jective interpretation.
Finally, this is a descriptive, comparative study with in-
trinsic limitations owing to baseline differences between
the atraumatic headache and minor head injury groups.
In particular, the increased number of female and black
subjects in the atraumatic headache group could skew
the prevalence of sinusitis in that group. Additionally, as
a comparative study, similar rates of sinusitis between
the two groups suggests a lack of association, but does
not completely exclude the possibility that sinusitis find-
ings are associated with acute headache in only a small,
selected group of patients with headache, or perhaps
only patients with certain types of headaches. This is
a question for a further investigation.
CONCLUSIONS
In addition to confirming that chronic sinusitis is a com-
mon incidental finding, our study extends this concept by
finding a similar prevalence of CT scan findings of sinus-
5
itis in ED patients with atraumatic headaches and patients
with mild head injury. This suggests that CT findings of
chronic sinusitis in patients with atraumatic headache
may be incidental, rather than causal.
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6 K. E. Kroll et al.

APPENDIX 1: DISCHARGE ICD-9 CODES

ICD-9 ICD-9 ICD-9

Code Atraumatic Headache Diagnosis Code Atraumatic Headache Diagnosis Code Minor Head Injury Diagnosis

310.2 POSTCONCUSSION SYNDROME 346.22 VARIANTS OF MIGRAINE NEC 850 CONCUSSION

339 CLUSTER HEADACHE SYNDROM 346.23 VARIANTS OF MIGRAINE NEC 850 CONCUSSION W/O COMA
339.01 EPISODIC CLUSTER HEADACHE 346.4 MENSTRUAL MIGRAINE, W/OU 850.11 CONCUSSION, W LOSS CONSC
339.02 CHRONIC CLUSTER HEADACHE 346.41 MENSTRUAL MIGRAINE, W/I 850.12 CONCUSSION, W LOSS CONSC
339.03 EPISODIC PAROXYSMAL HEMI 346.42 MENSTRUAL MIGRAINE, W/OU 850.9 CONCUSSION NOS
339.04 CHRONIC PAROXYSMAL HEMIC 346.43 MENSTRUAL MIGRAINE, W/I 959.01 HEAD INJURY UNSPECIFIED
339.05 SHORT LASTING UNILATERAL 346.7 CHRONIC MIGRAINE W/OUT A 339.2 POST-TRAUMATIC HEADACHE
339.09 OTH TRIGEMINAL AUTONOMIC 346.71 CHRONIC MIGRAINE W/OUT A 339.21 ACUTE POST-TRAUMATIC HEA
339.1 TENSION TYPE HEADACHE, U 346.72 CHRONIC MIGRAINE W/OUT A 339.22 CHRONIC POST-TRAUMATIC H
339.11 EPISODIC TENSION TYPE HE 346.73 CHRONIC MIGRAINE W/OUT A 339.2 POST-TRAUMATIC HEADACHE
339.12 CHRONIC TENSION TYPE HEA 346.8 MIGRAINE NEC
339.3 DRUG INDUCED HEADACHE NE 346.8 OTH FORMS OF MIGRAINE, W
339.41 HEMICRANIA CONTINUA 346.81 OTH FORMS OF MIGRAINE, W
339.42 NEW DAILY PERSISTENT HEA 346.82 OTH FORMS OF MIGRAINE WO
339.43 PRIMARY THUNDERCLAP HEAD 346.83 OTH FORMS OF MIGRAINE W
339.44 OTH COMPLICATED HEADACHE 346.9 MIGRAINE NOS
339.81 HYPNIC HEADACHE 346.9 MIGRAINE, UNSPEC, W/OUT
339.82 HEADACHE ASS W SEXUAL AC 346.91 MIGRAINE, UNSPEC, W INTR
339.83 PRIMARY COUGH HEADACHE 346.92 MIGRAINE, UNSPEC, W/OUT
339.84 PRIMARY EXERTIONAL HEADA 346.93 MIGRAINE, UNSPEC, W/INT
339.85 PRIMARY STABBING HEADACHE 349 LUMBAR PUNCTURE REACTION
339.89 OTHER HEADACHE SYNDROMES 461 ACUTE SINUSITIS*
346 MIGRAINE* 461 AC MAXILLARY SINUSITIS
346 CLASSICAL MIGRAINE 461.1 AC FRONTAL SINUSITIS
346 MIGRAINE WITH AURA, W/OU 461.2 AC ETHMOIDAL SINUSITIS
346.01 MIGRAINE WITH AURA, W IN 461.3 AC SPHENOIDAL SINUSITIS
346.02 MIGRAINE W AURA W/OUT ME 461.8 OTHER ACUTE SINUSITIS
346.03 MIGRAINE W AURA W INTRAC 461.9 ACUTE SINUSITIS NOS
346.1 COMMON MIGRAINE 473 CHRONIC SINUSITIS*
346.1 MIGRAINE W/OUT AURA, W/O 473 CHR MAXILLARY SINUSITIS
346.11 MIGRAINE W/OUT AURA, W I 473.1 CHR FRONTAL SINUSITIS
346.12 MIGRAINE W/OUT AURA W/OU 473.2 CHR ETHMOIDAL SINUSITIS
346.13 MIGRAINE W/OUT AURA W/I 473.3 CHR SPHENOIDAL SINUSITIS
346.2 VARIANTS OF MIGRAINE 473.8 CHRONIC SINUSITIS NEC
346.2 VARIANTS OF MIGRAINE, NE 473.9 CHRONIC SINUSITIS NOS
346.21 VARIANTS OF MIGRAINE, NE 784 HEADACHE
346.2 VARIANTS OF MIGRAINE, NE

ICD-9 = International Classification of Diseases, Ninth Revision.

Chronic Sinusitis Not Associated with Headaches 7

ARTICLE SUMMARY
1. Why is this topic important?
Headache is a common complaint in emergency depart-
ment (ED) patients. Whereas the majority of these pa-
tients have benign primary headache disorders, a small
percentage have more serious, secondary causes such as
subarachnoid hemorrhage, and to avoid missing these sec-
ondary causes, physicians need to be aware of potential
sources of misdiagnosis.
2. What does this study attempt to show?
This study compares the frequency of radiographic
findings of chronic sinusitis in ED patients presenting
with atraumatic headache to a control group consisting
of patients presenting with minor closed head injury.
3. What are the key findings?
We found a similar prevalence of computed tomogra-
phy (CT) scan findings of chronic sinusitis in ED patients
with atraumatic headaches and patients with mild head
injury.
4. How is patient care impacted?
Our finding suggests that CT findings of chronic sinus-
itis in patients with atraumatic headache are incidental,
rather than causal. When evaluating patients with acute
headache in the ED, physicians should not use findings
of chronic sinusitis in clinical decision-making, particu-
larly to exclude other, more serious etiologies of acute
headache.