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Treatment of acute rhinosinusitis diagnosed by clinical criteria or ultrasound

in primary care

Article  in  Scandinavian Journal of Primary Health Care · January 2003

DOI: 10.1080/02813430310001743

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 ORIGINAL PAPER

Treatment of acute rhinosinusitis diagnosed by

clinical criteria or ultrasound in primary care
A placebo-controlled randomised trial
Helena Varonen1, Ilkka Kunnamo2, Seppo Savolainen3, Marjukka Mäkelä4, Matti Revonta5,
Jarkko Ruotsalainen6 and Henrik Malmberg1
1
Department of Otorhinolaryngology, University of Helsinki, Finland, 2Karstula Health Centre, Karstula, Finland,
3
Department of Otolaryngology, Central Military Hospital, Helsinki, Finland, 4Stakes, Finnish Office for Health
Technology Assessment, Helsinki, Finland, 5Department of Otolaryngology, Central Hospital, Hämeenlinna, 6Juuka
Pharmacy, Juuka, Finland.
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Scand J Prim Health Care 2003;21:121–126. ISSN 0281-3432
Objecti7es – To compare antibiotics and placebo in patients with
clinically diagnosed acute maxillary sinusitis (AMS). To study
whether sinus ultrasound examination would help to detect those
patients who benefit from antibiotic therapy.
Design – A double-blind, randomised, placebo-controlled multicentre
trial.
Setting – Nine primary care sites in Finland.
Subjects – 150 adult patients (mean age 39.7 years) with a clinical
diagnosis of sinusitis.
For personal use only.
Results – A total of 146 patients completed the 2-week follow-up.
Patients receiving antibiotics achieved a slightly higher rate of
clinical success than patients receiving placebo (80% vs 66%; p =
0.068).
Conclusions – Antibiotics hasten symptom relief in AMS. Yet many
patients recover in 2 weeks without antimicrobial treatment. Only
half of patients with a clinical diagnosis of AMS have sinusitis in
ultrasound examination.
Key words: maxillary sinusitis, randomised controlled trial, sinusitis,
ultrasound.

Inter7ention – Antibiotics (amoxicillin 750 mg × 2, doxycycline 100

mg×2 or penicillin V 1500 mg×2) or placebo twice daily for 7 days; Helena Varonen, Kuninkaantie 4, FIN-02400 Kirkkonummi, Fin-
all patients were examined with sinus ultrasound after randomisation. land. E-mail: helena.7aronen@duodecim.fi
Main outcome measure – Clinical success (patients’ report of recov-
ery) in telephone interview at 2 weeks.

Acute maxillary sinusitis (AMS) is a common infec-
tious disease and by no means a settled question. In
a Finnish survey, 12% of patients consulting for
infectious diseases were diagnosed as having sinusitis
(1). Rhinoviruses are common in the sinus epithelium
of AMS patients (2,3), and may cause AMS in up to
50% of cases (4). Symptoms and signs are unspecific
(5 –7), and if AMS is diagnosed solely by clinical
criteria, antibiotics are prescribed unnecessarily to
many patients with viral infections (8). In a previous
primary care study, antibiotic treatment did not im-
prove the clinical course of AMS (9). Despite limited
research evidence on the effectiveness of antibiotics
for AMS, this disease nevertheless is most often
treated with antibiotics (10,11).
Fluid retention is usually regarded as indicating
bacterial infection in sinusitis (12). In studies of AMS
therapy, the diagnosis is most often based on radiog-
raphy or aspiration (13). However, these diagnostic
methods are impractical in the primary care setting
and not recommended in recent guidelines (8,14).
Ultrasound examination has been suggested as a
means to detect fluid in sinuses and to improve AMS
diagnosis (15,16). In this diagnostic – therapeutic trial
we compared the effect of antibiotics to that of
placebo in clinically diagnosed AMS in adults, and
studied whether sinus ultrasound examination would
help to detect patients who would benefit from antibi-
otic therapy.
PATIENTS AND METHODS
Setting and patients
The study took place in nine health centres in Fin-
land from November 1998 to October 1999
Although antibiotics are widely used for maxillary
sinusitis, research evidence on their effectiveness is
still limited.
“ Antibiotics hasten symptom relief in acute max-
illary sinusitis.
“ However, many patients recover in two weeks
without antimicrobial treatment.
“ Only about 50% of patients with a clinical diag-
nosis of acute maxillary sinusitis have sinusitis
confirmed by ultrasound.

DOI 10.1080/02813430310001743 Scand J Prim Health Care 2003; 21

 122 H. Varonen et al.
(Karstula, Saarijärvi, Halikko, Salo, Katriina, Simo,
Kuivaniemi, Heinävesi and Tikkurila). Ear, nose and
throat (ENT) specialists (SS and MR) gave a small
group tutorial of 1.5 h on sinus ultrasound to 60
physicians in participating health centres.
Our inclusion criteria covered adult patients (over
18 years of age) with a clinical diagnosis of AMS.
Reasons for exclusion were AMS symptoms lasting
over 30 days, antibiotics during the previous month,
allergy to study medications, pregnancy or breastfeed-
ing, exacerbation of a diagnosed chronic maxillary
sinusitis, previous paranasal sinus surgery, and clinical
suspicion of dental or frontal sinusitis or pansinusitis
or suspicion of a severe complication, and previous
sinus surgery.
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Data collection
Nurse receptionists at health centres screened patients
with upper respiratory tract infections to find study
patients. Nurses gave written information of the study
to possible rhinosinusitis patients and asked them to
fill in the patient information form while waiting for
the physician’s consultation. Data were collected on 12
symptoms related to AMS (nasal obstruction, nasal
discharge, headache, postnasal drip, cough, sinus pain,
For personal use only.
unilateral facial pain, maxillary toothache, hyposmia,
anosmia, malaise and fever), and three clinical signs
(purulent secretion in the nasal cavity, discharge in the
pharynx and tenderness in sinus tapping). Patients
assessed the symptoms on a 3-step scale (1= no,
2= little, 3= much). A symptom score of the 12
symptoms was counted by giving 2 points for ‘‘much’’
answers and 1 point for ‘‘little’’ answers. The points
for the three most important symptoms (maxillary
pain, postnasal drip and cough) were doubled. The
maximum symptom score was thus 30.
We also asked the patients whether they had had
symptoms for more than 5 days before the visit and
whether they had experienced 2 phases in the disease
(double sickening).
The physicians discussed the study with the patients,
recorded history and clinical findings, and delivered
the study medication if the patient had AMS on
clinical grounds. The minimum criterion for clinical
diagnosis of AMS was the presence of at least three
symptoms and one clinical sign. After the treatment
decision was made, the ultrasound examination was
performed by using a technique described in detail
earlier (12,15). The ultrasound device used was Sinus-
can 102 (Oriola, Espoo, Finland) with a frequency of
3 MHz and a transducer with an 8-mm diameter. The
criterion for AMS was a back wall echo on the screen
of the device at a distance of 3.5 cm or more,
indicating fluid in the maxillary sinus. None of the
other findings were considered sinusitis. To avoid bias,
Scand J Prim Health Care 2003; 21
the result was not disclosed to the patient because the
ultrasound-negative cases also received treatment.
To control the severity of AMS at the Karstula
health centre, also nasal samples for bacteriological
culture were taken and sinus radiography (occipito-
mental, Waters’ view) was examined between 15 min
and 1 h after the ultrasound examination. Criteria for
AMS were total opacification or an air–fluid level or
mucosal thickening of 6 mm or more. Bacterial culture
was performed according to common bacteriological
methods.
Randomisation and treatments
The patients were randomised to 1 of 4 treatment
options, all for 7 days: amoxicillin 750 mg× 2, peni-
cillin V 1500 IU× 2, doxycyclin 100 mg× 2 or placebo
1 × 2. The placebo group was doubled: two patients
out of five received placebo. The treatments were
previously randomised in blocks of 20 consecutive
patients at the Military Pharmacy in Helsinki and
distributed in identical sealed bottles. The study med-
ications were coded with six-number individual codes
and physicians, patients and the main researcher (HV)
remained blind to the treatments until the recruitment
was ended. During the trial, the senior researcher (SS)
kept the code and was the primary contact in the case
of adverse effects or severe complications. All study
centres also had the code in a closed envelope to be
opened only if SS could not be reached.
Symptomatic treatments with xylometazoline,
paracetamol or anti-inflammatory agents were possi-
ble if the physician considered them necessary, and
their use was recorded.
Follow-up
The patients received diaries for recording their symp-
toms daily over 2 weeks. The same list of 12 symptoms
with a 3-step scale as in the initial patient form was
used. Possible self-medication and side effects were
recorded daily in the diary as well as the patients’
overall estimate of whether they thought they contin-
ued to have sinusitis.
Two weeks (14 –16 days) after the initial consulta-
tion, the researcher (HV) interviewed the patients by
telephone, asking about subjective symptoms, their
severity, possible side effects and the patient’s estimate
of recovery or recurrence. The interviewer did not
know the patient’s history, treatment or the result of
the ultrasound examination.
After 1 year the researcher (HV) checked the patient
records to register recurrent or chronic sinusitis in the
study patients. Recurrent sinusitis was defined as
another episode of sinusitis diagnosed by a primary
care physician. Chronic sinusitis was defined as sinusi-
tis with symptoms lasting for more than 3 months.

Outcome measures
Our main outcome measure was frequency of recov-
ery at the 2-week follow-up (according to the tele-
phone interview). Other outcome measures included
subjective symptom scores on days 3 and 10 in pa-
tient diaries, frequency of side effects, duration of
sinusitis, use of additional medication and the fre-
quency of chronic or recurrent sinusitis and number
of physician consultations during the 1-year follow-
up.
Study size and statistical analysis
Previous studies have shown that approximately 75–
80% of patients with AMS treated with placebo
recover in 2 weeks (9,17). To find a 15% treatment
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difference from 75% to 90% at the significance level
of a =0.05 and b =0.20 (power=0.80), a sample size
of 98 patients in each treatment arm was needed.
We analysed the data by intention-to-treat in main
outcomes. Differences in proportions in study groups
were tested with the chi-squared or Fisher exact test.
Duration of sinusitis was analysed only in patients
who recovered fully during the 2-week follow-up. We
investigated differences in symptom scores between
the group using descriptive statistics, unpaired t-tests
For personal use only.
and the Mann-Whitney U-test. All reported p-values
are two-sided. We analysed all data with StatView
5.0.1 software (SAS Institute Inc.).
Ethical aspects
The ethics committee of the National Research and
Development Centre for Welfare and Health and the
local ethics committees at study centres accepted the
study protocol. The patients received written infor-
mation on the study and its possible harmful effects.
Because the study was placebo-controlled, study cen-
tres were provided with a second medication, doxycy-
cline for the amoxicillin group and amoxicillin for the
others. The second medication was given if the pa-
tient reconsulted with worsened symptoms and the
physician considered antibiotics necessary. Patients
and physicians stayed blind also to the second medi-
cation, knowing only that it contained an active
agent. Physicians ensured that the patients had suffi-
cient information and understood the process of the
study. The patients gave their written informed
consent.
RESULTS
Patients
The trial profile is presented in Fig. 1. Thirty-five
primary care physicians in nine health centres partici-
pated in patient recruitment. Of 187 patients with
suspected AMS considered for study, 150 were eligi-
Treatment of acute rhinosinusitis 123
ble and randomised; 105 females (70%) and 45 males
(30%). Reasons for exclusion are presented in Fig. 1.
Patients were aged between 18 and 75 years (mean
39.7 years). The baseline characteristics of the study
patients are presented in Table I.
Ultrasound examination was performed on 148
patients, and 74 (50%) tested positive for AMS. At
Karstula health centre, 32 patients had sinus radio-
graphies taken, and 13 (41%) had a radiologically
diagnosed AMS. Nasal bacterial cultures were ob-
tained from 28 patients in Karstula, and in the cul-
ture of 8 cases (29%) grew pathogens for acute
maxillary sinusitis.
Main outcome
The main outcome, recovery at the 2-week follow-up,
was slightly better in patients receiving active treat-
ment, antibiotics (70/88, 80%), than in the placebo
group (39/59 patients, 66%, chi-squared= 3.33,
d.f.= 1, p= 0.068). There were no differences be-
tween antibiotics (clinical success rates 18/23, 78% for
amoxicillin, 26/33, 79% for doxycycline and 26/32,
81% for penicillin V).
Other outcomes
Patients receiving antibiotics recovered faster than
those receiving placebo. On day 3, the difference in
symptom scores was 2.1 (p= 0.048, Table II). By day
10, the difference had disappeared. Mean disease
duration of AMS was 6.4 days in the placebo group
and 6.0 days in the antibiotics group (Table II).
Patients receiving placebo used additional medica-
tion, especially analgesics, more often than those
receiving antibiotics (Table II). Patients in the
placebo group started other antibiotics more often
(10/58, 17%) than patients in the active treatment
group (6/88, 7%, p= 0.09 Table II).
Subgroups of ultrasound positi6e and negati6e
patients
Ultrasound positive and negative patients had similar
symptom scores at the beginning of study (15.3, SD
4.3 and 15.4, SD 4.3, respectively). At the 2-week
follow-up, patients with sinusitis on ultrasound exam-
ination had recovered better (symptom score 2.8, SD
3.2) than those without findings (symptom score 4.1,
SD 3.8, p= 0.03). In the placebo group, patients who
had sinusitis on ultrasound started other antibiotics
and withdrew from the study more often than those
with no sinusitis on ultrasound (7/32, 22% versus
3/25, 12%, p= 0.33).
Side effects
We analysed side effects in the 130 patients who
completed the 2-week follow-up in the initial treat-
Scand J Prim Health Care 2003; 21
 124 H. Varonen et al.
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For personal use only.

Fig. 1. Flow chart of the study population.

Table I. Baseline characteristics of study patients (n = 148). ment arm. In the telephone interview at 2 weeks, 13
out of 48 (27%) patients in the placebo group and
Antibiotic Placebo 32 out of the 82 (39%) receiving antibiotics re-
(n=88) (n = 60)
ported side effects (Table III). Stomach pain, di-
Patient characteristics arrhoea and fatigue were the most common side
Mean age (SD) in years 40.6 (14.1) 38.1 (12.3) effects (Table III). Two patients receiving penicillin
Male/female 24 (27%)/ 20 (33%)/ V withdrew: one got nausea and the other stomach
64 (73%) 40(67%) pain and skin rash. One patient receiving amoxi-
History cillin stopped treatment because of diarrhoea, and
Previous sinusitis 74 (84%) 49 (82%) one in the placebo group discontinued treatment
Allergic rhinitis 24 (28%) 10 (17%) because of stomach pain and headache.
Vasomotor rhinitis 6 (7%) 5 (8%)
Asthma 8 (9%) 2 (3%)
Follow-up
Symptoms and signs One-year follow-up data were available for 144 pa-
Mean initial symptom score (SD) 15.3 (4.6) 15.3 (4.1)
Symptoms for more than 5 days 63 (72%) 45 (75%) tients (60 in the placebo arm and 84 in the antibi-
Double sickening 45 (51%) 35 (58%) otics group). Two patients in the placebo group
developed chronic sinusitis in follow-up, and both

Scand J Prim Health Care 2003; 21

 Treatment of acute rhinosinusitis 125

Table II. Other outcome measures.

Outcome measure Antibiotics Placebo Difference (95% CI) p-value

Mean symptom score (SD) on day 3 9.4 (4.7) 11.5 (5.2) 2.1 0.0481
Mean symptom score (SD) on day 10 5.2 (4.9) 5.4 (4.7) 0.2 0.601
Mean duration of sinusitis (days) 6.0 6.4 0.4 0.662
Percentage of patients using additional medication 37/88 (42%) 32/58 (55%) 13% (−3% to 29%) 0.123
Analgesics 26% 43% 17% (1% to 32%) 0.033
Vasoconstrictors and antihistamines 10% 12% 2% (−8% to 14%) 0.683
Antibiotics 7% 17% 10% (−1% to 21%) 0.093
Mean number (SD) of physician consultations during 3.9 (3.5) 5.1 (6.1) 1.2 0.141
1-year follow-up
Percentage of patients having recurrent sinusitis during 26% 24% −2% (−16% to 13%) 0.763
1-year follow-up
Percentage of patients consulting because of respiratory 32% 26% −6% (−21% to 9%) 0.423
tract infections during 1-year follow-up
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1
Mann-Whitney U-test.
2
T-test.
3
Chi-squared test.

had AMS in ultrasound examination. There were no
differences in the number of cases with recurrent
sinusitis in the study groups, but the patients who
received antibiotics consulted slightly more often be-
cause of respiratory tract infections during the fol-
low-up year (32% vs 26%, p= 0.42).
For personal use only.
lem is that our study lacks power and the ultrasound
subgroups are too small for definite conclusions to be
drawn. For the same reason, we cannot draw conclu-
sions about the different antibiotics in the study.
This randomised study in primary care has several
strengths: we combined diagnosis and treatment, the
study was conducted in a real-life situation and the

length of follow-up was adequate. The slow rate of

DISCUSSION patient recruitment was a disappointment to us, and
In our study, antibiotics were slightly more effective we tried to find out what the barriers had been. The
than placebo for patients with sinusitis diagnosed by barrier first mentioned was work pressure. Sinusitis is
clinical criteria. Recovery was similar at 2 weeks, mostly treated during busy on-call hours, when filling
however, patients who received antibiotics recovered study forms may be too much of a burden for the
faster, having lower symptom scores on day 3. Half physician. Another problem was the placebo arm.
of the study patients had AMS on ultrasound exami- Giving placebo to patients who normally would be
nation, and two of them developed chronic sinusitis, treated with antibiotics was such a radical change of
both in the placebo group. No complications were practice that the physicians might have needed better
seen in the ultrasound-negative patients. support from the researchers. Also, financial support
It seems that the ultrasound-positive patients in was lacking: we did not remunerate the participating
our study had a more severe pattern of disease and, if physicians for their work.
given placebo, they withdrew from the study and Overall, most patients with clinically diagnosed
started antibiotics during the 2-week follow-up more AMS recovered well without antibiotics. Also pa-
often than the ultrasound-negative patients. A prob- tients with AMS diagnosed by radiography and with
pathogens in nasal culture improved sometimes well
Table III. Side effects in patients who completed the 2-week when treated with placebo. Our study confirms previ-
follow-up in the initial treatment arm. ous findings (13,18): up to two-thirds of patients with
sinusitis recover well in 2 weeks with or without
Side effect Antibiotics Placebo p-value antibiotics. However, from the patients’ point of
(n=82) (n=48) (x2-test)
view, clinical success at the 2-week follow-up point
Diarrhoea 6 (7%) 3 (6%) 0.81 may not be the primary outcome. Patients with sus-
Stomach pain 18 (22%) 6 (12%) 0.18 pected AMS seek faster relief for their symptoms. A
Headache 3 (6%) 3 (4%) 0.50 recent study showed that adding fluticasone to xy-
Rash 2 (2%) 0 0.28
lometazoline and antimicrobial therapy improves
Vaginal discharge 3 (4%) 0 0.18
Fatigue 5 (6%) 3 (6%) 0.73 clinical success in acute rhinosinusitis (19).
All 32 (39%) 13 (27%) 0.17 We designed this study after the findings of van
Buchem et al. (9) were published: a primary care-

Scand J Prim Health Care 2003; 21

 126 H. Varonen et al.
based study found no benefit in antibiotic therapy for
AMS diagnosed by radiography. At that point, we
considered that another placebo-controlled study
comparing the first-line antibiotics would be ethical
and justified. Concentrating on one active treatment
instead of three might have been a better strategy. A
Cochrane review (13) and another meta-analysis (18)
on the therapy of AMS have later shown that there is
a small treatment effect and that different antibiotics
have similar efficacy.
More research is needed to compare feasible strate-
gies of AMS diagnosis in primary care to bridge the
gap between current practice and the evidence. Ultra-
sound seems accurate and practical and has no ad-
verse effects. Its use warrants further studies in
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primary care.
CONCLUSIONS
Antibiotics hasten symptom relief in AMS. However,
many patients recover in 2 weeks without antimicro-
bial treatment. Only half of patients with a clinical
diagnosis of AMS have sinusitis in ultrasound
examination.
For personal use only.
ACKNOWLEDGEMENTS
We thank all the patients and physicians who partici-
pated in this study as well as the nurses at the study
centres for their assistance. Stakes, the National Re-
search and Development Centre for Welfare and
Health covered the administrative and travel costs of
this study. Leiras-Schering and SmithKline Beecham
provided the study medication.
REFERENCES
1. Rautakorpi UM, Klaukka T, Honkanen P, Makela M,
Nikkarinen T, Palva E, et al. Antibiotic use by indication:
a basis for active antibiotic policy in the community. Scand
J Infect Dis 2001;33:920 –6.
2. Pitkaranta A, Starck M, Savolainen S, Poyry T, Suoma-
lainen I, Hyypia T, et al. Rhinovirus RNA in the maxillary
sinus epithelium of adult patients with acute sinusitis. Clin
Infect Dis 2001;33:909 – 11.
3. Gwaltney Jr JM, Scheld WM, Sande MA, Sydnor A. The
microbial etiology and antimicrobial therapy of adults with
acute community-acquired sinusitis: a fifteen-year experi-
ence at the University of Virginia and review of other
selected studies. J Allergy Clin Immunol 1992;90:457 – 61.
Scand J Prim Health Care 2003; 21
View publication stats
4. Pitkaranta A, Arruda E, Malmberg H, Hayden FG. Detec-
tion of rhinovirus in sinus brushings of patients with acute
community-acquired sinusitis by reverse transcription
PCR. J Clin Microbiol 1997;35:1791 – 3.
5. Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting
acute maxillary sinusitis in general practice population.
BMJ 1995;311:233 – 6.
6. Williams Jr JW, Simel DL, Roberts L, Samsa GP. Clinical
evaluation for sinusitis. Making the diagnosis by history
and physical examination. Ann Intern Med 1992;117:705 –
10.
7. Varonen H, Makela M, Savolainen S, Laara E, Hilden J.
Comparison of ultrasound, radiography, and clinical ex-
amination in the diagnosis of acute maxillary sinusitis: a
systematic review. J Clin Epidemiol 2000;53:940 – 8.
8. Hickner JM, Bartlett JG, Besser RE, Gonzales R, Hoff-
man JR, Sande MA. Principles of appropriate antibiotic
use for acute rhinosinusitis in adults: background. Ann
Emerg Med 2001;37:703 – 10.
9. Van Buchem FL, Knottnerus JA, Schrijnemaekers VJ,
Peeters MF. Primary-care-based randomised placebo-con-
trolled trial of antibiotic treatment in acute maxillary si-
nusitis. Lancet 1997;349:683 – 7.
10. Piccirillo JF, Mager DE, Frisse ME, Brophy RH, Goggin
A. Impact of first-line vs second-line antibiotics for the
treatment of acute uncomplicated sinusitis. JAMA
2001;286:1849– 56.
11. Poole MD. A focus on acute sinusitis in adults: changes in
disease management. Am J Med 1999;106:38 – 47.
12. Savolainen S, Pietola M, Kiukaanniemi H, Lappalainen E,
Salminen M, Mikkonen P. An ultrasound device in the
diagnosis of acute maxillary sinusitis. Acta Otolaryngol
Suppl 1997;529:148 – 52.
13. Williams Jr JW, Aguilar C, Makela M, Cornell J, Holle-
man DR, Chiquette E, et al. Antibiotics for acute maxillary
sinusitis. Cochrane Database Syst Rev 2000;2:CD000243.
14. Brooks I, Gooch WM, Jenkins SG, Pichichero ME, Reiner
SA, Sher L, et al. Medical management of acute bacterial
sinusitis. Recommendations of a clinical advisory commit-
tee on pediatric and adult sinusitis. Ann Otol Rhinol
Laryngol Suppl 2000;182:2 – 20.
15. Revonta M. Ultrasound in the diagnosis of maxillary and
frontal sinusitis. Acta Otolaryngol Suppl 1980;370:1 – 55.
16. Puhakka T, Heikkinen T, Makela MJ, Alanen A, Kallio T,
Korsoff L, et al. Validity of ultrasonography in diagnosis
of acute maxillary sinusitis. Arch Otolaryngol Head Neck
Surg 2000;126:1482 – 6.
17. Stalman W, van Essen GA, van der Graaf Y, de Melker
RA. Maxillary sinusitis in adults: an evaluation of placebo-
controlled double-blind trials. Fam Pract 1997;14:124 –9.
18. de Ferranti SD, Ioannidis JP, Lau J, Anninger WV, Barza
M. Are amoxycillin and folate inhibitors as effective as
other antibiotics for acute sinusitis? A meta-analysis. BMJ
1998;317:632– 7.
19. Dolor RJ, Witsell DL, Hellkamp AS, Williams Jr JW,
Califf RM, Simel DL. Comparison of cefuroxime with or
without intranasal fluticasone for the treatment of rhinosi-
nusitis. The CAFFS Trial: a randomized controlled trial.
JAMA 2001;286:3097 – 105.