IMAGING STEWARDSHIP IN THE AGE OF VALUE
MAX WINTERMARK, MD
R-SCAN: Imaging for Uncomplicated
Acute Rhinosinusitis
Hannes Kroll, MD, Jason Hom, MD, Neera Ahuja, MD, Cynthia (Daisy) Smith, MD,
Max Wintermark, MD
Acute rhinosinusitis is a symptomatic
inflammation of the nasal cavity and para-
nasal sinuses lasting less than 4 weeks [1]. In
subacute rhinosinusitis, symptoms last from
4 to 12 weeks, and in chronic sinusitis,
symptoms persist for greater than 12
weeks. If a patient has four or more
episodes of acute rhinosinusitis per year,
with interim symptom resolution, the term
“recurrent acute rhinosinusitis” is used [2].
Acute rhinosinusitis is a common entity
in the adult patient population. The preva-
lence of acute rhinosinusitis is 1 in 7 to 8
adults per year in the United States [3]. There
are approximately 26 million outpatient visits
per year for the management of
rhinosinusitis, which results in more than
$4.3 billion in direct medical expenses
[4,5]. Additional costs arise from the
sequelae of rhinosinusitis, with lost work
days and restricted-activity days for patients
suffering from rhinosinusitis [6,7].
Acute rhinosinusitis can be due to viral
or bacterial infection, with the vast majority
of cases due to a viral etiology. Only 0.5% to
2% of acute rhinosinusitis cases are
due to bacterial infections, usually a
bacterial superinfection of a viral process
[8,9]. Patients with acute viral and
bacterial rhinosinusitis present with similar
symptoms, including nasal congestion/
obstruction, purulent nasal discharge,
maxillary teeth discomfort, and facial pain.
Experts have identified several features that
are suggestive of bacterial infection,
including prolonged symptoms without
improvement and worsening of
symptoms after initial improvement [2].
Although rare, complications from acute
rhinosinusitis can occur through extension
of disease beyond the paranasal
sinuses into the surrounding structures.
They include preseptal cellulitis, orbital
82
cellulitis, subperiosteal abscess, meningitis,
intracranial abscess, osteomyelitis, and
septic cavernous sinus thrombosis.
Diagnosis of acute rhinosinusitis is
based on clinical criteria [2]: the presence of
less than 4 weeks of purulent nasal drainage
and the presence of nasal obstruction, facial
pressure and pain, or both. It may be further
supported by secondary signs including
anosmia, ear fullness, cough, and
headache. As highlighted by the Choosing
Wisely
campaigns of the American
Academy of Otolaryngology–Head and
Neck Surgery Foundation (http://www.
choosingwisely.org/clinician-lists/american-
academy-otolaryngology-head-and-neck-
surgery-radiographic-imaging-for-un
complicated-acute-rhinosinusitis/) and the
American Academy of Allergy,
Asthma and Immunology (http://www.
choosingwisely.org/societies/american-
academy-of-allergy-asthma-immunology/),
imaging plays no role in the diagnosis of
acute uncomplicated sinusitis. Clinicians
and patients should consider reserving sinus
imaging for complicated sinusitis and
chronic sinusitis and for use in
immunocompromised patients.
Despite these recommendations and
the supporting evidence, imaging of un-
complicated acute rhinosinusitis is still
frequently performed. Sinus radiographs
have been largely replaced by CT imaging,
owing to their low sensitivity and specificity
to detect paranasal sinus disease [10,11] and
CT’s superior three-dimensional anatomic
delineation of the sinus anatomy.
Sinus CT is the gold standard for par-
anasal sinus imaging. Its role in the setting
of sinusitis is to evaluate the pattern of
disease, the extent of disease, a potential
mechanical cause of disease (such as
outflow obstruction), and relevant
1546-1440/16/$36.00
anatomic details for surgical planning. Si-
nus CT is a highly sensitive test for sinusitis
and a normal study confidently rules out
sinusitis of any etiology. However,
abnormal sinus CT imaging findings,
including air–fluid levels, mucosal thick-
ening, and complete sinus opacification, are
nonspecific and can be seen with chronic
bacterial or viral sinusitis, as well as in up to
42% of asymptomatic healthy individuals
[12,13]. Another study found that mucosal
thickening and opacification is a common
finding in patients with common cold [14].
Although a sinus CT is a simple test,
it exposes patients to ionizing radiation
(with a risk of cataract in patients who
receive multiple sinus CT scans) and also
to certain costs not covered by insurance,
such as deductibles and co-pays.
OBSTACLES TO CHANGE
Multiple reasons can be identified for the
continued widespread use of imaging in
the diagnosis and management of un-
complicated acute rhinosinusitis.
CT sinus scans are fast and widely
available, and technology is rapidly
evolving to reduce associated radiation
exposure. The ability to quickly rule out
sinusitis with sinus CT may be a reason for
clinicians to rely on sinus imaging in acute
sinusitis, even if there is no change in pa-
tient outcome. Our current fee-for-service
system has placed increasing pressure on
referring physicians to make correct and
fast diagnoses to increase the number of
patients that can be seen in a set amount of
time. It has been perceived by clinicians
that it is faster to order an imaging study
than it is to explain to a patient why one
is not necessary. Misaligned financial in-
centives in our current health care system
may also favor doing more imaging because
ª 2016 American College of Radiology
n http://dx.doi.org/10.1016/j.jacr.2016.08.018
health systems and some outpatient offices
have invested in CT scanners and would
prefer to see them used. Lastly, the use of
cone-beam CT as an in-office technique
for the evaluation of sinusitis has increased.
Though it may potentially reduce radiation
exposure when compared with traditional
CT techniques, the risk of overuse owing to
ubiquitous availability, accessibility, and
self-referral is considerable [15-17].
The differentiation between acute,
chronic, uncomplicated, and complicated
sinusitis may sometimes be challenging for
the clinician. Historically, when faced
with diagnostic uncertainty, clinicians
have erred on the side of doing more
testing. This is particularly true in settings
like the emergency department, where fear
of malpractice is high and patient conti-
nuity is low. Patient preference also plays
an important role, particularly given the
increasing emphasis on patient satisfaction
scores; as experts have pointed out,
engaging in patient education and shared
decision making with patients can help if
patients request unnecessary imaging [2].
However, prolonged patient education
can be difficult, given time constraints.
RESOURCES TO MAKE
CHANGE
It is therefore crucial to reduce the number
of CT scans ordered for patients with acute
rhinosinusitis. These scans are associated
with radiation exposure and unnecessary
health care expenses, and they do not change
patient outcomes. Reducing unnecessary
imaging can be achieved through evidence-
based principles, such as the ACR
Appropriateness Criteria, and their imple-
mentation through various clinical decision-
making programs, such as the R-SCAN
initiative and the American College of
Physicians’ (ACP) High Value Care and
Transforming Clinical Practice resources.
The R-SCAN website provides guid-
ance for ordering physicians to assess
whether or not imaging in sinusitis is
indicated (https://rscan.org/resources/
topic-specific-resources). A link to the
ACR Appropriateness Criteria for rhino-
sinusitis is provided to clarify the different
imaging recommendations for acute,
subacute, or chronic rhinosinusitis in
immunocompetent and immunodeficient
patients; sinonasal polyposis; and sino-
nasal obstruction with suspected mass.
The documents on the R-SCAN
website (https://rscan.org/topics#
topic-specific-resources-6) and the
Consumer Reports website (https://www.
consumerreports.org/content/dam/cro/
news_articles/health/PDFs/Choosing
WiselySinisitusAAAAIlow.pdf) inform
patients that most cases of acute rhinosi-
nusitis are viral and have an uncomplicated
course. Furthermore, neither antibiotics
nor imaging tests are first-line strategies for
management of uncomplicated acute rhi-
nosinusitis. CT scans may be reserved for
patients with complications and for pa-
tients in need of surgical planning. The
ACP High Value Care cases are interactive
ADDITIONAL RESOURCES
Additional resources can be found online
at: http://dx.doi.org/10.1016/j.jacr.2016.
08.018.
patient care–related scenarios, with associ-
ated multiple-choice questions and de-
briefs, that are available for free with
continuing education, continuing
medical education, and maintenance of
certification credits for clinicians caring for
adult and pediatric patients. In addition,
the ACP Practice Advisor module focused
on avoiding unnecessary testing helps
practices identify potential imaging over-
use and work with other clinicians and
patients toward improvement.
The website also includes a recom-
mendation from the American Academy
of Otolaryngology–Head and Neck Sur-
gery Foundation, which states to “not
routinely obtain radiographic imaging for
patients who meet diagnostic criteria for
uncomplicated acute rhinosinusitis” [18].
CONCLUSIONS
Uncomplicated acute rhinosinusitis is a
common medical problem leading to sig-
nificant health care expenditures, in part
owing to frequent imaging overutilization.
Although CT imaging has a role in com-
plicated or recurrent sinusitis, chronic
sinusitis, and sinusitis in the immuno-
compromised patient, CT imaging of pa-
tients with uncomplicated acute
rhinosinusitis does not lead to improved
patient outcomes, increases the patient ra-
diation exposure, and is costly to the pa-
tient and the health care system. R-SCAN
and the ACP propose a methodology for
radiologists and their referring clinicians to
work with one another and their patients
and improve imaging utilization for un-
complicated acute rhinosinusitis.

Hannes Kroll, MD, and Max Wintermark, MD, are from the Department of Radiology, Neuroradiology Division, Stanford University,
Stanford, California. Jason Hom, MD, and Neera Ahuja, MD, are from the Department of Medicine, Division of Hospital Medicine,
Stanford University, Stanford, California. Cynthia (Daisy) Smith, MD, is from the Division of Medical Education, American College of
Physicians, Philadelphia, Pennsylvania.

The authors have no conflicts of interest related to the material discussed in this article.
The Radiology Support, Communication, and Alignment Network (R-SCAN; www.rscan.org) is a CMS-sponsored effort leveraging the
collaboration between radiologists and referring physicians to improve the appropriate utilization of imaging in patient care. R-SCAN is
aligned with the American Board of Internal Medicine Foundation’s Choosing Wisely
campaign and the American College of Physicians’
High Value Care Initiative and targets a number of emergency and outpatient imaging topics, including imaging for uncomplicated acute
rhinosinusitis. Max Wintermark, MD is a clinical advisor for R-SCAN.

Max Wintermark, MD: Department of Radiology, Stanford University, Neuroradiology Division, 300 Pasteur Drive, Room S047,
Stanford, CA 94305-5105; e-mail: Max.Wintermark@gmail.com.

Journal of the American College of Radiology 83

Kroll et al n Imaging Stewardship in the Age of Value
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Volume 14 n Number 1 n January 2017