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AIM: Sinus X-rays are still frequently used in the evaluation of paranasal sinusitis. Many radiology
departments nowadays provide the referring doctors with a single Waters' projection. Our purpose
was to evaluate the diagnostic accuracy of a single Waters' view vs high resolution computed
tomography (CT) in the diagnosis of paranasal sinusitis.
SUBJECTS AND METHODS: A total of 134 patients with suspected paranasal sinusitis underwent a
Waters' view X-ray and high resolution CT on the same day. The radiographs were evaluated
independently by nine experienced radiologists, who observed each sinus separately. Sensitivity,
specicity, accuracy, positive and negative predictive values were calculated for each sinus and for
each observer, using the CT ndings as a `gold standard'.
RESULTS: The weighted mean sensitivity for diagnosis of any abnormality in the maxillary sinus
was 67.7%, specicity 87.6%, accuracy 78.6%, positive predictive value 82.5% and negative
predictive value 76.9%. For this sinus the variation between observers was small, however, the
sensitivity for diagnosis of any disease in the frontal and ethmoid sinuses varied widely between
observers (range 1.954.0% and 058.9%, respectively). The sensitivity for the sphenoid sinus was
very low (range 03.8%), even in radiographs which seemed to demonstrate it well.
CONCLUSION: The Waters' view has its limits in the diagnosis of sinusitis of the maxillary sinuses
and its contribution for diagnosing lesions in the remaining sinuses is very poor. Whenever access to
CT is available, a low dose high-resolution CT study of the paranasal sinuses is highly recommended.
Konen, E. et al. (2000). Clinical Radiology 55, 856860.
q 2000 The Royal College of Radiologists
Key words: paranasal sinuses, sinusitis, computed tomography (CT), high-resolution, radiography.
INTRODUCTION
The study was based on 134 patients with suspected inammatory sinus disease who were referred to our department for
paranasal CT over the period of January 1999 to December
1995. Two groups were included: one group of adult outpatients referred by ENT practitioners for CT who consented
to undergo a sinus X-ray as well (n 110), and a second group
of inpatients, including children, whose sinus radiographs were
inconclusive and were therefore referred for CT for further
evaluation (n 24). Computed tomography and radiography
were performed on the same day in all patients, most of them
within 1 h. All radiographs were taken in the upright position
with a horizontal beam. The patients' ages ranged from 6 to 88
q 2000 The Royal College of Radiologists
857
evaluated for the nine observers. For these calculations, original scores were dichotomized to form two groups: pathology,
scores 14; and normal group, score 0. In order to evaluate the
sensitivity of the Waters' view in more specic abnormalities
(such as sinus opacity, air-uid levels and polyps), additional
calculations were performed for the maxillary sinus when
scores 24 were combined to present the pathology group.
Therefore, score 1 was excluded from analysis. Further separate
evaluation of scores 2, 3 and 4 for each sinus resulted in low
numbers, and was not performed due to limited clinical
signicance. In order to evaluate the accuracy of the Waters'
view with respect to specic abnormality we calculated an
extension index of the accuracy term, namely concordance,
between each specic diagnosis made on plain lms and CT
for each sinus (e.g., the rate of specic correct interpretations,
0, 1, 2, 3 or 4, made on the radiographs when compared with
CT results). Data analysis was performed using the BMDP
(Bio-Medical Data Processing) statistical software [16].
RESULTS
Maxillary Sinus
When all positive CT ndings (scores 14) were combined
to form the group of patients with sinus disease, the weighted
mean sensitivity of the radiographs was 67.7 6 8.4%, weighted
mean specicity was 87.6%, weighted mean accuracy was
78.6%, weighted mean PPV was 82.5% and weighted mean
NPV was 76.9% (Table 1).
When only CT scores 24 were counted (51 maxillary
Table 1 Comparison between the interpretations of Waters' views and high-resolution CT regarding the maxillary sinuses of 134 patients
Observer
True-positive
(n)
False-negative
(n)
False-positive True-negative
(n)
(n)
Inconclusive
answers
(n/%)
Accuracy
(%)
Sensitivity
(%)
Specicity
(%)
PPV
(%)
NPV
(%)
1
2
3
4
5
6
7
8
9
Weighted
mean (%)
67
81
91
98
73
87
74
70
79
54
42
30
23
50
30
30
47
38
11
21
24
27
9
21
17
8
21
2/0.7
2/0.7
4/1.5
2/0.7
1/0.4
9/3.4
27/10.1
9/3.4
8/3.0
2.6 6 2.9
75.6
76.3
79.5
81.2
77.9
80.3
80.5
78.8
77.3
78.6 6 1.9
55.4
65.9
75.2
81.0
59.3
74.4
71.2
59.8
67.5
67.7 6 8.4
92.4
85.3
83.2
81.4
93.8
85.2
87.6
94.4
85.3
87.6 6 4.7
85.9
79.4
79.1
78.4
89.0
80.6
81.3
89.7
79.0
82.5 6 4.5
71.3
74.4
79.9
83.7
73.0
80.1
80.0
74.0
76.3
76.9 6 4.1
134
122
119
118
135
121
120
134
122
Original scores dichotomized to form two groups: pathology, scores 14; and normal, score 0.
PPV, positive predictive value; NPV, negative predictive value.
858
CLINICAL RADIOLOGY
Table 2 Comparison between the interpretations of Waters' views and high resolution CT regarding the frontal sinuses of 126 patients*
Observer
True-positive
(n)
1
6
2
2
3
27
4
10
5
1
6
2
7
4
8**
9
5
Weighted
mean (%)
False-negative
(n)
False-positive True-negative
(n)
(n)
Inconclusive
answers
(n/%)
Accuracy
(%)
Sensitivity
(%)
Specicity
(%)
PPV
(%)
NPV
(%)
48
52
23
42
53
28
37
43
2
4
54
12
2
2
1
0/0
2/0.8
10/5.6
2/0.8
0/0
53/21.0
30/13.5
10/4.0
5.0 6 6.9
80.2
76.1
60.7
76.6
78.2
66.7
71.8
75.8
78.5 6 4.9
11.1
3.7
54.0
19.2
1.9
6.7
9.8
10.4
14.6 6 16.3
99.0
98.0
71.3
93.9
99.0
98.8
99.4
96.9
94.5 6 9.3
75.0
33.3
33.3
45.5
33.3
50.0
80.0
45.5
49.2 6 18.0
80.3
78.7
85.4
81.6
78.7
85.6
82.9
81.4
81.7 6 2.6
196
192
134
186
196
167
180
188
Original scores dichotomized to form two groups: pathology, scores 14, and normal if score 0.
* Eight children younger than 13 years were eliminated.
** This observer did not agree to ll scores for the frontal sinus and therefore was excluded from the analysis.
PPV, positive predictive value; NPV, negative predictive value.
Frontal Sinus
Only 252 frontal sinuses were evaluated (after excluding
eight children aged less than 13 years). Sensitivity rate varied
greatly among observers from 1.9% to 54.0% (Table 2). The
weighted mean specicity rate was 94.5%, the weighted mean
accuracy was 78.5%, the weighted mean PPV was 49.2%, and
weighted mean NPV was 81.7%.
The concordance rate between the specic interpretations
made on plain lms and CT ranged between 64 and 84%
(weighted mean 76.7 6 5.5). Frontal sinus opacication was
demonstrated on CT in 10 cases, six of which were not
diagnosed on the radiographs by any of the observers, one
case detected by two observers and three cases by one observer.
One observer did not agree to ll scores for the frontal sinus
and was therefore excluded from this analysis. The other
observers could not commit themselves to a diagnosis
regarding the frontal sinuses in 5.2% of the radiographs.
859
Index (CTDI) of 7 mGy (CT TWIN: operation manual/appendix c.5), while a single Waters' view may expose the patient to
5 mGy and the three conventional sinus radiographs expose
the patient to 813 mGy [24], depending on the quality of the
X-ray equipment used.
In summary, our data suggest that the single Waters' view
has limited value in the diagnosis of maxillary sinusitis and is
even less sensitive for abnormalities in the other sinuses. A
normal X-ray of the paranasal sinuses cannot exclude potentially signicant pathology particularly in the frontal, ethmoid
and sphenoid sinuses, and should therefore not be relied upon
as a guide to treatment. We therefore conrm recommendations
[1] that imaging of the paranasal sinuses should be obtained by
a low dose, high resolution CT study, rather than the Waters'
projection X-ray lm.
Acknowledgement. We thank Prof. M. Hertz for editorial assistance in
preparation of the manuscript, the technicians Gregory Muzikansky and
Dani Bashi and the secretaries Rachel Elias and Pnina Butlikov for their
cooperation and support.
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