## Investigation of Choice for Chronic Sinusitis **Key Point:** CT paranasal sinuses is the gold standard imaging modality for chronic sinusitis, providing superior detail of bony anatomy, extent of disease, and potential complications. ### Why CT is Superior | Feature | CT | Plain X-ray | MRI | Endoscopy | |---------|----|----|-----|----------| | Bony detail | Excellent | Poor | Poor | N/A | | Soft tissue | Good | Poor | Excellent | Visual only | | Complications (orbital, intracranial) | Detects well | Misses | Detects | Cannot assess | | Cost | Moderate | Low | High | Procedural | | Radiation | Yes | Yes | No | N/A | | Time to diagnosis | Fast | Fast | Slow | Immediate | **High-Yield:** CT is essential for: - Confirming diagnosis when clinical suspicion is high - Assessing disease severity and extent - Evaluating for orbital cellulitis, subperiosteal abscess, or intracranial extension - Surgical planning (if functional endoscopic sinus surgery [FESS] is contemplated) ### Role of Other Investigations **Nasal endoscopy:** Useful for direct visualization and obtaining cultures, but does NOT replace imaging for diagnosis confirmation or complication assessment. **MRI:** Reserved for suspected complications (cavernous sinus thrombosis, meningitis) or when orbital involvement is unclear on CT; not first-line for uncomplicated chronic sinusitis. **Plain radiographs (Water's view):** Outdated for chronic sinusitis diagnosis; poor sensitivity and specificity; cannot assess bony erosion or complications. **Clinical Pearl:** In chronic sinusitis, CT findings may show mucosal thickening, air-fluid levels, complete opacification, or osteitis (bone remodeling), which guide medical vs. surgical management decisions. [cite:Park 26e Ch 3] 
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