Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis

Intranasal corticosteroids reduced acute rhinosinusitis in children with allergic rhinitis: A nested case-control study

BACKGROUND

Children with allergic rhinitis (AR) have substantially more acute rhinosinusitis than children without AR. We evaluated whether intranasal corticosteroids (INCS), second-generation antihistamines (SGH), and/or intranasal antihistamines (INH) for AR affect acute rhinosinusitis in children with AR aged 2-18 years.

METHODS

By using the National Health Research Institutes Database 2005 of Taiwan, a cohort of patients with AR aged 2-18 years treated with AR medications between 2002 and 2018 was made, within which a nested case-control study was performed. Risk settings for acute rhinosinusitis cases matched controls for age, sex, and comorbidities. Current users of INCS, INH, and/or SGH were compared with remote and recent users of any AR medications and current users of INCS with and without SGH were compared with current users of SGH.

RESULTS

Current users of SGH and/or INCS had a higher risk of acute rhinosinusitis than remote users of AR drugs, and current users of SGH had a higher risk of acute rhinosinusitis than recent users; however, no difference in the risk of acute rhinosinusitis was found between current users of INCS and recent users of AR drugs. Current users of INCS with and without SGH had a lower risk of acute rhinosinusitis than current users of SGH alone.

CONCLUSIONS

Treatment of INCS with and without SGH diminished the risk of acute rhinosinusitis compared with treatment using SGH alone. Adequate INCS treatment for patients with AR is important to reduce the incidence of acute rhinosinusitis.

Safety of a New Sinus Irrigation Device in Rhinosinusitis: A Pilot Study

BACKGROUND

Puncture and lavage of the paranasal sinuses, previously the primary treatment for unresponsive acute bacterial rhinosinusitis before surgery, has been abandoned due to procedural discomfort and advancements in antibiotic efficacy and endoscopic surgery. The rise in antibiotic-resistant bacteria has renewed the interest in minimally invasive sinus lavage to both avoid aggressive surgical interventions and identify appropriate antibiotic therapy. In this article, we describe the safety and feasibility of a new device in human patients and evaluate its efficacy as a treatment before the traditional sinus surgery in acute rhinosinusitis.

METHODS

The device with its seeker-shaped guiding tube and rotating wire can enter the sinus cavity through the natural ostium, pulverize the inspissated mucus, and enable lavage and culture sampling without the need for sinus puncturing. It was tested in 6 patients with chronic sinusitis under general anesthesia during endoscopic sinus surgery and in additional 10 patients with maxillary acute bacterial rhinosinusitis in outpatient settings under local anesthesia.

RESULTS

The device enabled rapid, efficient, and atraumatic insertion of the wire into the occluded sinuses. The rotating wire permitted pulverization of the thick mucus, which enabled irrigation without mucosal damage or adverse events. Overall, 9 of 10 patients with acute bacterial rhinosinusitis demonstrated remarkable improvements and were discharged the following day with no acute symptoms. The visual analog scale score for pain dropped from 8.9 to 0.4. The remaining one patient underwent endoscopic sinus surgery subsequently. None of the patients treated during endoscopic sinus surgery developed any adverse events.

The Genotoxic Effect of Nasal Steroids on Human Nasal Septal Mucosa and Cartilage Cells In Vitro

OBJECTIVE

To determine whether budesonide (Bud) and triamcinolone acetate (TA) cause DNA fractures in the nasal mucosa and septal cartilage cells through examinations using the comet assay technique.

STUDY DESIGN

Prospective, controlled experimental study.

SETTING

University hospital.

METHODS

Septal mucosal epithelial and cartilage tissue samples were taken from 9 patients. Cell cultures were prepared from these samples. Then, budesonide and triamcinolone acetate active ingredients at 2 different doses of 0.2 and 10 µM were separately applied to the cell cultures formed from both tissues of each patient, except the control cell culture, for 7 days in one group and 14 days in one group. After the applications, genotoxic damage was scored with the comet assay technique and the groups were compared.

RESULTS

In both the budesonide and triamcinolone acetate groups, the comet scores at low and high doses, on the 7th and 14th days were found to be significantly higher in both cartilage and epithelial tissue than in the control group.

CONCLUSION

The study results showed that budesonide and triamcinolone acetate lead to a significantly high rate of genotoxic damage in both epithelial tissue and cartilage tissue.

Vascular permeability in chronic rhinosinusitis enhances accumulation and retention of nanoscale pegylated liposomes

Chronic rhinosinusitis (CRS) is a debilitating inflammatory disorder of the sinonasal mucosa that substantially diminishes patient quality of life. Progress surrounding management of this disease has been crippled by a lack of therapeutic innovation. It has been posited that increased vascularity within the diseased sinuses of patients with CRS may allow for improved systemic drug delivery via nanoscale liposomal carriers. Such a system could enhance drug distribution, accumulation, and retention within the sinuses, ultimately leading to improved patient outcomes. PEGylated liposomes loaded with indocyanine green (ICG) were synthesized, characterized and systemically administered in a mouse model of CRS. Accumulation and retention of ICG in sinonasal tissue were evaluated. Compared to healthy controls, CRS mice showed significant sinonasal tissue accumulation and retention of PEGylated liposomal ICG for up to 21 days (P < 0.001). Conversely, free ICG was eliminated from the body after 24 h in both groups.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Oral prednisolone for acute lower respiratory tract infection in clinically unrecognised asthma: an exploratory analysis of the Oral Steroids for Acute Cough (OSAC) randomised controlled trial

Background

Acute lower respiratory tract infection (ALRTI) is often treated in primary care with antibiotics. The recent Oral Steroids for Acute Cough (OSAC) randomised controlled trial (RCT) showed corticosteroids were not an effective alternative in adults without a diagnosis of asthma with ALRTI.

Aim

To investigate if corticosteroids are beneficial for ALRTI in patients with unrecognised asthma.

Design & setting

An exploratory analysis was undertaken of the primary care OSAC trial.

Method

A subgroup analysis was performed in patients who responded ‘yes’ to the following International Primary Care Airways Group (IPCAG) question: did you have wheeze and/or at least two of nocturnal cough or chest tightness or dyspnoea in the past year. Sensitivity analyses were carried out on those who answered ‘yes’ to wheeze and at least two of the nocturnal symptoms. The primary outcomes were as follows: duration of cough (0–28 days, minimum clinically important difference [MCID] of 3.79 days) and mean symptom severity score (range 0–6; MCID 1.66 units).

Results

In total, 40 (10%) patients were included in the main analysis: mean age 49 years (standard deviation [SD] = 17.9), 52% male. Median cough duration was 3 days in both prednisolone (interquartile range [IQR] = 2–6 days) and placebo (IQR = 1–6 days) groups (adjusted hazard ratio [HR] = 1.10; 95% confidence interval [CI] = 0.47 to 2.54; P = 0.83), equating to 0.24 days longer in the prednisolone group (95% CI = 1.23 days shorter to 2.88 days longer). Mean symptom severity difference was –0.14 (95% CI = –0.78 to 0.49; P=0.65) comparing prednisolone with placebo. Similar findings were found in the sensitivity analysis.

Conclusion

No evidence was found to support the use of corticosteroids for ALRTI in patients with clinically unrecognised asthma. Clinicians should not use the IPCAG questions to target oral corticosteroid treatment in patients with ALRTI.

Acute bacterial sinusitis in children: an updated review

Background

In the pediatric age group, approximately 7.5% of upper respiratory tract infections (URIs) are complicated by acute bacterial sinusitis (ABS). Despite its prevalence, ABS is often overlooked in young children. The diagnosis and management present unique challenges in primary care. This is an updated narrative review on the evaluation, diagnosis, and management of ABS.

Methods

A PubMed search was performed using the key term ‘acute sinusitis’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies, and reviews. The search was restricted to the English literature and children.

Results

Haemophilus influenzae (non-typeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the major pathogens in uncomplicated ABS in otherwise healthy children. In complicated ABS, polymicrobial infections are common. The diagnosis of acute sinusitis is mainly clinical and based on stringent criteria, including persistent symptoms and signs of a URI beyond 10 days, without appreciable improvement; a URI with high fever and purulent nasal discharge at onset lasting for at least 3 consecutive days; and biphasic or worsening symptoms.

Conclusion

Data from high-quality studies on the management of ABS are limited. The present consensus is that amoxicillin-clavulanate, at a standard dose of 45 mg/kg/day orally, is the drug of choice for most cases of uncomplicated ABS in children in whom antibacterial resistance is not suspected. Alternatively, oral amoxicillin 90 mg/kg/day can be administered. For those with severe ABS or uncomplicated acute sinusitis who are at risk for severe disease or antibiotic resistance, oral high-dose amoxicillin-clavulanate (90 mg/kg/day) is the drug of choice.

Headache and rhinosinusitis: A review

PURPOSE OF REVIEW

To explain our current understanding of headache attributed to rhinosinusitis, an often inappropriately diagnosed secondary headache.

RECENT FINDINGS

Recent studies have shown that headache attributed to rhinosinusitis is often over-diagnosed in patients who actually have primary headache disorders, most commonly migraine. Failure to recognize and treat rhinosinusitis, however, can have devastating consequences. Abnormalities of the sinuses may also be treatable by surgical means, which may provide headache relief in appropriately selected patients.

SUMMARY

It is important for the practicing physician to understand how rhinosinusitis fits into the differential diagnosis of headache, both to avoid overdiagnosis in patients with primary headache, and to avoid underdiagnosis in patients with serious sinus disease.

Overuse of diagnostic tools and medications in acute rhinosinusitis in Spain: a population-based study (the PROSINUS study)

OBJECTIVES

Acute rhinosinusitis (ARS) has a high incidence. Diagnosis is clinical, and evolution is mostly self-limited. The aim of this study was to describe the sociodemographic characteristics and use of diagnostic tools and medications in patients with ARS.

DESIGN

This is a prospective observational study in real-life clinical practice.

SETTING

Patients with clinical diagnosis of ARS (n=2610) were included from ear, nose and throat clinics in Spain. A second visit at resolution was done.

PARTICIPANTS

Patients were classified according to the duration of symptoms: viral ARS (≤10 days), postviral ARS (>10 days, ≤12 weeks) and chronic rhinosinusitis (>12 weeks).

MAIN OUTCOME MEASURES

Sociodemographic characteristics, symptoms, disease severity, quality of life (Sino-Nasal Outcome Test-16), used diagnostic tools and medications, and the management performed by primary care physicians (PCPs) and by otorhinolaryngologists (ORLs) were assessed.

RESULTS

Of the patients 36% were classified as having viral ARS, 63% postviral ARS and 1% as chronic rhinosinusitis. Working in a poorly air-conditioned environment was a risk factor (OR: 2.26, 95% CI 1.27 to 4.04) in developing postviral ARS. A higher number of diagnostic tools (rhinoscopy/endoscopy: 80% vs 70%; plain X-ray: 70% vs 55%; CT scan: 22% vs 12%; P<0.0001) were performed in postviral than viral cases. PCPs performed more X-rays than ORLs (P<0.0001). Patients, more those with postviral than viral ARS, received a high number of medications (oral antibiotics: 76% vs 62%; intranasal corticosteroids: 54% vs 38%; antihistamines: 46% vs 31%; mucolytic: 48% vs 60%; P<0.0001). PCPs prescribed more antibiotics, antihistamines and mucolytics than ORLs (P<0.0068). More patients with postviral than viral ARS reported symptoms of potential complications (1.5% vs 0.4%; P=0.0603). Independently of prescribed medications, quality of life was more affected in patients with postviral (38.7±14.2 vs 36.0±15.3; P=0.0031) than those with viral ARS. ARS resolution was obtained after 6.04 (viral) and 16.55 (postviral) days, with intranasal corticosteroids being associated with longer (OR: 1.07, 95% 1.02 to 1.12) and phytotherapy with shorter (OR: 0.95, 95% CI 0.91 to 1.00) duration.

CONCLUSIONS

There is a significant overuse of diagnostic tools and prescribed medications, predominantly oral antibiotics, by PCPs and ORLs, for viral and postviral ARS.

Management of rhinosinusitis: an evidence based approach

PURPOSE OF REVIEW

The most recent recommendations for the management of both acute (ARS) and chronic rhinosinusitis (CRS) based on the strongest data available for each treatment modality are summarized in this review. The clinical relationships between CRS and its comorbidities are also discussed.

RECENT FINDINGS

The most promising advances in rhinosinusitis management involve the use of mAbs (anti-IgE, anti-IL-5, anti-IL-4Rα) in trials of CRS with nasal polyposis. Otherwise, the mainstays of treatment for both ARS and CRS have largely remained the same over the past several years.

SUMMARY

The treatment of ARS primarily involves symptomatic control with intranasal corticosteroids and nasal saline irrigation; antibiotics should be reserved for the patients who are believed to have bacterial rhinosinusitis. Treating CRS effectively involves using intranasal corticosteroids and irrigation, systemic corticosteroids, and potentially systemic antibiotics. Biologics (mAbs) have shown benefit in clinical studies. Providers should also be aware of concomitant disease processes that may afflict patients with CRS.

Effect of Oral Prednisolone on Symptom Duration and Severity in Nonasthmatic Adults With Acute Lower Respiratory Tract Infection: A Randomized Clinical Trial

IMPORTANCE

Acute lower respiratory tract infection is common and often treated inappropriately in primary care with antibiotics. Corticosteroids are increasingly used but without sufficient evidence.

OBJECTIVE

To assess the effects of oral corticosteroids for acute lower respiratory tract infection in adults without asthma.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, placebo-controlled, randomized trial (July 2013 to final follow-up October 2014) conducted in 54 family practices in England among 401 adults with acute cough and at least 1 lower respiratory tract symptom not requiring immediate antibiotic treatment and with no history of chronic pulmonary disease or use of asthma medication in the past 5 years.

INTERVENTIONS

Two 20-mg prednisolone tablets (n = 199) or matched placebo (n = 202) once daily for 5 days.

MAIN OUTCOMES AND MEASURES

The primary outcomes were duration of moderately bad or worse cough (0 to 28 days; minimal clinically important difference, 3.79 days) and mean severity of symptoms on days 2 to 4 (scored from 0 [not affected] to 6 [as bad as it could be]; minimal clinically important difference, 1.66 units). Secondary outcomes were duration and severity of acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, and adverse events.

RESULTS

Among 401 randomized patients, 2 withdrew immediately after randomization, and 1 duplicate patient was identified. Among the 398 patients with baseline data (mean age, 47 [SD, 16.0] years; 63% women; 17% smokers; 77% phlegm; 70% shortness of breath; 47% wheezing; 46% chest pain; 42% abnormal peak flow), 334 (84%) provided cough duration and 369 (93%) symptom severity data. Median cough duration was 5 days (interquartile range [IQR], 3-8 days) in the prednisolone group and 5 days (IQR, 3-10 days) in the placebo group (adjusted hazard ratio, 1.11; 95% CI, 0.89-1.39; P = .36 at an α = .05). Mean symptom severity was 1.99 points in the prednisolone group and 2.16 points in the placebo group (adjusted difference, -0.20; 95% CI, -0.40 to 0.00; P = .05 at an α = .001). No significant treatment effects were observed for duration or severity of other acute lower respiratory tract infection symptoms, duration of abnormal peak flow, antibiotic use, or nonserious adverse events. There were no serious adverse events.

CONCLUSIONS AND RELEVANCE

Oral corticosteroids should not be used for acute lower respiratory tract infection symptoms in adults without asthma because they do not reduce symptom duration or severity.

TRIAL REGISTRATION

ISRCTN.com Identifier: ISRCTN57309858.

Contemporary Use of Corticosteroids in Rhinology

PURPOSE OF REVIEW

Exogenously administered corticosteroids are widely used today in the field of rhinology. Allergic rhinitis (AR), non-allergic rhinitis (NAR), acute rhinosinusitis (ARS), chronic rhinosinusitis with (CRSwNP) and without (CRSsNP) nasal polyps, and autoimmune disorders with nasal manifestations are common diseases treated effectively with intranasal and oral glucocorticoids. We focus on physiological pathways, therapeutic benefits, indications, contra-indications, and side effects of glucocorticoid utilization in the treatment of rhinologic disorders such as AR, NAR, ARS, CRSsNP, and CRSwNP.

RECENT FINDINGS

Second-generation intranasal steroid (INS) agents have pharmacokinetic characteristics that minimize their systemic bioavailability, resulting in minimum risk for systemic adverse events. Several studies have demonstrated the symptomatic efficacy of both intranasal and oral corticosteroids in ARS. Moreover, intranasal and systemic steroid administration has been repeatedly proven beneficial in the conservative and perioperative management of CRSwNP. For patients with AR, there is no need for oral steroids, with the exception of severe cases, as there is lack of superiority to INS. SCUAD patients challenge currently available treatment schemes, underlining the importance of research in the field. Corticosteroids' effectiveness in the treatment of various rhinologic disorders is indisputable. However, their characteristics, and potential side effects, make a clear consensus for utilization difficult.

[The use of intranasal glucocorticosteroids in the treatment of rhinosinusitis: Focus on mometasone furoate]

The authors discuss the mechanism of action, effectiveness, and safety of intranasal glucocorticosteroids (inGCS) used to treat acute, recurrent and chronic rhinosinusitis (RS). The last version of the European guidelines concerning the application of inGCS assigns the highest level of evidence-Ia and the highest strength of recommendations-A to these medications when applied for the treatment of acute and polypoid rhinosinusitis. Moreover, they acquire the status of the agents of choice for the therapy of chronic RS without polyps. Mometasone furoate is one of the best explored preparations of this group of medicines. It is possessed of favourable pharmacodynamic and pharmacokinetic properties when prescribed for local application. The new mometasone furoate preparation in the form of an intranasal spray Dezrinit produced by "Teva" Ltd. was registered in the Russian Federation. In a comparative randomized clinical trial (RCT), the preparation was shown to be an equivalent to the Nasonex spray.

Pediatric Acute Bacterial Sinusitis: Diagnostic and Treatment Dilemmas

Acute bacterial sinusitis (ABS) is a common complication of a simple upper respiratory infection. Acute bacterial sinusitis and an upper respiratory infection, however, have different management plans. This article will help clinicians establish when a diagnosis of ABS can be made based on the latest guidelines from the American Academy of Pediatrics. Also covered will be the pathophysiology of ABS, the role of diagnostic imaging, the recognition of complications of ABS, and treatment options.

Clinical practice guideline (update): adult sinusitis

OBJECTIVE

This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS).

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.

ACTION STATEMENTS

The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.

Impact of saline irrigation and topical corticosteroids on the postsurgical sinonasal microbiota

BACKGROUND

Topical treatments with nasal saline irrigation, topical steroid sprays, or corticosteroid rinses can improve sinonasal symptoms in chronic rhinosinusitis (CRS). However, the impact of these therapies on commensals (Corynebacterium) and on biofilm pathogens associated with CRS (Staphylococcus aureus and Pseudomonas) is not well characterized.

METHODS

Paired nasal and sinus swabs were collected endoscopically from 28 controls and 14 CRS patients with nasal polyposis (CRSwNP) who had not received systemic antibiotics or corticosteroids in the previous 8 weeks. Total DNA from swab eluents were extracted and analyzed by 16S rRNA gene-based pyrosequencing. A total of 359,077 reads were obtained and classified taxonomically. The association of use of topical therapies with sinonasal microbiota composition was assessed by factor/vector-fitting. The proportional abundances of sinonasal bacteria between topical therapy users and nonusers were further compared by 2-tailed Kolmogorov-Smirnov test among controls and among CRSwNP participants.

RESULTS

Nasal saline irrigation, with or without added budesonide, was not associated with significantly distinct sinonasal microbiota composition or significantly decreased Pseudomonas or S. aureus abundances among either controls or CRSwNP participants. Corynebacterium was slightly lower in controls that reported using saline irrigation than those who did not. No significant association was found between nasal saline irrigation and the proportional abundances of Pseudomonas, S. aureus, and Corynebacterium in CRSwNP participants. However, male CRSwNP patients were noted to have significantly higher Corynebacterium proportional abundances than their female counterparts. The use of topical steroid sprays was associated with a distinct microbiota in control subjects, characterized by higher proportional abundances of Dolosigranulum and Simonsiella and a lower proportional abundance of Campylobacter.

CONCLUSION

Nasal saline irrigation is not associated with a distinct alteration in the proportional abundance of commensal bacteria or biofilm-forming pathogens in CRSwNP patients. However, use of topical intranasal corticosteroid sprays in control subjects is associated with a distinct sinonasal microbiota.

Systemic corticosteroids for acute sinusitis

BACKGROUND

Acute sinusitis is the inflammation and swelling of the nasal and paranasal mucous membranes and is a common reason for patients to seek primary care consultations. The related impairment of daily functioning and quality of life is attributable to symptoms such as facial pain and nasal congestion.

OBJECTIVES

To assess the effects of systemic corticosteroids on clinical response rates and to determine adverse effects and relapse rates of systemic corticosteroids compared to placebo or standard clinical care in children and adults with acute sinusitis.

SEARCH METHODS

We searched CENTRAL (2014, Issue 1), MEDLINE (1966 to February week 1, 2014) and EMBASE (January 2009 to February 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic corticosteroids to placebo or standard clinical care for patients with acute sinusitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of the trials and extracted data.

MAIN RESULTS

Five RCTs with a total of 1193 adult participants met our inclusion criteria. We judged methodological quality to be moderate in four trials and high in one trial. Acute sinusitis was defined clinically in all trials. However, the three trials performed in ear, nose and throat (ENT) outpatient clinics also used radiological assessment as part of their inclusion criteria. All participants were assigned to either oral corticosteroids (prednisone 24 mg to 80 mg daily or betamethasone 1 mg daily) or the control treatment (placebo in four trials and non-steroidal anti-inflammatory drugs (NSAIDs) in one trial). In four trials antibiotics were prescribed in addition to oral corticosteroids or control treatment, while one trial investigated the effects of oral corticosteroids as a monotherapy.When combining data from the five trials, participants treated with oral corticosteroids were more likely to have short-term resolution or improvement of symptoms than those receiving the control treatment: at days three to seven (risk ratio (RR) 1.3, 95% confidence interval (CI) 1.1 to 1.6; risk difference (RD) 17%, 95% CI 6% to 29%) and at days four to 14 (RR 1.2, 95% CI 1.0 to 1.5; RD 14%, 95% CI 1% to 27%). A sensitivity analysis including the four trials with placebo as a control treatment showed similar results but with a lesser effect size: at days three to seven (RR 1.2, 95% CI 1.1 to 1.3; RD 11%, 95% CI 4% to 17%) and days four to 14 (RR 1.1, 95% CI 1.0 to 1.2; RD 8%, 95% CI 2% to 13%). Statistical heterogeneity was high for many analyses. Subgroup analyses revealed that corticosteroid monotherapy had no beneficial effects. Furthermore, scenario analysis showed that outcomes missing from the trial reports might have introduced attrition bias (a worst-case scenario showed no statistically significant beneficial effect of oral corticosteroids). No trial reported effects on relapse or recurrence rates. Reported side effects in patients treated with oral corticosteroids were mild (nausea, vomiting, gastric complaints) and did not significantly differ from those receiving placebo.

AUTHORS' CONCLUSIONS

Oral corticosteroids as a monotherapy appear to be ineffective for adult patients with clinically diagnosed acute sinusitis. Current data on the use of oral corticosteroids as an adjunctive therapy to oral antibiotics are limited: almost all trials are performed in secondary care settings and there is a significant risk of bias. This limited evidence suggests that oral corticosteroids in combination with antibiotics may be modestly beneficial for short-term relief of symptoms in acute sinusitis, with a number needed to treat to benefit of seven for resolution or symptom improvement. A large primary care factorial trial is needed to establish whether oral corticosteroids offer additional benefits over antibiotics in acute sinusitis.

Intranasal glucocorticosteroids - not only in allergic rhinitis In the 40th anniversary of intranasal glucocorticosteroids' introduction

It has been 40 years since Niels Mygind's publication in British Medical Journal on intranasal application of beclomethasone dipropionate aerosol in allergic rhinitis (AR). Since then a new era in treatment of allergic and nonallergic upper airway diseases began. This publication presents current concepts on application of intranasal glucocorticosteroids (inGCS) in treatment of upper airway diseases and in particular of AR and rhinosinusitis. Nonquestionable advantage of inGCS is their strong anti-inflammatory local action with little impact on general health responsible for few and benign side effects. Main way of action of glucocorticosteroids is connected with binding to the intracellular glucocorticosteroid receptor and its impact on nuclear cytoplasmic transcriptional factors. Glucocorticosteroids suppress gene expression of factors responsible for generating and supporting inflammatory processes, proinflammatory cytokines and chemokines production, and adhesive molecules expression. It appears that glucocorticosteroids have also other mechanisms of action, non-involving intracellular receptors, leading to inhibition of early and late phase of allergic reaction. At the moment the following glucocorticosteroids are registered in Poland: beclomethasone, budesonide, fluticasone propionate, fluticasone furoate, and mometasone furoate. Furoates earn special attention as their lateral furoate ester chain makes the molecules highly lipophilic, and hence easily absorbed by nasal mucous membranes, epithelium and cell membrane phospholipids. This minimizes their general action and maximizes local action. According to current state of knowledge topical glucocorticosteroids are used in the following upper airway diseases with different inflammatory mechanisms: AR, non-AR, particularly NARES, acute rhinosinusitis, chronic rhinosinusitis with and without nasal polyps, adenoid hypertrophy and rhinitis in bronchial asthma.

Limited Evidence for Effects of Intranasal Corticosteroids on Symptom Relief for Recurrent Acute Rhinosinusitis

Objective

To systematically review the evidence base on the effectiveness of intranasal corticosteroids in adult patients with recurrent acute rhinosinusitis.

Data Sources

Pubmed, EMBASE, and the Cochrane Library.

Review Methods

A comprehensive search was performed up to March 20, 2013. Two reviewers independently screened publications on title and abstract. Design of selected studies was assessed on directness of evidence and risk of bias. For included studies, risk differences with 95% confidence intervals were extracted or recalculated.

Results

Of 1850 unique records, 3 trials were included. Risk of bias was high and directness of evidence was low for 2 trials, the third trial had low risk of bias with moderate directness of evidence. They found a statistical significant difference for the median number of days to clinical success (defined as patients’ report of symptoms to be cured or much improved) favoring intranasal corticosteroids (6 days) over placebo (9 days), while the difference in proportion of patients reporting clinical success after 21 days of treatment was 20% favoring intranasal corticosteroids over placebo.

Conclusion and Recommendation

The evidence for the benefit of intranasal corticosteroids on symptom relief in adult patients with recurrent acute rhinosinusitis is rather limited (ie, 3 trials are available; the best evidence is derived from 1 low risk of bias trial providing moderate directness of evidence that intranasal corticosteroids may speed up relief of symptoms in patients with recurrent acute rhinosinusitis). A large methodologically rigorous randomized trial in antibiotic-naïve patients is needed to provide a more definite recommendation.