Some people will also have nasal polyps, which are grape-like swellings of the normal nasal lining inside the nasal passage and sinuses. Topical intranasal corticosteroids are used with the aim of reducing inflammation in order to improve patient symptoms.
We included nine randomised controlled trials RCTs with a total of participants in this review. The studies varied in size: some were small, with as few as 20 patients, while others included over participants. Most studies recruited adult patients, but one study only included children.
In all of the studies the participants had chronic rhinosinusitis with nasal polyps. The studies either compared different types of steroids three studies , high-dose versus low-dose steroids five studies , twice daily versus once daily steroids, or different delivery methods aqueous nasal spray versus aerosol - one study.
All of the studies had a placebo group. Two small studies 56 participants, unclear risk of bias evaluated disease severity and looked at the primary adverse effect, epistaxis nosebleed , but no other outcomes. No difference was found between the two steroids but we assessed the evidence to be of very low quality. One study participants, unclear risk of bias found no difference in disease severity nasal symptoms scores.
We assessed this evidence to be of very low quality. Effectiveness disease severity and nasal polyps size was similar between the high-dose and low-dose groups low quality evidence. Although all studies reported more improvement in polyp score in the high-dose group, the significance of this is unclear because the improvements seen were small.
The primary adverse effect, epistaxis, was more common when higher doses were used moderate quality evidence. We identified only one poorly reported study with a high risk of bias. It was unclear how many participants there were: 91 were recruited into three arms. There had also been significant differences between the participants in the two groups when they started the study. We were unable to draw any meaningful conclusions from this study.
We found no evidence that one type of intranasal steroid is more effective than another in patients with chronic rhinosinusitis, nor that higher doses are better than lower, nor that the effectiveness of a spray differs from an aerosol.
We found no studies that compared nasal drops with spray. We did find moderate quality evidence of an increased risk of epistaxis nosebleed as an adverse effect of treatment when higher doses were used. More research in this area is clearly needed. In the future studies should be well designed: they should measure chronic rhinosinusitis-specific health-related quality of life and adverse effects as outcomes, and look at what happens to patients taking intranasal steroids in the longer term.
We found insufficient evidence to suggest that one type of intranasal steroid is more effective than another in patients with chronic rhinosinusitis, nor that the effectiveness of a spray differs from an aerosol. We identified no studies that compared drops with spray. It is unclear if higher doses result in better symptom improvements low quality evidence , but there was moderate quality evidence of an increased risk of epistaxis as an adverse effect of treatment when higher doses were used.
This included all levels of severity of epistaxis and it is likely that the proportion of events that required patients to discontinue usage is low due to the low numbers of withdrawals attributed to it. If epistaxis is limited to streaks of blood in the mucus it may be tolerated by the patient and it may be safe to continue treatment. However, it may be a factor that affects compliance.
There is insufficient evidence to suggest that the different types of corticosteroid molecule or spray versus aerosol have different effects. Lower doses have similar effectiveness but fewer side effects. Clearly more research in this area is needed, with specific attention given to trial design, disease-specific health-related quality of life outcomes and evaluation of longer-term outcomes and adverse effects.
This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis. The condition can occur with or without nasal polyps. Topical intranasal corticosteroids are used with the aim of reducing inflammation in the sinonasal mucosa in order to improve patient symptoms. Current use in the 3 months before the registration of an event and highest average daily dose give a much stronger association. Current use is also associated with a significantly increased risk of heart failure adjusted OR of 2.
Cardiovascular risk showed a clear dose—response relationship [ ]. A study from Hissaria et al. In the above-mentioned controlled trial by Venekamp et al. Two studies in asthmatic and ophthalmologic patients receiving short-courses of GCS, showed a development of hypo mania [ , ] as well as depression symptoms [ ].
Naber et al. The onset of symptoms was within 3 days of use and there was no correlation between daily dose and daily ratings of mood. Brown et al. Mood changes returned back to normal after discontinuation of therapy. A randomised controlled trial by Campieri et al. Mean body weight increased with 2.
Bar-Meir et al. Inflammatory diseases of the nose and paranasal sinuses in children include upper respiratory tract infections, chronic rhinitis, ARS and CRS. Bacterial infection is expected when at least 3 symptoms are present among which discoloured discharge, purulent secretion in nasal cavity, severe local pain with a unilateral predominance, fever, elevated C-reactive protein or erythrocyte sedimentation rate, and double sickening i.
The diagnosis is confirmed by either nasal endoscopy showing edema, purulent drainage or nasal polyps in the middle meatus or CT scan showing ostiomeatal complex or sinus opacification. Of note, the presence of nasal polyps is much less common in pediatric patients than in adult patients with CRS [ ]. Three clinical trials can be found in literature that investigated the use of oral GCS in the pediatric rhinosinusitis population, of which only one is controlled Table There was also a significant beneficial effect of oral GCS in cough, nasal obstruction and post-nasal drainage symptom scores.
Recurrence of symptoms 6 months after the end of treatment was not statistically significant between the groups. Additionally, a retrospective study involving 35 young CRS patients 1—21 years undergoing serial sinus CT scans due to medical reasons, evaluated Lund Mackay ostiomeatal complex score in relation to three different treatment schemes [ ] antibiotics, intranasal topical GCS and oral systemic GCS. The data suggested that the use of systemic GCS was associated with a significant increase in the likelihood of radiologic improvement.
The retrospective study design, the small and heterogeneous population, heterogeneous treatment modalities, and the lack of adjustments, limit the possibilities to assess clinical significance of the findings. A second uncontrolled study [ 5 ] evaluated cytokine pattern of 30 asthmatic CRS patients 4—12 years before and after the treatment of amoxicillin—clavulanate, fluticasone propionate aqueous nasal spray and a short course of oral deflazacort.
The uncontrolled study design and uncertainty whether the patients used prescribed drugs, limits the possibilities to assess effect of systemic GCS. As an example, the Childhood Asthma Management Program trial followed the annual bone mineral accretion of children 5—12 years with mild-to-moderate asthma [ , ]. Oral GCS bursts produced a dosage-dependent reduction in bone mineral accretion 0. The authors conclude that multiple oral GCS bursts over a period of years can produce a dosage-dependent reduction in bone mineral accretion and increased risk for osteopenia in children with asthma.
At the end of the treatment, the mean weight change did not differ statistically significantly between the groups. A systematic review has been performed to determine the most common and serious drug-related AE of long courses of oral GCS in children [ ].
Literature search of several databases was performed to identify all studies in which systemic GCS had been administered to pediatric patients ranging from 28 days to 18 years of age for at least 15 days of treatment. The group found 91 studies that represented a total of children and contained reports of adverse drug reactions, the majority in patients with leukaemia, haemangioma and asthma.
The three most frequent adverse drug reactions were weight gain Increased susceptibility to infection was the most serious adverse drug reaction. However, based on studies on pediatric asthma, a single short-term systemic GCS course could be considered in pediatric patients suffering from CRS that is not responding to other therapies such as intranasal GCS, antibiotics, supporting therapy saline douchings, decongestants and adenoidectomy.
Option in patients suffering from very severe and therapy-resistant disease, in combination with antibiotics. Besides clinical consequences, systemic GCS use may also have some health economic implications that should be considered in its benefit-harm trade-off. Generally, the direct costs for systemic GCS are among the lowest quartile of prices of medications available worldwide. However, the indirect costs due to adverse events of especially long-term, high-dose systemic GCS use could be more substantial.
Two industry-funded studies have assessed the cumulative economic burden of GCS associated adverse events regardless of dose, duration or indication [ , ]. Manson et al. A second review [ ] included 47 studies reporting on adverse events of systemic GCS. Subsequently, a cost analysis was undertaken from the US perspective. It was unclear whether any patients with allergic rhinitis or rhinosinusitis were included. Most frequently reported adverse events were psychiatric and gastric conditions, infections and fractures.
The authors estimated the potential cost reductions if the daily GCS dose would be reduced. The findings from both reviews should be interpreted with caution given the heterogeneous and often low-quality and retrospective nature of the studies included and the difficulty in excluding confounding due to underlying disease activity.
Besides these two reviews with no particular disease focus, some studies focused on the costs of systemic GCS related adverse events within a specific population such as asthma [ , ] or rheumatologic diseases [ , ] and found increased costs in the GCS exposed populations. None were specifically focusing on rhinitis or rhinosinusitis. We conclude that given the limited amount of current evidence, more studies on the economic burden and cost-effectiveness of systemic GCS use in rhinitis and rhinosinusitis treatment are required.
However, in AR, allergen immunotherapy AIT is an alternative option for patients suffering from uncontrolled symptoms. AIT modifies the natural disease course and recent well-performed trials have demonstrated reductions in both symptoms and use of rescue medication in patients with AR for both the subcutaneous as well as sublingual administration route [ ]. One study from compared the efficacy of one depot MP injection with a pre-seasonal administration of an alum-precipitated pyridine extracted grass pollen immunotherapy and found similar results between the two groups in terms of symptom improvement [ ].
For CRS patients, current alternatives for oral GCS during exacerbations consist of antibiotics and when patients remain uncontrolled, sinus surgery is the next step in line [ 4 ]. Gevaert et al. They found a beneficial effect on NP score of doxycycline that was comparable to MP after 8 weeks. Also, omalizumab and mepolizumab treatment had better results on NP score than the oral GCS treatment. Omalizumab and mepolizumab additionally showed better symptom control compared to MP. Currently only data on the oral steroid-sparing effects of mepolizumab and benralizumab in asthma are available [ ], but with the increased implementation of these therapies in CRSwNP, studies evaluating the steroid-sparing effect for upper airway exacerbations will be necessary.
This manuscript provided an overview of the current evidence for the beneficial effects of systemic GCS in the different subtypes of upper airway diseases, as well as in the pediatric age group and aimed at providing recommendations for the specific disease entities. However, multiple AEs have been widely described and therefore physicians should be aware of the risks associated with oral GCS and make a good risk—benefit assessment prior to prescribing them.
In this paper, we summarize these potential AEs; given the current evidence in literature, a clear assessment of the risks associated with oral steroid use in upper airway disease cannot be made. Currently available data show a wide variability in diseases, patients, duration of treatment and follow-up and therefore this topic needs to be addressed in a systematic way in order to provide a substantiated recommendation for the use and dosing of oral GCS in the upper airway disease population.
We can conclude that, although some beneficial effects of systemic GCS have been demonstrated in chronic upper airway diseases such as AR and CRSwNP, systemic GCS should not be considered as a first line of treatment for these disease types.
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It is unclear whether or not there is a benefit from using antibiotics as well as saline irrigation and INCS. We looked for studies of antibiotics taken directly into the nose topical but did not find any, so cannot comment further on this route for treatment Something done with the aim of improving health or relieving suffering.
For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. The results of this review suggest that, for people with CRS with nasal polyps, adding oral corticosteroids is beneficial in reducing the size of the polyps and probably also in reducing symptom severity when compared to placebo. There was a lack of reliable evidence on adverse effects.
The results for longer-term outcomes Outcomes are measures of health for example quality of life, pain, blood sugar levels that can be used to assess the effectiveness and safety of a treatment or other intervention for example a drug, surgery, or exercise. More , which are important to determine whether there is sustained benefit, suggest that the difference between the groups becomes smaller, but the evidence is inconclusive.
No evidence was found for people with CRS without nasal polyps. Short-course oral corticosteroids alone for chronic rhinosinusitis have potential short-term benefits with tolerated side effects, but the benefits are unlikely to last, hence the need for additional ongoing INCS. We are still uncertain whether a short course of oral steroids is beneficial to patients with chronic rhinosinusitis on top of other treatment such as INCS or antibiotics.
What all these reviews have shown is that more and better research in this area is clearly needed. Meanwhile there is certainly some benefit to be had from using saline irrigations and intranasal corticosteroids. For patients seen by specialist doctors where polyps are seen in the nose, steroid tablets may also have a place in treatment. In cases where no polyps are seen, the case for antibiotics is less clear and should be discussed carefully between the doctor and patient.
As a senior lecturer at UEA, I am involved in a number of research projects including leading a national study to understand risk factors that contribute to chronic sinusitis. What works for chronic sinusitis? Hello, for the sake of love for God, I advise everyone who suffers from chronic sinusitis to use: nano silver water.
It is available in a bottle with spray. Nothing helped, I spent a fortune trying to smell again getting rid of tiredness and pain in my head. This kills the germs and will rid of snot. All the best. Sinusitis or sinus infection is inflammation of the air cavities within the passages of the nose which can be caused by infection, allergies, or irritation. Most people do not spread sinus infections to other people and bacterial sinusitis is usually treated with antibiotics.
Early treatment of allergic sinusitis may prevent secondary bacterial sinus infections. Treatment of sinusitis may include nasal drops as well as acetaminophen for pain or discomfort. I have had chronic sinusitis for 40 years and am 72 yrs. The only way for me to breathe is on home oxygen and daily corticosteroid sprays and antibiotic nasal sprays. My ridges in the nose get swollen, painful and infected. I also get upper respiratory infections, leading to bacterial pneumonia from mucus draining into my lungs down the back of my throat.
I have ended up with COPD, chronic bronchitis, many pulmonary embollisms and chronic pneumonia leaving severe lung damage. I , for one, find life unbearable and expensive just to be survive with my sick lungs and definitely say that the sprays have helped save my life many times. Your email address will not be published. Search and hit Go. Mayo Clinic does not endorse companies or products.
Advertising revenue supports our not-for-profit mission. This content does not have an English version. This content does not have an Arabic version. Diagnosis Your doctor may ask about your symptoms. Methods for diagnosing chronic sinusitis include: Imaging tests. These might pinpoint a deep inflammation or physical blockage, such as polyps, tumors or fungi, that's difficult to detect using an endoscope. Looking into your sinuses. A thin, flexible tube with a fiber-optic light inserted through your nose allows your doctor to see the inside of your sinuses.
This can help your doctor see a deviated nasal septum, polyps or tumors. An allergy test. If your doctor suspects that allergies might be triggering your chronic sinusitis, he or she might recommend an allergy skin test. A skin test is safe and quick and can help detect what allergen is responsible for your nasal flare-ups. Samples from your nasal and sinus discharge cultures. Cultures are generally unnecessary for diagnosing chronic sinusitis.
However, when the condition fails to respond to treatment or is worsening, your doctor may swab inside your nose to collect samples that might help determine the cause, such as bacteria or fungi. Endoscopic sinus surgery Open pop-up dialog box Close. Endoscopic sinus surgery The upper left illustration shows the frontal A and maxillary B sinuses, as well as the ostiomeatal complex C. Request an Appointment at Mayo Clinic.
Neti pot Open pop-up dialog box Close. Neti pot A neti pot is a container designed to rinse the nasal cavity. Share on: Facebook Twitter. Show references AskMayoExpert. Chronic rhinosinusitis. Mayo Clinic; Bennett JE, et al. Philadelphia, Pa. Accessed April 30, Peters AT, et al. Diagnosis and management of rhinosinusitis: A practice parameter update. Annals of Allergy, Asthma and Immunology Journal. Wyler B, et al.