Q/Which treatments are safe and effective for chronic sinusitis?
A / FOR ADULTS WITH CHRONIC RHINOSINUSITIS (CRS), INTRANASAL STEROID (INS) therapy is more likely than placebo to improve symptoms (50% vs 32%; strength of recommendation [SOR]: A, systematic reviews).
Nasal saline irrigation (SI) alleviates symptoms better than no therapy (SOR: A, systematic reviews), but it's probably not as effective as INS treatment (SOR: B, randomized controlled trial [RCT] with wide confidence interval).
Long-term (12 weeks) macrolide therapy doesn't alter patient-oriented quality-of-life measures (SOR: A, systematic reviews).
Endoscopic sinus surgery improves CRS symptoms--nasal obstruction, discharge, and facial pain--over baseline (SOR: A, systematic reviews). Surgery and medical therapy appear about equivalent in terms of symptom improvement and quality-of-life measures (SOR: B, systematic reviews of low-quality RCTs).
The TABLE (1-4) shows the major results of the meta-analyses for the various medical therapy trials.
Two systematic reviews with meta-analyses evaluated treatment with INS for CRS with nasal polyps (40 RCTs; 3624 patients, mean age 48 years, 64% male) and without polyps (10 RCTs; 590 patients, mean age 39 years, 51% male). (1,2) Trials reported sino-nasal symptom outcomes differently and couldn't be combined. In addition to reducing rate of polyp occurrence, for both CRS with and without polyps, key findings were:
* Global symptom scores were better for INS than placebo.
* Proportion of patients responding was greater for INS than with placebo.
There was no significant difference between adverse event rates with INS and placebo.
A systematic review and meta-analysis (8 RCTs, 389 patients) compared different SI regimens for CRS. (3) The standardized mean difference was used to combine trials using various symptom outcomes. Key findings included the following:
* SI was better than no treatment.
* SI adjunctive therapy (with an antihistamine) improved disease-specific quality-of-life scores.
* SI was less effective than INS therapy for symptom improvement.
Hypertonic and isotonic saline yielded similar symptom scores. No adverse effects were reported.
One meta-analysis evaluated patient-reported outcomes with 12 weeks of macrolide therapy compared to placebo using the results of the SinoNasal Outcome Test (SNOT). The SNOT is a quality-of-life questionnaire that lists symptoms and the social-emotional consequences of CRS; a negative change in the SNOT score, on a 0 to 5 scale, indicates improvement. Overall the SNOT score improved 8% with macrolide therapy--statistically significant, but of uncertain clinical importance. (4)
Surgery improves nasal obstruction, pain, and postnasal discharge
A systematic review of 21 studies (prospective RCTs, prospective controlled clinical trials, cohort studies, case series, and retrospective record reviews) with a total of 2070 patients analyzed the effectiveness of endoscopic sinus surgery alone for improving CRS symptoms. (5) Mean duration of post-operative follow-up was 14 months. Meta-analysis was performed separately for each symptom and the standard mean difference of the symptom severity score before and after surgery was reported as the effect size (ES) for the outcome measure (an ES of 0.2 is considered small; 0.6, moderate; 1.2, large; and 2, very large).
All symptoms improved compared to their preoperative severity scores. Nasal obstruction improved the most (ES=1.73; 95% CI, 1.45-2.02). Large symptom improvement was also observed for facial pain (ES=1.13; 95% CI, 0.96-1.31) and postnasal discharge (ES=1.19; 95% CI, 0.96-1.43).
Surgery and medical therapy may provide comparable symptom relief
A recent Cochrane review of 4 low-quality RCTs including 378 patients compared surgical with medical interventions for CRS with nasal polyps. Study heterogeneity and selective outcome reporting prevented meta-analysis.
The 3 comparison groups were endoscopic sinus surgery vs systemic steroids + INS; polypectomy vs systemic steroid + INS; and endoscopic surgery + INS vs antibiotic + "high-dose" INS. Overall, neither surgery nor medical therapy was superior in terms of patient-reported symptom scores or quality-of-life measures. (6)
(1.) Kalish L, Snidvongs K, Sivasubramaniam R, et al. Topical steroids for nasal polyps. Cochrane Database Syst Rev. 2012;(12):CD006549.
(2.) Snidvongs K, Kalish L, Sacks R, et al. Topical steroids for chronic rhinosinusitis without polyps. Cochrane Database Syst Rev. 2011;(8):CD009274.
(3.) Harvey R, Hannan SA, Badia L, et al. Nasal saline irrigation for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev. 2007;(3):CD006394.
(4.) Pynnonen MA, Venkatraman G, Davis GE. Macrolide therapy for chronic rhinosinusitis: a meta-analysis. Otolaryngol Head Neck Surg. 2013;148:366-373.
(5.) Chester AC, Antisdel JL, Sindwani R. Symptom-specific outcomes of endoscopic sinus surgery: a systematic review. Otolaryngol Head Neck Surg. 2009;140:633-639.
(6.) Rimmer J, Fokkens W, Chong LY, et al. Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps. Cochrane Database Syst Rev. 2014;(12):CD0069991.
Darrell R. Over, MD, MSc
University of Arkansas for Medical Sciences (South Central) Family Medicine Residency, Pine Bluff
Rick Guthmann, MD, MPH
Advocate Illinois Masonic Family Medicine Residency, Chicago
TABLE How medical treatment regimens for chronic rhinosinusitis compare Treatment Outcome CRS Number Number of comparison investigated patients of participants with RCTs polyps? INS vs Global Yes 7 445 placebo (1,2) symptom scores No 5 286 Proportion Yes 4 234 responding to treatment No 4 263 Polyp Yes 6 437 recurrence SI vs no Global No 3 129 treatment (3) symptom scores SI plus Rhinasthma No 1 14 certrizine vs disease-specific certrizine (3) QoL scores INS vs Rhinoconjunctivitis No 1 21 isotonic disease-specific or hypertonic QoL scores SI (3) Hypertonic SI Disease-specific No 3 80 vs isotonic symptom scores SI (3) Macrolide vs 5-point SNOT No 1 124 placebo (4) QoL score Treatment Outcome Treatment Results comparison investigated duration favor INS vs Global 2-24 wk INS placebo (1,2) symptom scores 1-6 mo INS Proportion 3 wk-1 yr INS responding to treatment 2-20 wk INS Polyp 3 mo-1 yr INS recurrence SI vs no Global 1-6 mo SI treatment (3) symptom scores SI plus Rhinasthma 4 wk SI plus certrizine vs disease-specific certrizine certrizine (3) QoL scores INS vs Rhinoconjunctivitis 7 days INS isotonic disease-specific or hypertonic QoL scores SI (3) Hypertonic SI Disease-specific 7 days Neither vs isotonic symptom scores SI (3) Macrolide vs 5-point SNOT 3 mo Macrolide placebo (4) QoL score Treatment Outcome Magnitude 95% CI or comparison investigated of effect P value INS vs Global SMD = -0.46 -0.65 to -0.27 placebo (1,2) symptom scores SMD = -0.37 -0.60 to -0.13 Proportion 50% INS -- responding 35% placebo to treatment 48% INS -- 28% placebo Polyp RR = 0.59 0.45 to 0.79 recurrence SI vs no Global SMD = 1.42 1.01 to 1.84 treatment (3) symptom scores SI plus Rhinasthma 92% upper P=.02 certrizine vs disease-specific airway score certrizine (3) QoL scores improvement INS vs Rhinoconjunctivitis Isotonic SI -5.5 to-1.06 isotonic disease-specific SMD = -3.29 or hypertonic QoL scores SI (3) Hypertonic SI -4.92 to -0.84 SMD = -2.88 Hypertonic SI Disease-specific SMD = 0.34 -0.11 to 0.80 vs isotonic symptom scores SI (3) Macrolide vs 5-point SNOT SMD = -0.43 -0.82 to -0.05 placebo (4) QoL score CI, confidence interval; CRS, chronic rhinosinusitis; INS, intranasal steroid; QoL, quality of life; RCTs, randomized controlled trials; RR, relative risk; SI, saline irrigation; SMD, standard mean difference; SNOT, SinoNasal Outcome Test.
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|Title Annotation:||CLINICAL INQUIRIES: Evidence-based answers from the Family Physicians Inquiries Network|
|Author:||Over, Darrell R.|
|Publication:||Journal of Family Practice|
|Date:||Nov 1, 2016|
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