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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).

Evidence summary

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
How medical treatment regimens for chronic rhinosinusitis compare

Treatment        Outcome               CRS        Number   Number of
comparison       investigated          patients   of       participants
                                       with       RCTs

INS vs           Global                Yes        7        445
placebo (1,2)    symptom
                 scores                No         5        286

                 Proportion            Yes        4        234

                 to treatment          No         4        263

                 Polyp                 Yes        6        437

SI vs no         Global                No         3        129
treatment (3)    symptom

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

                 to treatment          2-20 wk     INS

                 Polyp                 3 mo-1 yr   INS

SI vs no         Global                1-6 mo      SI
treatment (3)    symptom

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

SI vs no         Global                SMD = 1.42      1.01 to 1.84
treatment (3)    symptom

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
Geographic Code:1USA
Date:Nov 1, 2016
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