Takaisin Tulosta

Topical steroids for chronic rhinosinusitis

Evidence summaries
Editors
Last reviewed as up-to-date 24.11.2017Latest change 9.3.2017

Level of evidence: C

Topical steroid may have beneficial effects on symptom control of chronic rhinosinusitis with or without polyps. For disease severity, there may be improvement for all symptoms. There are probably no differences between intranasal steroids.

Comment: The quality of the evidence is downgraded by study quality (inadequate allocation concealment, short follow-up time) and inconsistency (heterogeneity in patients, interventions and outcomes).

Summary

A Cochrane review «»1 «Snidvongs K, Kalish L, Sacks R et al. ...»1 [withdrawn from publication] included 10 RCTs with a total of 590 subjects. Chronic rhinosinusitis was defined as chronic inflammation of the mucosa of the nose and paranasal sinuses, with symptoms persisting for more than 12 weeks, plus either positive endoscopic signs and/or CT findings. Nine out of ten studies recruited patients from tertiary care. The steroid agents used differed across the studies. When compared to placebo, topical steroid improved sino-nasal symptom scores (SMD -0.37; 95% CI -0.60 to -0.13; 5 trials, n = 286) and had a greater proportion of responders (RR 1.69; 95% CI 1.21 to 2.37; 4 trials, n = 263). With a limited number of studies, the subgroup analyses of patients who had received sinus surgery vs. those who had not was not significant. Subgroup analyses by topical delivery method revealed more benefit when steroid was administered directly to the sinuses than with simple nasal delivery (SMD -0.30; 95%CI -0.55 to -0.06). There were no differences between groups for quality of life and adverse events.

Another Cochrane review «»2 «Chong LY, Head K, Hopkins C et al. Intranasal ster...»2 included 18 RCTs with a total of 2738 patients. The patients were with nasal polyps in 14 studies and without in 4 studies. Only one study was conducted in children. The trials studied intranasal corticosteroids vs. placebo or no intervention. Only one study (n=20 without polyps) measured the primary outcome, disease-specific HRQL using the Rhinosinusitis Outcome Measures-31 (RSOM-31). There was no significant difference (numerical data not available). The second primary outcome, disease severity , was measured using the Chronic Sinusitis Survey in a study (n=134, without polyps), which found no difference (MD 2.84, 95% CI -5.02 to 10.70; scale 0 to 100). Another study (chronic rhinosinusitis with nasal polyps) reported an increased chance of improvement in the intranasal corticosteroids group (RR 2.78, 95% CI 1.76 to 4.40; n=109). Six studies provided data on at least 2 of the symptoms used in the EPOS 2012 criteria to define chronic rhinosinusitis (nasal blockage, rhinorrhoea, loss of sense of smell and facial pain/pressure). When all 4 symptoms in the EPOS criteria were available on a scale of 0 to 3 (higher = more severe symptoms), the average MD in change from baseline was -0.26 (95% CI -0.37 to -0.15; 2 studies, n=243). Although there were more studies for only nasal blockage and rhinorrhoea (MD -0.31, 95% CI -0.38 to -0.24; 6 studies, n=1702), the MD was almost identical to when loss of sense of smell was also considered (4 studies; n=1345). When considering the results for the individual symptoms, benefit was shown in the intranasal corticosteroids group. The effect size was larger for nasal blockage (MD -0.40, 95% CI -0.52 to -0.29; 6 studies, n=1702) than for rhinorrhoea (MD -0.25, 95% CI -0.33 to -0.17; 6 studies, n=1702) or loss of sense of smell (MD -0.19, 95% CI -0.28 to -0.11; 4 studies, n=1345). There was heterogeneity in the analysis for facial pain/pressure (MD -0.27, 95% CI -0.56 to 0.02; 2 studies, n=243). There was an increased risk of epistaxis with intranasal corticosteroids (RR 2.74, 95% CI 1.88 to 4.00; 13 studies, n=2508). It is unclear whether there is a difference in the risk of local irritation (RR 0.94, 95% CI 0.53 to 1.64; 11 studies, n=2124).

The third Cochrane review «»3 «Chong LY, Head K, Hopkins C et al. Different types...»3 included 9 RCTs with a total of 911 patients. None of the studies evaluated the first primary outcome measure, disease-specific HRQL.

  • Fluticasone propionate vs. beclomethasone dipropionate: Two small studies (n=56, with polyps) evaluated disease severity and looked at the primary adverse effect: epistaxis. There are no numerical data but there was no difference between the steroids.
  • Fluticasone propionate versus mometasone furoate: One study (n=100, with polyps) evaluated disease severity (nasal symptoms scores) and reported no difference (no numerical data available).
  • High-dose versus low-dose steroids: Five studies (n=663, with polyps): 3 using mometasone furoate (400 µg vs. 200 µg in adults and older children, 200 µg vs. 100 µg in younger children) and 2 using fluticasone propionate drops. The results from the high-dose and low-dose groups were similar. Although all studies reported more improvement in polyp score in the high-dose group, the significance of this is unclear due to the small size of the improvements. The primary adverse effect, epistaxis, was more common when higher doses were used (RR 2.06, 95% CI 1.20 to 3.54; n=637). There was a broad definition of epistaxis, from frank bleeding to flecks of blood in the mucus.

References

  1. Snidvongs K, Kalish L, Sacks R et al. WITHDRAWN: Topical steroid for chronic rhinosinusitis without polyps. Cochrane Database Syst Rev 2016;(4):CD009274. «PMID: 27111710»PubMed
  2. Chong LY, Head K, Hopkins C et al. Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis. Cochrane Database Syst Rev 2016;4():CD011996. «PMID: 27115217»PubMed
  3. Chong LY, Head K, Hopkins C et al. Different types of intranasal steroids for chronic rhinosinusitis. Cochrane Database Syst Rev 2016;4():CD011993. «PMID: 27115215»PubMed