Chronic sinusitis treatments compared in systematic review
Saline irrigation improved symptom scores compared with no treatment, and topical corticosteroid therapy improved overall symptom scores, improved polyp scores, and reduced polyp recurrence after surgery.
A new evidence review supports daily high-volume saline irrigation with topical corticosteroid therapy as a first-line therapy for chronic sinusitis.
There were 29 studies in the review: 12 meta-analyses of more than 60 randomized, controlled trials, 13 systematic reviews, and 4 randomized controlled trials that were not included in any of the meta-analyses. The paper appeared in the Sept. 1 Journal of the American Medical Association.
Saline irrigation improved symptom scores compared with no treatment (standardized mean difference [SMD], 1.42; 95% CI, 1.01 to 1.84; a positive SMD indicates improvement). Topical corticosteroid therapy improved overall symptom scores (SMD, −0.46; 95% CI, −0.65 to −0.27; a negative SMD indicates improvement), improved polyp scores (SMD, −0.73; 95% CI, −1.0 to −0.46; a negative SMD indicates improvement), and reduced polyp recurrence after surgery (relative risk, 0.59; 95% CI, 0.45 to 0.79).
Systemic corticosteroids and oral doxycycline (both for 3 weeks) reduced polyp size compared with placebo for 3 months after treatment (P<0.001). Leukotriene antagonists improved nasal symptoms compared with placebo in patients with nasal polyps (P<0.01). Macrolide antibiotic for 3 months was associated with improved quality of life at 24 weeks after therapy compared with placebo for patients without polyps (SMD, −0.43; 95% CI, −0.82 to −0.05).
The authors noted that systemic antibiotic therapy is not recommended for managing nasal polyposis. However, if there is an infection, a broad-spectrum antibiotic may be needed. An endoscopic-directed sinus swab of purulent secretions within the middle meatus may guide a culture-directed course of oral antibiotics. A course of doxycycline, 200 mg, once followed by 100 mg for 21 days or a leukotriene antagonist may be considered to further reduce polyps. Patients with chronic sinusitis who experience persistent symptoms despite comprehensive medical therapy may consider endoscopic sinus surgery.
“Given the high prevalence and large economic burden of chronic sinusitis, future research should improve the quality of evidence for individual therapies and validate treatment pathways to optimize the quality of care,” the authors wrote. “Furthermore, the studies included in this review considered chronic sinusitis as a single clinical entity with subgroups defined only by polyp status. Future research should develop personalized therapies that target precise features of the patient's abnormal immune-environment interaction to maximally improve outcomes.”