Steroids for acute sinusitis in adults and children

Acute sinusitis is a common reason for primary care visits; it is one of the 10 most common diagnoses in outpatient clinics, presenting with various symptoms and signs that include purulent nasal discharge and congestion and cough lasting beyond the typical seven to 10 days of a viral upper respiratory infection. There have been suggestions, based on studies of allergic rhinitis and chronic sinusitis, that intranasal corticosteroids (INCS) may relieve symptoms and hasten recovery in acute sinusitis due to their anti-inflammatory properties.

A critical systematic review of the literature found four well-conducted, randomised, placebo-controlled intervention studies, involving 1943 participants treated for 15 or 21 days. The results suggest that there may be a modest effect with INCS in the resolution or improvement of symptoms. Only minor adverse events such as epistaxis, headache and nasal itching were reported. Given the small number of studies included in this review, it is recommended that further randomised controlled trials be conducted. The evidence is up to date as of May 2013.

Authors' conclusions: 

Current evidence is limited for acute sinusitis confirmed by radiology or nasal endoscopy but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy.

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Background: 

Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school.

Objectives: 

We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis in adults and children.

Search strategy: 

We searched CENTRAL 2013, Issue 4, MEDLINE (January 1966 to May week 2, 2013), EMBASE (1990 to May 2013) and bibliographies of included studies.

Selection criteria: 

Randomised controlled trials (RCTs) comparing INCS treatment to placebo or no intervention in adults and children with acute sinusitis. Acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop-outs before the end of the study, rates of relapse, complications and return to school or work.

Data collection and analysis: 

Two review authors independently extracted data, assessed trial quality and resolved discrepancies by consensus.

Main results: 

No new trials were found for inclusion in this update. Four studies involving 1943 participants with acute sinusitis met our inclusion criteria. The trials were well-designed and double-blind and studied INCS versus placebo or no intervention for 15 or 21 days. The rates of loss to follow-up were 7%, 11%, 41% and 10%. When we combined the results from the three trials included in the meta-analysis, participants receiving INCS were more likely to experience resolution or improvement in symptoms than those receiving placebo (73% versus 66.4%; risk ratio (RR) 1.11; 95% confidence interval (CI) 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement of symptoms or complete relief: for mometasone furoate 400 µg versus 200 µg (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop-out and recurrence rates for the two treatment groups and for groups receiving higher doses of INCS.

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