Antifungal therapy for chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is an extremely common condition. Since fungus has been implicated in the development of CRS, it has been proposed that antifungal therapies may be beneficial in its treatment. As antifungals can be expensive and are associated with side effects, it is imperative that the benefits of this therapy are well-documented before broadly endorsing it as treatment. This review summarises the evidence for the efficacy of both topical and systemic antifungal therapies in the management of symptoms in CRS. We included six studies with a total of 380 patients in the review. There is no evidence that either topical or systemic antifungal therapies have any benefit over placebo for the symptomatic treatment of CRS and therefore there is no evidence to support their use.

Authors' conclusions: 

On the basis of this meta-analysis, there is no evidence to support the use of either topical or systemic antifungal treatment in the management of CRS.

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Background: 

Chronic rhinosinusitis (CRS) is an inflammatory disorder of the nose and sinuses. Since fungi were postulated as a potential cause of CRS in the late 1990s, there has been increasing controversy about the use of both topical and systemic antifungal agents in its management. Although interaction between the immune system and fungus has been demonstrated in CRS, this does not necessarily imply that fungi are the cause of CRS or that antifungals will be effective its management.

Objectives: 

To assess the effectiveness of topical or systemic antifungal therapy in the treatment of CRS.

Search strategy: 

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 8 March 2011.

Selection criteria: 

All randomised, placebo-controlled trials considering the use of topical or systemic antifungal therapy in the treatment of CRS and allergic fungal sinusitis (AFS). CRS was defined using either the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) or American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) criteria.

Data collection and analysis: 

We reviewed the titles and abstracts of all studies obtained from the searches and selected trials that met the eligibility criteria. We extracted data using a pre-determined data extraction form. There was significant heterogeneity of outcome data reporting with reports containing both parametric and non-parametric representations of data for the same outcomes. Means and standard deviations for change data were unavailable for a number of trials. Due to the limited reported data, we contacted authors and used original data for data analysis.

Main results: 

Six studies were included (380 participants). Five studies investigated topical antifungals and one study investigated systemic antifungals. The risk of bias in all included studies was low, with all trials being double-blinded and randomised. Pooled meta-analysis showed no statistically significant benefit of topical or systemic antifungals over placebo for any outcome. Symptom scores in fact statistically favoured the placebo group. Adverse event reporting was statistically significantly higher in the antifungal group.

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