Podcast: Treatments for chronic rhinosinusitis

Chronic rhinosinusitis is a common disorder of the nose and sinuses, and, in April 2016, the Cochrane ENT Group published a series of six reviews1 looking at the evidence on medical treatments in routine patient care. Carl Philpott from Norwich Medical School in the UK describes the findings of all six reviews in this Evidence Pod.

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John: Hello, I'm John Hilton, editor of the Cochrane Editorial unit. Chronic rhinosinusitis is a common disorder of the nose and sinuses, and, in April 2016, the Cochrane ENT Group published a series of six reviews looking at the evidence on medical treatments in routine patient care. Carl Philpott from Norwich Medical School in the UK describes the findings of all six reviews in this Evidence Pod.

Carl: Chronic rhinosinusitis is defined by symptoms such as blockage, discharge and loss of smell, and affects as many as one in every ten people. Although a small number of patients might need surgery, medical treatment is the mainstay, including common treatments such as saline rinses, nasal steroids, oral steroids and antibiotics. We covered all of these in our six Cochrane Reviews and, over the next few minutes, I’ll summarise what we found, starting with intranasal corticosteroids.
Although we categorised the quality of the evidence as low because of the level of detail recorded in the trials, intranasal corticosteroids do seem to lead to improvements for all symptoms. But there is no evidence that one type is more effective than another, that higher doses are better than lower, or that a pump spray is more, or less, effective than an aerosol. Nosebleeds were more common in the steroid group, and worse with higher doses, but this adverse effect included all levels of severity, including small streaks of blood.
We found two trials of nasal saline irrigations that had studied very different patient groups and treatments. This makes it difficult to draw conclusions for practice. However, the evidence suggests that there was no benefit of a low-volume nebulised saline spray over nasal steroids, but that there may be some benefit of daily, large-volume (150 ml) saline irrigation with a hypertonic solution compared with placebo.
Turning to systemic antibiotics, there is little evidence that these are effective in patients with chronic rhinosinusitis overall but we did find moderate quality evidence of a modest improvement in disease-specific quality of life in patients without nasal polyps who took three months of an antibiotic in the macrolide class (roxithromycin). However, this improvement was small and wasn’t seen until the end of the three-month course of treatment and had gone again by three months later. Reported side-effects were few but this probably reflects the small number of participants in all the studies.
Finally, for patient with chronic rhinosinusitis with nasal polyps, adding oral corticosteroids reduced both the size of the polyps and symptom severity when compared to placebo. But the results for longer-term outcomes were inconclusive because of the low quality of data. Low quality was also a problem for our assessment of adverse effects, with some studies not reporting these well and a complete lack of data on important longer-term effects. Short-course oral steroids alone have potential short-term benefits with tolerated side effects, but there is still a need for additional steroids to be given through the nose. It also seems that occasional, intermittent courses of oral corticosteroids may have a place within a long-term treatment strategy. In summary, clear guidance is needed on how short courses of oral corticosteroids can be used alone or as an adjunct to long-term topical treatment for both primary and secondary care; and future research needs to address the timing of administration of oral steroids and the safety of using multiple short courses over time.

John: Thanks Carl. To find out more about these six reviews, and related ones from the Cochrane ENT Group, simply go to Cochrane Library dot com and search ‘chronic rhinosinusitis’.

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