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Topical steroids for nasal polyps

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Abstract

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Background

Chronic rhinosinusitis with nasal polyps (CRSwNP) represents inflammatory changes throughout the nose and sinuses from a group of disorders which all lead to swelling and overgrowth of the nasal mucosa. Topical corticosteroids have been the most widely used treatment, with each clinician using different regimes, at different doses, in different settings and with or without sinus surgery. CRSwNP requires ongoing medical management to prevent recurrence.

Objectives

To assess the effects of topical corticosteroids on CRSwNP and to analyse various subgroups, including patients who had sinus surgery immediately prior to the delivery of the corticosteroids, surgery any time prior to the topical corticosteroids or patients who had never had previous surgery. Also to assess the most effective dose and delivery methods for topical corticosteroids.

Search methods

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CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials.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 search was 10 April 2012.

Selection criteria

Randomised controlled trials studying topical corticosteroids for patients with CRSwNP.

Data collection and analysis

At least two authors reviewed the search results and selected trials meeting the eligibility criteria, obtaining full texts and contacting authors. We documented our justification for the exclusion of studies. At least two authors extracted data using a pre‐determined, standardised data form.

Main results

Forty studies (3624 patients) met the inclusion criteria. The trials were at low (21 trials), medium (13 trials) and high (six trials) risk of bias. The primary outcomes were sino‐nasal symptoms, polyp size and polyp recurrence after surgery. When compared to placebo, topical corticosteroids improved overall symptom scores (standardised mean difference (SMD) ‐0.46; 95% confidence interval (CI) ‐0.65 to ‐0.27, P < 0.00001; seven trials, n = 445) and had a higher proportion of patients whose symptoms improved (responders) (risk ratio (RR) 1.71; 95% CI 1.29 to 2.26, P = 0.0002; four trials, n = 234). Topical corticosteroids also decreased the polyp score (SMD ‐0.73; 95% CI ‐1.00 to ‐0.46, P < 0.00001; three trials, n = 237) and had a greater proportion of patients with a reduction in polyp size (responders) (RR 2.09; 95% CI 1.65 to 2.64, P < 0.00001; eight trials, n = 785) when compared to placebo. Topical corticosteroids also prevented polyp recurrence after surgery (RR 0.59; 95% CI 0.45 to 0.79, P = 0.0004; six trials, n = 437). Subgroup analyses by sinus surgery status revealed a greater benefit in reduction of polyp score when topical steroid was administered any time after sinus surgery (SMD ‐1.19; 95% CI ‐1.54 to ‐0.83) compared to patients who had never had surgery (SMD ‐0.13; 95% CI ‐0.53 to 0.28, P < 0.00001). There was no difference between groups in terms of adverse events.

Authors' conclusions

Topical corticosteroids are a beneficial treatment for CRSwNP and the adverse effects are minor, with benefits outweighing the risks. They improve symptoms, reduce polyp size and prevent polyp recurrence after surgery. Patients having sinus surgery may have a greater response to topical corticosteroids but further research is required.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Topical corticosteroids for nasal polyps

This review summarises the evidence for the effects of corticosteroids being delivered into the nose by spray (topical delivery) as part of the management of nasal polyps. Nasal polyps develop as a result of chronic inflammation of the mucous lining of the nose and sinuses and they can cause nasal obstruction, poor sinus drainage, loss of smell/taste, a runny nose or nasal congestion.

We included 40 studies in the review, with a total of 3624 patients. The evidence shows that the use of topical corticosteroids is beneficial in the treatment of nasal polyps. They are effective in reducing symptoms, nasal obstruction and the size of the polyps, and help to prevent polyps regrowing after surgery. From the combined data, the effect on the polyp size was greater when corticosteroids were used in patients who had previously undergone sinus surgery. There was no difference in the reported side effects between topical corticosteroids and placebo and the benefits definitely outweigh the risks.