Systemic corticosteroids for acute sinusitis
Abstract
Background
Acute sinusitis is a common reason for patients to seek primary care consultations. The related impairment of daily functioning and quality of life is attributable to symptoms such as facial pain and nasal congestion.
Objectives
To assess the effectiveness of systemic corticosteroids in relieving symptoms of acute sinusitis.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2011, which includes the Acute Respiratory Infections (ARI) Group's Specialised Register, the Database of Reviews of Effects (DARE) and the NHS Health Economics Database, MEDLINE (1966 to June week 2, 2011) and EMBASE (January 2009 to June 2011).
Selection criteria
Randomised controlled trials (RCTs) comparing systemic corticosteroids to placebo or standard clinical care for patients with acute sinusitis.
Data collection and analysis
Two review authors independently assessed methodological quality of the trials and extracted data.
Main results
Four RCTs with a total of 1008 adult participants met our inclusion criteria. We judged studies to be of moderate methodological quality. Acute sinusitis was defined clinically in all trials. However, the three trials performed in ear, nose and throat (ENT) outpatient clinics also used radiological assessment as part of their inclusion criteria. All participants received oral antibiotics and were assigned to either oral corticosteroids (prednisone 24 mg to 80 mg daily or betamethasone 1 mg daily) or the control treatment (placebo in three trials and non‐steroidal anti‐inflammatory drugs (NSAIDs) in one trial). In all trials, participants treated with oral corticosteroids were more likely to have short‐term resolution or improvement of symptoms than those receiving the control treatment: at Days 3 to 7, risk ratio (RR) 1.4, 95% CI 1.1 to 1.8; risk difference (RD) 20% (6% to 34%) and at Days 4 to 10 or 12, RR 1.3, 95% CI (1.0 to 1.7), RD 18% (3% to 33%). An analysis of the three trials with placebo as a control treatment showed similar results but with a lesser effect size: Days 3 to 6: RR 1.2, 95% CI (1.1 to 1.4), RD 12% (5% to 19%) and Days 4 to 10 or 12: RR 1.1, 95% CI (1.0 to 1.2), RD 10% (3% to 16%). Scenario analysis showed that outcomes missing from the trial reports might have introduced attrition bias (a worst‐case scenario showed no statistically significant beneficial effect of oral corticosteroids). We did not identify any data on the long‐term effects of oral corticosteroids on this condition, such as effects on relapse or recurrence rates. Reported side effects of oral corticosteroids were limited and mild.
Authors' conclusions
Current evidence suggests that oral corticosteroids as an adjunctive therapy to oral antibiotics are effective for short‐term relief of symptoms in acute sinusitis. However, data are limited and there is a significant risk of bias. High quality trials assessing the efficacy of systemic corticosteroids both as an adjuvant and a monotherapy in primary care patients with acute sinusitis should be initiated.
PICOs
Plain language summary
Systemic corticosteroids for acute sinusitis
Acute sinusitis is a common reason for consultation in primary care. This condition is associated with unpleasant symptoms such as facial pain, headache, blocked or congested nose and sleep disturbance. Nowadays, it is thought that symptoms of acute sinusitis are caused not only by viral or bacterial infections but particularly by the body's inflammatory response to these infections. Consequently, it is possible that anti‐inflammatory therapy might be effective in patients with acute sinusitis by relieving the blockage in the nose and sinuses and therefore reducing symptoms. An earlier review found only modest beneficial effects of corticosteroids delivered by nasal spray. However, it is unclear if this is because the nasal steroids did not actually reach the nasal passages because they are blocked in this condition, or because anti‐inflammatory drugs do not work.
This systematic review examines the effectiveness of corticosteroids given systemically (i.e. by mouth, or by injection) in patients with acute sinusitis to provide a more definite answer on the use of corticosteroids for acute sinusitis. We found four randomised controlled trials of moderate methodological quality, which included a total of 1008 participants with acute sinusitis. After combining the results of these trials we found that participants treated with oral corticosteroids in addition to oral antibiotics were more likely to have short‐term symptom relief than those who received control treatment (placebo or non‐steroidal anti‐inflammatory drugs plus oral antibiotics). Reported side effects of oral corticosteroids in these studies were limited and mild. Given the limited number of trials included in this review and their moderate methodological quality, additional randomised controlled trials on the effectiveness of systemic corticosteroids in primary care patients with acute sinusitis are needed in order to provide a more definite answer on their use. In addition, it is important to study the efficacy of oral corticosteroids in patients who are not also receiving antibiotics.
