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Review |

Medical Therapies for Adult Chronic Sinusitis A Systematic Review

Luke Rudmik, MD, MSc1; Zachary M. Soler, MD, MSc2
[+] Author Affiliations
1Department of Surgery, Division of Otolaryngology—Head and Neck Surgery, University of Calgary, Calgary, Alberta
2Department of Otolaryngology—Head and Neck Surgery, Division of Rhinology and Sinus Surgery, Medical University of South Carolina, Charleston
JAMA. 2015;314(9):926-939. doi:10.1001/jama.2015.7544.
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Importance  Chronic sinusitis is a common inflammatory condition defined by persistent symptomatic inflammation of the sinonasal cavities lasting longer than 3 months. It accounts for 1% to 2% of total physician encounters and is associated with large health care expenditures. Appropriate use of medical therapies for chronic sinusitis is necessary to optimize patient quality of life (QOL) and daily functioning and minimize the risk of acute inflammatory exacerbations.

Objective  To summarize the highest-quality evidence on medical therapies for adult chronic sinusitis and provide an evidence-based approach to assist in optimizing patient care.

Evidence Review  A systematic review searched Ovid MEDLINE (1947-January 30, 2015), EMBASE, and Cochrane Databases. The search was limited to randomized clinical trials (RCTs), systematic reviews, and meta-analyses. Evidence was categorized into maintenance and intermittent or rescue therapies and reported based on the presence or absence of nasal polyps.

Findings  Twenty-nine studies met inclusion criteria: 12 meta-analyses (>60 RCTs), 13 systematic reviews, and 4 RCTs that were not included in any of the meta-analyses. Saline irrigation improved symptom scores compared with no treatment (standardized mean difference [SMD], 1.42 [95% CI, 1.01 to 1.84]; a positive SMD indicates improvement). Topical corticosteroid therapy improved overall symptom scores (SMD, −0.46 [95% CI, −0.65 to −0.27]; a negative SMD indicates improvement), improved polyp scores (SMD, −0.73 [95% CI, −1.0 to −0.46]; a negative SMD indicates improvement), and reduced polyp recurrence after surgery (relative risk, 0.59 [95% CI, 0.45 to 0.79]). Systemic corticosteroids and oral doxycycline (both for 3 weeks) reduced polyp size compared with placebo for 3 months after treatment (P < .001). Leukotriene antagonists improved nasal symptoms compared with placebo in patients with nasal polyps (P < .01). Macrolide antibiotic for 3 months was associated with improved QOL at a single time point (24 weeks after therapy) compared with placebo for patients without polyps (SMD, −0.43 [95% CI, −0.82 to −0.05]).

Conclusions and Relevance  Evidence supports daily high-volume saline irrigation with topical corticosteroid therapy as a first-line therapy for chronic sinusitis. A short course of systemic corticosteroids (1-3 weeks), short course of doxycycline (3 weeks), or a leukotriene antagonist may be considered in patients with nasal polyps. A prolonged course (3 months) of macrolide antibiotic may be considered for patients without polyps.

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Figure 1.
Proposed Mechanisms of Action for Chronic Sinusitis Medical Therapies

GM-CSF indicates granulocyte-macrophage colony-stimulating factor; IL, interleukin; LO, lipoxygenase; NF-κB, nuclear factor κ enhancer of B cells; TGF, transforming growth factor; TH2, T helper 2; TNF, tumor necrosis factor.

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Figure 2.
Evidence-Based Approach to Medical Therapy for Chronic Sinusitis

aPersistent symptoms implies that the patient is still experiencing chronic sinusitis–specific symptoms that are negatively effecting quality of life and daily productivity or functioning.

bMild symptoms implies that the patient is still experiencing chronic sinusitis–specific symptoms but they are not negatively effecting quality of life and daily productivity or functioning.

cPatient and physician should participate in an open discussion about the known benefits and the potential adverse effects of systemic corticosteroids to help inform patient decision making.

dRisk of cardiac arrhythmia and cardiovascular death; risk of rhabdomyolysis in patients currently taking an oral 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor.

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