Background: Acute sinusitis is a common problem in the ambulatory setting, affecting 31 million Americans annually. Many patients are prescribed antibiotics despite little evidence of benefit. Intranasal steroids may improve symptoms, but the benefits are unclear. A 2009 Cochrane review of four randomized controlled trials (RCTs) demonstrated a small improvement of acute sinusitis symptoms at 15 to 21 days with intranasal steroids; however, interpretation was limited by the heterogeneity of outcome measures. Hayward and colleagues provided an updated systematic review and meta-analysis of the effectiveness of intranasal steroids for acute sinusitis in the ambulatory care setting while accounting for heterogeneity among RCTs.
The Study: This systematic review included RCTs that compared intranasal steroids with placebo in children or adults who presented in the outpatient setting with signs and symptoms of acute sinusitis or rhinosinusitis. Studies examining patients with chronic or allergic sinusitis and studies examining specific populations with underlying chronic conditions were excluded from the meta-analysis. Primary outcomes included the percentage of participants with improvement or complete resolution of symptoms. Secondary outcomes included average change in symptom scores over 0 to 21 days, adverse events, recurrence rates, and days missed from school or work.
Results: In five RCTs that studied the resolution or improvement of symptoms at days 14 to 21, intranasal steroids had a significant but modest clinical benefit with a number needed to treat (NNT) of 13. Because of the heterogeneity among RCTs, a subgroup analysis on outcome timing and dosage was performed. Intranasal steroids had a significant effect on symptom improvement at 21 days (NNT = 9), but no significant effect at 14 to 15 days. Three trials assessing mometasone (Nasonex) nasal spray demonstrated a significant effect at days 15 to 21, with an NNT of 13. A significant dose-response relationship was found for mometasone; 800 mcg per day (NNT = 8) led to a greater reduction in symptoms than 400 mcg per day (NNT = 14). Compared with patients taking placebo, those who used intranasal steroids reported significantly greater improvement in facial pain, nasal congestion, rhinorrhea, headache, and postnasal drip. Meta-analysis did not demonstrate a significant difference in the rate of adverse events between patients using intranasal steroids and patients using placebo. Common adverse events included headache, epistaxis, nasal irritation, and pharyngitis. Recurrence of acute sinusitis occurred in 5 to 15 percent of patients taking intranasal steroids and in 4 to 37 percent of patients taking placebo.
Conclusion: Intranasal steroids for the treatment of acute sinusitis provide a small but significant improvement in symptoms, most notably for facial pain and nasal congestion. This benefit is most marked when treatment is provided for a longer period of time (21 days) and when medications are given at higher dosages (up to 800 mcg of mometasone per day). The authors surmised that 66 percent of patients with acute sinusitis would improve in 14 to 21 days with placebo, and an additional 7 percent would improve with intranasal steroids.
editors’ note: The most common etiology of acute sinusitis is a viral infection, with only 0.5 to 2 percent of cases progressing to an acute bacterial infection requiring antibiotics.1 Viral and bacterial acute sinusitis generally are self-limited illnesses. Nevertheless, antibiotics are commonly prescribed in the outpatient setting. For patients with 10 or more days of persistent symptoms, watchful waiting without antibiotic or steroid therapy is appropriate.1 Hayward and colleagues provide modest evidence supporting the use of intranasal steroids for acute sinusitis. However, an accompanying editorial notes that the only two specific symptoms demonstrated to significantly improve with intranasal steroids were nasal congestion and facial pain, which had relatively small improvements for the potential cost of the medicine.2 More studies examining antibiotic-naïve patients are needed before recommendations can be made on the use of intranasal steroids for acute sinusitis. Until then, intranasal steroid therapy remains an individual decision to be made between patient and physician.3—m.b. and sumi sexton, md, Associate Editor, American Family Physician