Steroids for acute sinusitis

Every year, nearly 37 million Americans suffer from the sinus pressure, nasal congestion, cough and postnasal drip that accompany sinusitis.

Doctors often prescribe antibiotics to relieve acute sinusitis, which can develop following a chest cold. However, steroid nasal sprays — either alone or with antibiotic therapy — may better ease symptoms and speed recovery, suggests a new review by Israeli researchers.

Sinusitis is an inflammation of the mucous membranes that line the sinus cavities. Steroid sprays like Flonase, Nasonex and Rhinocort, which work by reducing inflammation to promote drainage in the sinuses, are often prescribed to treat chronic sinusitis and allergies symptoms.

But the use of steroids sprays for acute sinusitis is not as universally accepted.

In this review, Anca Zalmanovici, a family physician at Rabin Medical Center in Petach Tikva, and her co-author analyzed data from four randomized controlled trials including nearly 2,000 participants, all with clinical symptoms of acute sinusitis.

The review appears in the current issue of The Cochrane Library , a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

Two of the studies evaluated patients at treatment centers in the United States, one took place in Turkey and the other included 71 medical centers in 14 countries.

Study participants, who underwent X-rays or nasal endoscopy to confirm diagnosis, received either a placebo or intranasal corticosteroids for two or three weeks, alone or in combination with antibiotics. Intranasal corticosteroids used included fluticasone propionate (Flonase), mometasone furoate (Nasonex) and budesonide (Rhinocort).

Overall, 73 percent of the patients treated with nasal steroids experienced relief or marked improvement of symptoms during the study period, compared with only 66.4 percent of patients who received the placebo.

“For every 100 patients treated with intranasal corticosteroids, seven additional patients had complete or marked symptom relief,” compared to those in the placebo group, the reviewers found.

Researchers pooled data from three of the four studies, excluding the lowest-quality study from the statistical analysis.

None of the studies reported serious side effects, and rates of sinusitis relapse were similar between the treatment and placebo groups.

Stronger doses of nasal steroids appeared to work better. Patients receiving daily doses of 400 micrograms were more likely to experience relief of sinusitis symptoms, than were patients receiving 200-microgram doses.

Although there is not enough evidence to suggest that nasal steroids can stand alone for acute sinusitis treatment, “the results of these studies and reviews support the current clinical rationale of adding an intranasal corticosteroid to antibiotic therapy,” reviewers say.

Allen Seiden, M.D., director of the University of Cincinnati Taste and Smell Center, said that more data are required before routine recommendations on intranasal corticosteroids can be made.

“It seems to have been a well-conducted review, with thorough statistical analysis. However, in the end, it analyzed relatively few studies,” Seiden said.

He added that the review lacked information about how individual diagnoses were made, and said that even with X-rays and nasal endoscopy, distinguishing between viral and bacterial infections can be difficult, a problem that may influence the choice of treatment.

When it comes to treating sinus infections, “patients vary as to when they will seek medical intervention. Some will come in after only a day or two of symptoms; some not for two to three weeks,” Seiden said. Longer waits can make symptoms harder to treat, he said, “while many patients with symptoms for only a few days will in fact have a viral infection.”

Although there are few downsides to using nasal steroids such as those in the review —they are fairly expensive, Seiden said. According to the National Institute of Allergy and Infectious Diseases, diagnosing and treating sinusitis costs Americans nearly $6 billion every year.

Zalmanovici A, Yaphe J. Steroids for acute sinusitis (Review). Cochrane Database of Systematic Reviews 2007, Issue 2.

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.

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