Clinical Inquiries

Which treatments are safe and effective for chronic sinusitis?

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For adults with chronic rhinosinusitis (CRS), intranasal steroid (INS) therapy is more likely than placebo to improve symptoms (50% vs 32%; strength of recommendation [SOR]: A, systematic reviews).

Nasal saline irrigation (SI) alleviates symptoms better than no therapy (SOR: A, systematic reviews), but it’s probably not as effective as INS treatment (SOR: B, randomized controlled trial [RCT] with wide confidence interval).

Long-term (12 weeks) macrolide therapy doesn’t alter patient-oriented quality-of-life measures (SOR: A, systematic reviews).

Endoscopic sinus surgery improves CRS symptoms—nasal obstruction, discharge, and facial pain—over baseline (SOR: A, systematic reviews). Surgery and medical therapy appear about equivalent in terms of symptom improvement and quality-of-life measures (SOR: B, systematic reviews of low-quality RCTs).


The TABLE1-4 shows the major results of the meta-analyses for the various medical therapy trials.

How medical treatment regimens for chronic rhiosinusitis compare image

Two systematic reviews with meta-analyses evaluated treatment with INS for CRS with nasal polyps (40 RCTs; 3624 patients, mean age 48 years, 64% male) and without polyps (10 RCTs; 590 patients, mean age 39 years, 51% male).1,2 Trials reported sinonasal symptom outcomes differently and couldn’t be combined. In addition to reducing rate of polyp occurrence, for both CRS with and without polyps, key findings were:

  • Global symptom scores were better for INS than placebo.
  • Proportion of patients responding was greater for INS than with placebo.

There was no significant difference between adverse event rates with INS and placebo.

A systematic review and meta-analysis (8 RCTs, 389 patients) compared different SI regimens for CRS.3 The standardized mean difference was used to combine trials using various symptom outcomes. Key findings included the following:

  • SI was better than no treatment.
  • SI adjunctive therapy (with an antihistamine) improved disease-specific quality-of-life scores.
  • SI was less effective than INS therapy for symptom improvement.

Hypertonic and isotonic saline yielded similar symptom scores. No adverse effects were reported.


Evidence-based answers from the Family Physicians Inquiries Network

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