Oral Corticosteroid for Chronic Rhinosinusitis May Be Lower Risk Than Surgery

What is the threshold effectiveness for oral corticosteroid (OCS) use to avert endoscopic sinus surgery (ESS) that would minimize OCS risk exposure in patients with chronic rhinosinusitis (CRS)?

BOTTOM LINE: The inclusion of OCS as part of appropriate medical therapy (AMT) for CRS may be the lower-risk strategy.

BACKGROUND: The rationale for prescribing OCS to patients with CRS is to avoid the greater risks of ESS; however, if OCS proves ineffective in preventing surgery, the patient is exposed to the risks of both. Therefore, determining the likelihood of OCS effectiveness in averting ESS is key to deciding whether it should be prescribed.

STUDY DESIGN: Probabilistic risk analysis.

SETTING: Department of Otolaryngology—Head and Neck Surgery, University of Toronto, Ontario, Canada.

SYNOPSIS: Researchers set out to identify the threshold effectiveness for OCS that would make the inclusion of OCS in AMT the lower-risk strategy—the minimum effectiveness required to avoid further intervention (MERAFI). Drawing on incidences and impacts of adverse events associated with OCS and ESS reported in literature, they constructed a risk model from which to conduct a probabilistic risk analysis. Monte Carlo analysis was performed to identify MERAFI for CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). The MERAFI values were found to be 20.8% and 16.8% for CRSsNP and CRSwNP, respectively, indicating that if the probability of OCS preventing surgery exceeds these thresholds, then AMT with OCS becomes the lower-risk strategy. Authors noted that different age groups and patient-specific comorbidities may have different complication and adverse event probabilities, however, and the length of treatment and durability of symptom relief remain open questions. Study limitations were related to the source data and the validity of the model construction.

CITATION: Leung RM, Smith TL, Kern RC, et al. Should oral corticosteroids be used in medical therapy for chronic rhinosinusitis? A risk analysis [published online ahead of print July 7, 2020]. Laryngoscope.