Is the use of topical nasal therapies with saline alone and in combination with antibiotics, antifungals or corticosteroids effective in the treatment of chronic rhinosinusitis (CRS)?
Background: There is a shift from using surgical intervention solely as means to establish a patent drainage for CRS to topical therapy to the mucosa to prevent infection and inflammation and facilitate sinonasal mucociliary clearance. However, evidence for topical nasal therapy use both with and without pharmacologic adjuncts is often contradictory.
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October 2013Study design: Systematic literature search.
Setting: The Medline database (1966 to May 2012), EMBASE database (1980 to May 2012) and the Cochrane Central Register of Controlled Trials.
Synopsis: Randomized controlled trials in four categories were identified: Topical saline in CRS patients (16), topical antibiotics in CRS patients (2), topical antifungal treatment for CRS (4) and topical steroids in CRS patients (25). For nasal saline irrigations: Application methods included nasal saline irrigations and sprays. Trials included patients with rhinitis with seasonal exacerbations, perennial rhinitis and recurrent acute rhinosinusitis. After pooling data, topical saline use produced statistically significant improvement in symptom and disease-specific quality of life scores. Adding saline spray to the antihistamine and saline irrigations delivered with large volume and low positive pressure produced significant improvement in disease-specific quality of life scores. For topical antibiotics: Both studies concluded that the addition of an antibiotic to a topical solution did not provide any statistically significant improvement in symptom, quality of life and endoscopy scores. For topical antifungals: The primary objective was to evaluate the effect of topical amphotericin B on CRS clinical outcomes. Topical antifungal therapies were not shown to be significantly different in efficacy than saline controls on CRS outcomes. For topical corticosteroids: There is insufficient evidence to support a clear benefit of topical steroids in patients with CRS without polyps, but a relatively high level of evidence shows effectiveness in decreasing nasal polyp size.
Bottom line: A low evidence level supports culture-directed antibiotic use in CRS patients. A high evidence level supports nasal saline irrigation use and topical steroid use in decreasing nasal polyp size, while showing no greater efficacy for topical antifungals on CRS outcomes.
Citation: Wei CC, Adappa ND, Cohen NA. Use of topical nasal therapies in the management of chronic rhinosinusitis. Laryngoscope. 2013;123:2347-2359.
—Reviewed by Amy Eckner