Steroidal Sprays for Rhinosinusitis: Experts Assess a Review

In a review of the literature published in The Cochrane Library, two Israeli authors conclude that the use of topical corticosteroid nasal sprays-either alone or in combination with antibiotic therapy-shows an advantage over placebo in the treatment of the symptoms of acute rhinosinusitis. But should these results change the way otolaryngologists treat a condition that is one of the most common reasons for office visits?

The researchers, Anca Zalmanovici, MD, and John Yaphe, MD, family physicians at Rabin Medical Center in Petach Tikva, Israel, reviewed four major studies. The studies, which were double-blind and placebo-controlled, included some 2000 participants in 16 countries.

In the studies reviewed, diagnosis was determined by X-ray or nasal endoscopy, and defined as having symptom duration of less than eight weeks. The intranasal corticosteroids prescribed were fluticasone propionate (Flonase), mometasone furoate (Nasonex), and budesonide (Rhinocort).

Of those treated with steroids, 73% showed relief or marked improvement of their symptoms during the study period (15 and 21 days), whereas 66.4% of those using placebo showed such improvement. These differences may seem modest but are statistically significant. For every 100 patients treated with intranasal corticosteroids, seven additional patients had complete or marked symptom relief, the researchers point out.

In addition, higher doses of nasal steroids worked better than lower ones. Subjects receiving daily doses of 400 micrograms experienced a greater rate of relief from symptoms than those receiving 200 micrograms per day.

There were no serious side effects reported in the steroid treatment. However, a significant deterrent to prescribing the sprays is cost. Without insurance coverage, the sprays can cost about $100 per month. And the introduction of generic versions has not lowered that price significantly. A physician may consider such a sum rather steep for the hastened relief of an acute condition that resolves with no treatment at all in more than 80% of cases.

However, each year some 37 million Americans suffer the symptoms of acute rhinosinusitis, and many demand relief-from specialists, as well as primary care physicians-of a condition that disrupts job productivity, education, and quality of life.

What’s an Otolaryngologist to Do?

Although some otolaryngologists rarely see acute rhinosinusitis in its early stages, and encounter mostly exacerbated cases after preliminary treatment has failed, other specialists, including Berrylin J. Ferguson, MD, of the University of Pittsburgh School of Medicine, often get calls from patients within days of their showing symptoms. Like most physicians, she will not consider prescribing antibiotics within seven days of onset. Rather, she starts these patients on time-tested remedies for colds, including plenty of fluids and vitamin C, with, perhaps, an over-the-counter topical decongestant. (Not all traditional home therapies are advisable. Bradley Marple, MD, Professor of Otolaryngology at University of Texas Southwestern Medical School, cautioned that patients who seek relief via steam inhalation risk burning themselves.)

Berrylin J. Ferguson, MD

When severe symptoms persist for more than a week, a closer look may be warranted. Dr. Marple believes that nothing can replace a careful history and exam. At this point many doctors will start patients on an antibiotic regimen, but Dr. Marple pointed out that of an estimated one billion upper respiratory infections each year, only 0.5% to 2% involve bacterial infection.