What is the role of steroids, such as prednisone, in treating sinusitis?

Role of Steroids in Treating Sinusitis

Intranasal corticosteroids are recommended as first-line therapy for sinusitis, while systemic steroids should be reserved only for specific cases of chronic rhinosinusitis with nasal polyps or severe symptoms unresponsive to other treatments.

Types of Sinusitis and Steroid Recommendations

Acute Viral Sinusitis (Common Cold)

• Steroids not indicated
• Self-limiting condition that resolves within 7-10 days
• Focus on symptomatic relief with saline irrigation and analgesics

Acute Post-Viral Sinusitis

• Intranasal corticosteroids: May provide symptomatic relief
• Systemic steroids: Not recommended as they do not improve recovery at 7-14 days 1
• While systemic steroids show a small effect on facial pain at days 4-7, the benefits do not outweigh potential risks 1

Acute Bacterial Sinusitis

• First-line treatment: Amoxicillin or amoxicillin-clavulanate for 5-7 days 2
• Intranasal corticosteroids: May be used as adjunctive therapy
• Systemic steroids: Only considered when patient fails to respond to initial treatment and has marked mucosal edema 1

Chronic Rhinosinusitis Without Nasal Polyps (CRSsNP)

• Intranasal corticosteroids: First-line therapy
• Systemic steroids: Not well-studied; insufficient evidence to recommend 1

Chronic Rhinosinusitis With Nasal Polyps (CRSwNP)

• Intranasal corticosteroids: First-line therapy
• Short courses of systemic steroids: Beneficial as adjunctive therapy
  • Typically oral prednisolone 25-60 mg for 7-20 days 1
  • Produces significant reduction in total symptom score and nasal polyp size at 2-3 weeks 1
  • Effects on symptoms diminish by 10-12 weeks, though polyp size reduction may persist longer 1

Evidence for Steroid Use

Intranasal Corticosteroids

• Well-established safety profile with minimal systemic absorption
• Effective for reducing inflammation and mucosal edema
• Can be used safely for extended periods
• Should be properly administered to maximize effectiveness:
  • Head tilted forward
  • Spray directed away from nasal septum
  • Continue regular use for optimal effect

Systemic Corticosteroids (e.g., Prednisone)

• Short-term use (7-21 days) in CRSwNP shows:
  • Significant reduction in total symptom score at 2-4 weeks (p<0.00001) 1
  • Significant reduction in nasal polyp score at 2-3 weeks (p<0.00001) 1
  • Effects on symptoms not maintained at 10-12 weeks 1
• In acute post-viral sinusitis:
  • Small but significant effect on facial pain at days 4-7 1
  • No significant effect on nasal discharge 1
  • No improvement in overall recovery at 7-14 days 1

Clinical Approach to Using Steroids in Sinusitis

1. Determine sinusitis type (acute viral, post-viral, bacterial, or chronic with/without polyps)
2. For most sinusitis types: Start with intranasal corticosteroids
3. For CRSwNP: Consider short course of systemic steroids (e.g., prednisolone) when symptoms are severe
4. For acute bacterial sinusitis: Consider systemic steroids only when patient fails to respond to initial treatment and has marked mucosal edema 1

Potential Adverse Effects of Systemic Steroids

• Short-term: Insomnia, mood changes, gastrointestinal disturbances
• Long-term concerns (with repeated courses): Adrenal suppression, osteoporosis, avascular necrosis
• Rare but serious: Cases of fatal varicella-zoster in immunocompetent patients 1

Key Considerations

• Benefits of systemic steroids must be weighed against potential risks
• Short courses (7-21 days) are generally safe but should not be used repeatedly
• Always combine with intranasal corticosteroids for optimal management of chronic rhinosinusitis with nasal polyps
• Antibiotics remain the mainstay of treatment for bacterial sinusitis, with steroids serving as adjunctive therapy

Remember that sinusitis is often self-limiting, and supportive care measures like adequate hydration, analgesics, warm facial packs, and saline irrigation can provide significant symptom relief 1.