What is the role of steroid adjunct therapy in acute sinusitis?

Role of Steroid Adjunct Therapy in Acute Sinusitis

Intranasal corticosteroids may provide modest benefits as adjunctive therapy in acute sinusitis, while systemic corticosteroids should generally be avoided due to limited evidence of benefit and potential adverse effects.

Intranasal Corticosteroids

Evidence for Use

• A Cochrane review found that intranasal steroids increased symptom improvement rates from 66% to 73% after 15-21 days (number needed to treat of 14) 1
• Intranasal steroids have demonstrated benefits for facial pain and congestion symptoms 1, 2
• The anti-inflammatory effects of intranasal corticosteroids include:
  • Decreased vascular permeability
  • Inhibition of inflammatory mediators (histamine, leukotrienes, platelet-activating factor)
  • Reduction of inflammatory cell infiltration 1

Clinical Application

• Consider as adjunctive therapy to antibiotics in acute bacterial sinusitis 1
• Most beneficial for symptoms related to obstruction (congestion, facial pain, headache) 3
• Prescription options studied include mometasone, fluticasone, flunisolide, and budesonide 1
• Over-the-counter option includes triamcinolone acetonide (though not specifically studied for acute sinusitis) 1

Limitations and Considerations

• Benefits are modest but clinically important 1
• Intranasal steroids are unlikely to reach the interior of paranasal sinuses 1
• Minor adverse events include epistaxis, headache, and nasal itching 1
• Most effective when used for 21 days rather than 14-15 days 2
• Higher doses may provide greater benefits (dose-response relationship) 2

Systemic Corticosteroids

Evidence Against Use

• No benefit over placebo when used as monotherapy 1, 4
• Limited evidence for benefit when combined with antibiotics 1, 4
• Confidence in results is limited by significant risk of attrition bias 1
• Adverse events include nausea, vomiting, and gastric complaints 1, 4

Specific Scenarios

• May have modest short-term benefit for symptom relief when combined with antibiotics (number needed to treat of 7) 1
• Additional research needed to establish true effect 1
• Should be discouraged as an intervention with questionable efficacy 1

Other Adjunctive Therapies

Recommended Options

• Analgesics (NSAIDs, acetaminophen) for pain relief 1
• Saline irrigation for symptomatic relief 1
  • May improve quality of life and decrease symptoms 1
  • Hypertonic saline (3-5%) may have superior benefit to isotonic saline 1

Options with Limited Evidence

• Decongestants - unknown effects on acute sinusitis symptoms 1
• Guaifenesin (mucolytic) - unknown effects on acute sinusitis symptoms 1
• Antihistamines - questionable efficacy and should not be used unless there is a clear allergic component 1

Special Considerations

Recurrent Acute Sinusitis

• Multi-modal approach including intranasal corticosteroids, saline irrigation, and mucolytics/expectorants recommended 5
• Consider extending antibiotic treatment duration to 3-4 weeks 5
• Consider antihistamines only if allergic rhinitis is present 5

Pitfalls to Avoid

• Using systemic steroids as monotherapy (ineffective) 4
• Overlooking contributing factors like smoking or GERD 5
• Prolonged use of decongestants (limit to 5 days) 5
• Using antihistamines in non-allergic patients 1
• Narcotics for pain management (rarely necessary and should be discouraged) 1

In conclusion, intranasal corticosteroids offer modest but clinically important benefits in acute sinusitis, particularly for symptoms of congestion and facial pain. Systemic corticosteroids should generally be avoided due to limited evidence of benefit and potential adverse effects. Analgesics and saline irrigation are reasonable adjunctive therapies with favorable risk-benefit profiles.