What is the appropriate use of steroids for treating sinusitis?

Appropriate Use of Steroids for Sinusitis Treatment

Intranasal corticosteroids are the recommended first-line steroid therapy for sinusitis, while short courses of oral corticosteroids should be reserved only for severe cases with nasal polyps or when rapid symptomatic improvement is needed. 1, 2

Types of Steroids and Their Role in Sinusitis

Intranasal Corticosteroids

• First-line steroid therapy for both acute and chronic sinusitis
• Provide modest but clinically significant benefits by reducing inflammation, decreasing vascular permeability, and inhibiting inflammatory cell infiltration 1
• Increase symptom improvement rates from 66% to 73% after 15-21 days (number needed to treat of 14) 1, 2
• Options include fluticasone, mometasone, flunisolide, budesonide, and triamcinolone acetonide 2
• Most effective when used regularly rather than as-needed 3

Oral (Systemic) Corticosteroids

• Should be limited to specific situations:
  • Severe sinusitis with significant nasal polyps 1, 4
  • Cases requiring rapid symptomatic improvement 4
  • Short duration only (5-7 days) 1
• Not recommended as monotherapy for acute sinusitis without polyps 5
• May be used as adjunct therapy with antibiotics in severe cases 6
• Single administration of parenteral (injectable) corticosteroids is discouraged, and recurrent administration is contraindicated due to potential long-term side effects 1

Evidence-Based Treatment Algorithm

1. First-line approach:

   • Intranasal corticosteroids + saline irrigation 1, 2
   • Continue for at least 8-12 weeks for chronic sinusitis 1
   • Proper administration technique is crucial (see below)

2. For severe symptoms or nasal polyps:

   • Add short course (5-7 days) of oral corticosteroids 1, 4
   • Example: Methylprednisolone 1 mg/kg with progressive dose reduction 6

3. For persistent symptoms:

   • Consider adding antibiotics if bacterial infection is suspected 1
   • Continue intranasal corticosteroids during and after antibiotic treatment 1

Proper Administration of Intranasal Corticosteroids

• Shake container well before use
• Clear nasal passages before application
• Tilt head slightly forward
• Insert tip just inside nostril, aimed away from septum
• Spray while breathing in gently through the nose
• Avoid sniffing forcefully after application 3

Important Cautions and Side Effects

Intranasal Corticosteroids

• Generally safe with minimal systemic absorption 3
• Potential local side effects:
  • Nasal irritation, epistaxis (nosebleeds)
  • Localized Candida infections (rare) 3
• Long-term use concerns in children (growth velocity) 3

Oral Corticosteroids

• Significant potential adverse effects with prolonged use:
  • Mood disturbances, insomnia
  • Gastrointestinal disturbances
  • Hyperglycemia
  • Adrenal suppression
  • Increased risk of infection 5

Common Pitfalls to Avoid

1. Using decongestants for too long: Limit topical decongestants to 3-5 days maximum to avoid rebound congestion and rhinitis medicamentosa 1, 2, 7

2. Inappropriate use of oral steroids: Avoid using oral steroids:

   • As monotherapy for sinusitis without polyps 5
   • For extended periods beyond 5-7 days 1
   • In patients with uncontrolled diabetes, glaucoma, or psychiatric disorders

3. Poor intranasal steroid technique: Incorrect administration reduces effectiveness and increases risk of side effects 3

4. Using antihistamines inappropriately: Only use if there is a clear allergic component to the sinusitis 2

5. Discontinuing intranasal steroids too early: Benefits may take several days to appear; consistent use for at least 8-12 weeks is recommended for chronic sinusitis 1

By following these evidence-based recommendations, clinicians can optimize the use of steroids in sinusitis treatment while minimizing potential adverse effects and maximizing patient outcomes.