How do I treat a patient with chronic inflammatory sinusitis using steroids?

Treatment of Chronic Inflammatory Sinusitis with Steroids

Intranasal corticosteroids should be your first-line steroid therapy for chronic inflammatory sinusitis, used daily as maintenance treatment, with short courses of oral corticosteroids (2-3 weeks) reserved only for severe cases with nasal polyps or marked mucosal edema. 1, 2

Primary Treatment Approach: Intranasal Corticosteroids

Intranasal corticosteroids are the most effective medication class for controlling the major symptoms of chronic sinusitis including nasal congestion, rhinorrhea, and inflammation. 1, 3 These agents work by:

• Decreasing vascular permeability and reducing inflammatory cell infiltration (especially eosinophils) 4, 1
• Inhibiting release of inflammatory mediators including histamine, leukotrienes, and prostanoids 4, 1
• Improving nasal blockage with a moderate effect size (mean difference -0.40 on a 0-3 scale) 5

The evidence supporting intranasal corticosteroids is robust: they improve overall symptom scores (standardized mean difference -0.46), reduce polyp size (standardized mean difference -0.73), and prevent polyp recurrence after surgery (relative risk 0.59). 6, 5

Specific Intranasal Corticosteroid Recommendations

• Use high-potency agents such as mometasone, fluticasone, or budesonide 4, 1
• Combine with high-volume saline irrigation for enhanced effectiveness - this is the evidence-based first-line combination therapy 1, 6
• Continue for at least 3-4 weeks before assessing response; for chronic disease, long-term maintenance is typically needed 3, 7
• Instruct patients to direct spray away from the nasal septum to minimize risk of septal perforation and epistaxis 1, 2

Common pitfall: Intranasal corticosteroids may not directly penetrate the paranasal sinuses, but their anti-inflammatory effects on the nasal mucosa and ostia are sufficient to provide clinical benefit. 4, 1

When to Add Oral Corticosteroids

Oral corticosteroids should NOT be used routinely - reserve them for specific clinical situations only. 4, 2

Indications for Short-Course Oral Steroids (2-3 weeks):

• Chronic rhinosinusitis with nasal polyps - this is the strongest indication 1, 2, 6
• Failure to respond to intranasal corticosteroids plus antibiotics after 3-5 days 2
• Marked mucosal edema on examination 1, 2
• Need for rapid symptomatic improvement in severe cases 7

Oral Corticosteroid Dosing Protocol:

Use prednisone 25 mg daily for 2 weeks, then transition to intranasal corticosteroids for maintenance. 2 Alternative regimens include methylprednisolone 1 mg/kg tapered over 15-21 days. 8

Critical limitation: The evidence for oral corticosteroids shows only short-term benefit (2-4 weeks) with effects disappearing by 10-12 weeks. 1, 8 Benefits include:

• Modest improvement in symptom resolution (risk ratio 1.17 for facial pain relief at 4-7 days) 2
• Temporary reduction in polyp size for up to 3 months 1, 6
• Improved total symptom scores at 2-4 weeks 1

What NOT to Do

Do not use oral corticosteroids as monotherapy - they must always be combined with intranasal corticosteroids. 1, 2

Do not use systemic steroids for acute post-viral rhinosinusitis - the evidence shows no benefit and the condition is self-limiting. 1, 2

Avoid antihistamines for routine sinusitis treatment - they have side effects without proven efficacy in relieving sinus symptoms. 4, 3

Complete Treatment Algorithm

1. Start all patients with chronic inflammatory sinusitis on:

   • Intranasal corticosteroid spray (e.g., mometasone or fluticasone) daily 1, 3
   • High-volume saline irrigation 1, 6

2. If bacterial infection is documented (symptoms ≥10 days or severe symptoms with fever/purulent discharge):

   • Add antibiotics (amoxicillin or amoxicillin-clavulanate) for minimum 3 weeks 4, 2
   • Continue intranasal corticosteroids 4, 2

3. If nasal polyps are present or patient fails initial therapy:

   • Add oral corticosteroids (prednisone 25 mg daily × 2 weeks) 1, 2
   • Then transition back to intranasal corticosteroids for long-term maintenance 2

4. If no improvement after 3-4 weeks of appropriate therapy:

   • Consider referral to ENT specialist for evaluation 1, 3
   • May need endoscopic sinus surgery if anatomic obstruction present 4

Safety Considerations

Intranasal corticosteroids are safe for long-term use - at recommended doses they do not cause clinically significant systemic effects. 4, 3 The main adverse effect is epistaxis (risk ratio 2.74), but this typically consists of minor streaks of blood. 5

Short courses of oral corticosteroids (≤3 weeks) have low risk of significant adverse events, though patients may experience insomnia, mood changes, and gastrointestinal disturbances. 1, 8

Monitor patients on oral steroids who have diabetes - use the lower dose range (prednisone 25 mg rather than higher doses) to minimize glycemic fluctuations. 2

Periodically examine the nasal septum in patients on long-term intranasal corticosteroids to check for mucosal erosions. 1, 3