Clinical Question

Do intranasal corticosteroids, with or without antibiotics, hasten the resolution of symptoms of acute bacterial rhinosinusitis?

Evidence-Based Answer

Compared with patients not treated with intranasal corticosteroids, those who receive them have greater improvement or resolution of symptoms at two to three weeks, regardless of whether antibiotics are used. In a single head-to-head study, patients taking intranasal corticosteroids alone fared slightly better than those taking antibiotics alone. Higher doses of intranasal corticosteroids work better than lower doses. (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)

Practice Pointers

Although acute bacterial rhinosinusitis is usually self-limited, up to 98% of office visits for “sinusitis” lead to a prescription for an antibiotic. Yet, even when stricter criteria are used for making the diagnosis, antibiotics yield modest benefits.¹

These authors evaluated the role of intranasal corticosteroids, with and without antibiotics, in the treatment of acute bacterial rhinosinusitis in children and adults. Intranasal corticosteroid agents used included fluticasone (Flonase), mometasone (Nasonex), and budesonide (Rhinocort). Four double-blind, placebo-controlled trials of almost 2,000 patients were reviewed, but only three of the trials were included in the meta-analysis because one study had methodologic flaws and a high drop-out rate. The primary outcome of symptom resolution or improvement was measured at 15 days in one study and at 21 days in the other studies.

In the study with the high drop-out rate, symptoms improved more rapidly with intra-nasal corticosteroids vs. placebo (approximately three to four days). Meta-analysis of the other three studies showed that patients using intranasal corticosteroids had a 73% chance of having symptom resolution or improvement vs. 66% of those using a placebo inhaler (relative risk = 1.11; 95% confidence interval, 1.04 to 1.18; number needed to treat [NNT] = 15). In one of the studies in which patients received high-dose mometasone (400 mcg), the NNT was 12.

Only one study compared intranasal corticosteroid monotherapy with antibiotic monotherapy. The intranasal corticosteroids–only group had a statistically significant improvement of 0.6 points on the 15-point mean symptom score when compared with the antibiotic-only group.

No major adverse effects were reported in the trials, and minor effects included epistaxis, headache, and nasal irritation.

The American Academy of Pediatrics updated its guidelines for management of acute bacterial rhinosinusitis in patients one to 18 years of age.² Although the guidelines state that a three-day observation period is permissible before treatment with amoxicillin, no comment is made on the use of intranasal corticosteroids. The Infectious Diseases Society of America recommends saline irrigation and/or intranasal corticosteroids, especially in refractory cases or in patients with a history of allergic symptoms.³ Recommendations from the University of Michigan Health System state that intranasal corticosteroids are “likely to be effective.”⁴