Medical management of chronic rhinosinusitis – a review of traditional and novel medical therapies

ABSTRACT

Introduction: Chronic rhinosinusitis (CRS) is a commonly seen persistent inflammatory disease process affecting the paranasal sinuses with extensively reported economic implications. Despite an elusive pathophysiologic mechanism underlying this disease process, treatment outcomes are encouraging with the employment of an array of medical and surgical therapies.

Areas covered: The goal of this paper is to provide a comprehensive, up to date analysis of the literature concerning the medical management of CRS by summarizing the evidence in support of traditional medical therapies for the management of CRS in addition to highlighting novel medical therapies currently under investigation.

Expert opinion: The current staples of medical therapy for CRS based on the strength of available evidence include topical and oral corticosteroids, oral antibiotics and topical saline. The introduction of immunomodulatory therapies (‘Biologics’) for the treatment of CRS shows promise but have yet to be employed in a widespread fashion due to the need for additional research to better elucidate their role.

KEYWORDS:

• Chronic rhinosinusitis
• sinusitis
• intranasal corticosteroids
• oral corticosteroids
• antimicrobial therapy
• topical saline
• anti-IGE
• Anti-IL-5
• Anti-IL-4/IL-13
• Anti-IL-25

Article highlights

• In the absence of an exact mechanism underlying the pathophysiology of CRS, current non-specific medical therapies for CRS remain empiric with various combinations of oral and topical therapies employed with varying degrees of success

• There is currently a lack of consensus regarding the definition of maximal medical therapy in CRS, with the most common regimens including topical intranasal corticosteroids and oral antibiotics with or without the administration of systemic corticosteroids.

• There is considerable support in the literature for the use of topically delivered steroids in CRS, with the strongest evidence in favor of standard topical steroid formulations.

• There is strong evidence for the use of oral corticosteroids in CRSwNP both preoperatively and postoperatively, with limited, low quality evidence supporting its use in CRSsNP.

• Oral antibiotics are of variable benefit for CRS, with the strongest evidence in favor of short term non macrolide antibiotics for CRSsNP. Long term low dose macrolide therapy has been recommended as an optional strategy due to contradictory evidence.

• There is substantial evidence supporting the benefits of topical saline in CRS both in the preoperative and postoperative clinical setting

• Although current evidence is limited, biologicals therapies (anti-IgE, anti-IL-5, Anti-IL-4/IL-13 and anti-IL-25) represent a promising tool for the treatment of medically and/or surgically refactory CRSwNP.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

This paper was not funded.