Update on the management of chronic rhinosinusitis

Figures & data

Figure 1 Diagnosis of CRS.

Note: © 2007 Sage Publications. Reproduced with permission from Rosenfeld RM, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007;137(3 Suppl)S1–S31.

Figure 2 Factors associated with CRS.

Note: © 2003 Sage Publications. Adapted with permission from Benninger M, et al. Otolaryngol Head Neck Surg. 2003;129(3 suppl):S1–S32.

Figure 3 CRS differentiation by inflammatory mediators.

Note: Data from Van Zele T, et al. Differentiation of chronic sinus diseases by measurement of inflammatory mediators. Allergy. 2006;61:1280–1289.

Table 1 Randomized controlled trials evaluating intranasal saline in CRS

Author	Year	Outcome measures	Treatment groups	Delivery method	Results
Shoseyov et al^Citation51	1998	Symptom and radiological scores in children	3.5% HTS versus ITS	1 mL nasal drops	Improved cough score in HTS group; other scores similar
Bachmann et al^Citation52	2000	Symptom, endoscopic, mucociliary clearance, rhinometry and olfactometry scores	HTS versus ITS	200 mL irrigator	Improved symptom scores in both groups; no difference between groups
Heatley et al^Citation53	2001	SNOT-20 and RSOM31 scores	2.7% HTS via bulb syringe versus irrigation pot versus reflexology placebo	Bulb syringe versus irrigator	Improved scores in all groups, with no difference between groups and placebo
Rabago et al^Citation54	2002	QoL, RSDI, and SIA scores	2% HTS versus control	300 mL nasal cup	Improved RSDI and SIA in saline group versus controls
Cordray et al^Citation55	2005	QoL scores	HTS versus triamcinolone versus ITS	Nasal spray	Improvements in steroid and HTS groups
Pinto et al^Citation56	2006	Symptoms post-ESS	ITS versus HTS versus control	Nasal spray	No symptom improvement in ITS or HTS group over control. More pain in HTS group
Hauptmanand Ryan^Citation57	2007	Acoustic rhinometry, saccharine clearance times, symptoms	ITS versus HTS	Nasal spray	ITS and HTS improved saccharine clearance times and symptoms of nasal stuffiness. ITS improved nasal patency
Pynnonen et al^Citation48	2007	SNOT-20 score, symptom frequency, and medication usage	ITS via large volume irrigation versus spray	Large volume irrigation versus spray	Improved SNOT-20 score and symptom frequency in irrigation over spray group
Liang et al^Citation49	2008	Symptom and endoscopy scores post-ESS	Buffered ITS + medical treatment versus medical treatment	500 mL pulsatile irrigator	Improved endoscopy and symptom scores in irrigation group with mild CRS only
Freeman et al^Citation50	2008	Endoscopy scores post-ESS	ITS + medical treatment versus medical treatment	2 mL atomized	Improved endoscopic appearance at 3 weeks; no difference at 3 months

Abbreviations: CRS, chronic rhinosinusitis; HTS, hypertonic saline; ITS, isotonic saline; SNOT-20, Sino-Nasal Outcome Test; RSOM31, rhinosinusitis outcomes measure; QoL, quality of life; RSDI, rhinosinusitis disability index; SIA, symptoms severity assessment; ESS, endoscopic sinus surgery.

Table 2 Randomized controlled trials evaluating topical antibiotics in CRS

Author	Year	Outcome measures	Treatment groups	Treatment protocol	Result
Sykes et al^Citation68	1986	Symptoms, bacterial culture, sinus radiograph, saccharin clearance, allergy testing	Dexamethasone/tramazoline/neomycin versus dexamethasone/ tramazoline versus placebo	Nasal spray QID × 4 weeks	Improvements in both treatment groups over placebo; no difference with addition of topical antibiotic
Desrosiers et al^Citation69	2001	Symptoms, QoL, endoscopy	Tobramcyin in saline versus saline	Large-particle nebulizer TID × 4 weeks	Improvements in both groups; no benefit of tobramycin over saline
Videler et al^Citation70	2008	Symptoms, QoL, endoscopy	Bacitracin/colimycin versus placebo	RhinoFlow nebulizer BID + oral levofloxacin	Improvements in both groups, with no benefit over placebo
Jervis-Bardy et al^Citation71	2012	Bacterial culture, symptoms, endoscopy post-ESS	Mupirocin versus saline in Staphylococcus aureus-positive patients	240 mL irrigation BID × 1 month	Staphylococcus aureus culture negativity in 88.9% of mupirocin versus 0% of saline group; improved early endoscopic score in mupirocin group over saline; no difference in symptoms between groups

Abbreviations: CRS, chronic rhinosinusitis; QID, four times daily; QoL, quality of life; TID, three times daily; BID, twice daily; ESS, endoscopic sinus surgery.

Table 3 Randomized controlled trials evaluating oral steroids in CRSwNP

Author	Year	N	Outcome measures	Treatment groups	Results
Hissaria et al^Citation80	2006	41	Symptoms, MRI, endoscopy	Prednisolone 50 mg daily versus placebo × 14 days	Improved symptoms, MRI and endoscopic appearance in steroid group versus control
Kroflic et al^Citation81	2006	40	Symptoms, endoscopy, histology, intraoperative bleeding	Methylprednisolone 1 mg/kg daily versus nasal furosemide × 7 days pre-ESS	Improved symptoms and polyp size in both groups with no clinical difference between groups
van Zele et al^Citation82	2010	47	Endoscopy, rhinometry, symptoms, SEC, nasal IL-5, IgE, MMP-9, ECP	Methylprednisolone taper over 20 days versus oral doxycycline × 20 days versus placebo	Improved polyp size, nasal patency, inflammatory markers and symptoms in steroid group versus placebo
Kirtsreesakul et al^Citation83	2011	109	Symptoms,rhinometry,endoscopy	Prednisolone 50 mg daily versus placebo × 14 days	Improved symptoms, nasal patency and polyp size in steroid group versus control
vaidyanathan et al^Citation84	2011	60	Endoscopy, symptoms, QoL, rhinometry, CRP, EDN	Prednisolone 25 mg daily versus placebo × 14 days, both followed by intranasal fluticasone	Improved polyp size, symptoms, QoL, serum EDN, and CRP in steroid group versus control

Abbreviations: CRSwNP, chronic rhinosinusitis with nasal polyposis; MRI, magnetic resonance imaging; ESS, endoscopic sinus surgery; SEC, serum eosinophil count; IL-5, interleukin 5; IgE, immunoglobulin E; MMP-9, matrix metalloproteinase-9; ECP, eosinophilic cationic protein; QoL, quality of life; CRP, C-reactive protein; EDN, eosinophil-derived neurotoxin.

Figure 4 Efficacy of antibiotics in CRS.

Note: Data from Anon JB, et al. Otolaryngol Head Neck Surg. 2004;130(1 Suppl):1–45.

Abbreviations: HD, high dose; TMP/SMX, trimethoprim-sulfamethoxazole.

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