The Many Faces of Rhinosinusitis: Case Challenges

Gordon H. Sun, MD, MS

September 22, 2015

Symptom Relief in CRS

The 2015 AAO-HNSF guideline for adult rhinosinusitis has added action statements for certain therapies for CRS, a significant change from the 2007 version. The new AAO-HNSF guideline recommends saline nasal irrigation, corticosteroid nasal sprays, or both to relieve the symptoms of CRS.[1] Either isotonic or hypertonic saline is appropriate; there is no evidence to suggest that either type is superior.[24] Although the guideline suggests that irrigation is better than nasal spray as a delivery mechanism for saline, this recommendation is based on a single randomized trial that demonstrated a statistically significant, but not a clinically meaningful, improvement in the sinonasal symptoms of CRS when patients used isotonic saline irrigation instead of spray.[24,25]

Several systematic reviews have concluded that topical intranasal corticosteroids are effective in improving symptoms in CRS patients with or without nasal polyps, with minimal adverse effects.[26,27,28] In comparison, patients diagnosed with CRS and nasal polyposis can benefit from oral corticosteroid therapy, but there is a lack of high-level evidence to support the its use in CRS without polyps.[29,30,31] The AAO-HNSF guideline does not directly address the use of oral corticosteroids for either circumstance.

The guideline specifically recommends against the routine use of either topical or systemic antifungal therapy for patients with CRS. Multiple systematic reviews of randomized controlled trials have concluded that antifungal therapy provided no clinical benefit to patients and resulted in a significantly higher rate of adverse events, such as elevated values on liver function tests, compared with placebo.[28,32,33]

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