Corticosteroids are often prescribed to treat inflammation in acute rhinosinusitis. The preparations mainly used in this case are intranasal corticosteroids, for example, fluticasone or budesonide. Various studies have been conducted to prove whether corticosteroids in acute rhinosinusitis are effective and have a good safety profile.

Intranasal vs. Systemic Corticosteroids in Acute Rhinosinusitis
Illustration: a woman is getting rhinosinusitis
Image source: https://med.uth.edu

Action Mechanism of Corticosteroids in Acute Rhinosinusitis

The ostiomeatal complex (OMC) plays an important role in clearing secretions in the paranasal sinuses. Inflammation of this complex can interfere with sinus drainage and give rise to the various rhinosinusitis symptoms. Corticosteroid use in the treatment of rhinosinusitis because of its anti-inflammatory effect.

The anti-inflammatory effect of corticosteroids comes from their ability to reduce certain cytokines (e.g., interleukin, TNF-α, IFN-γ, GM-CSF) from macrophages, monocytes, lymphocytes, fibroblasts, and epithelial cells. This affects the recruitment, localization, protein synthesis, and survival of the inflammatory cells.



Effectiveness of Corticosteroids in Acute Rhinosinusitis Treatment

a. Effectiveness of Intranasal Corticosteroids in Acute Rhinosinusitis

Hayward et al. performed a systematic review and meta-analysis of 6 studies totaling 2495 patients. They found that intranasal corticosteroids helped reduce acute sinusitis symptoms, especially when given for up to 21 days. The increase in dose is reported to be directly proportional to the resolution of symptoms and individual symptom scores, suggesting that facial pain and nasal congestion are the complaints most responsive to intranasal corticosteroids.

Similar results were reported by a Cochrane meta-analysis of 4 studies involving 1943 participants. Intranasal corticosteroids were reported to accelerate the resolution of acute sinusitis symptoms compared to placebo (73% vs. 66.4%). Higher intranasal corticosteroid doses were also reported to have a stronger effect on symptom improvement or total resolution. Symptom improvement is due to this corticosteroid, regardless of whether or not antibiotics are given.

The intranasal corticosteroids used in the Cochrane study were fluticasone, mometasone, and budesonide. No major side effects were reported due to the use of intranasal corticosteroids, but there were minor side effects such as epistaxis, headache, and nasal irritation. This result is in line with another study by Demoly et al., which reported that the side effects that occurred were only local and mild (epistaxis and headache) without systemic effects.

A systematic review by the American Academy of Otolaryngology-Head and Neck Surgery suggests that although it appears beneficial, the use of intranasal corticosteroids for acute rhinosinusitis still requires a better methodological study, especially in antibiotic-naïve patients, before it can become a recommendation for routine therapy.


b. Effectiveness of Systemic Corticosteroids in Acute Rhinosinusitis

The Cochrane meta-analysis also studied five randomized clinical trials involving 1193 patients for oral corticosteroids' efficacy in acute sinusitis. Participants were divided into groups that received prednisone 24–80 mg/day or betamethasone 1 mg/day with a control group.

Of the five clinical trials, 4 combined oral corticosteroids with antibiotics, while 1 used corticosteroid as monotherapy. The results indicated that oral steroids as monotherapy were not beneficial in the improvement of acute sinusitis symptoms. However, oral corticosteroids have been reported to improve symptoms in the short term in conjunction with antibiotics, although the risk of yield bias remains high.
Several other studies also reported similar results:
  • Ratau et al. 's study on 1 mg/day of betamethasone as an amoxicillin-clavulanate adjuvant therapy. 
  • Study of Gehanno et al. on 3x8 mg of methylprednisolone for five days as adjuvant therapy for amoxicillin-clavulanate.
However, because systemic corticosteroids are at greater risk of severe side effects, they should be avoided, especially where intranasal options are available. Additionally, the common studies regarding the benefits of systemic corticosteroids when combined with antibiotics is the study in a secondary health care unit, so there is a high risk of bias.


Summary
The results of existing studies show that the administration of intranasal corticosteroids can help relieve and accelerate the resolution of acute rhinosinusitis symptoms without causing systemic side effects. Side effects that arise are local and mild to a moderate degree, namely epistaxis, headaches, and nasal irritation.

The administration of systemic corticosteroids as monotherapy has been reported to be ineffective. However, systemic corticosteroids as adjuvant antibiotic therapy have been reported to improve symptoms of acute rhinosinusitis. Further studies on this matter still need to be done given the high risk of bias in existing studies.

The administration of systemic corticosteroids in acute rhinosinusitis should be avoided to prevent systemic side effects, especially when intranasal corticosteroid options are available.


References
1. Demoly P. Safety of intranasal corticosteroids in acute rhinosinusitis. Am J Otolaryngol. 2008;29(6):403-413. DOI:10.1016/j.amjoto.2007.11.004
2. Fernandes AM, Valera FC, Anselmo-Lima WT. Mechanism of action of glucocorticoids in nasal polyposis. Braz J Otorhinolaryngol. 2008;74(2):279–83.
3. Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology. 2020;58(Suppl S29):1-464. DOI:10.4193/Rhin20.600
4. Hayward G, Heneghan C, Perera R, Thompson M. Intranasal corticosteroids in acute sinusitis management: a systematic review and meta-analysis. Ann Fam Med. 2012;10(3):241-249. DOI:10.1370/afm.1338
5. Hox V, Lourijsen E, Jordens A, et al. Benefits and harm of systemic steroids for short- and long-term use in rhinitis and rhinosinusitis: an EAACI position paper. Clin Transl Allergy. 2020;10:1. DOI:10.1186/s13601-019-0303-6
6. Potter PC, Pawankar R. Indications, efficacy, and safety of intranasal corticosteroids in rhinosinusitis. World Allergy Organ J. 2012;5(Suppl 1): S14-S17. DOI:10.1097/WOX.0b013e31823f7216
7. Pujols L, Mullol J, Roca-Ferrer J, et al. Expression of glucocorticoid receptor alpha- and beta isoforms in human cells and tissues. Am J Physiol Cell Physiol. 2002;283(4): C1324–31.
8. van Loon JW, van Harn RP, Venekamp RP, et al. Limited evidence for intranasal corticosteroids' effects on symptom relief for recurrent acute rhinosinusitis. Otolaryngol Head Neck Surg. 2013;149(5):668-673.
9. Venekamp RP, Thompson MJ, Hayward G, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD008115. DOI: 10.1002/14651858.CD008115.pub3.
10. Zalmanovici Trestioreanu A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2013;2013(12): CD005149. Published 2013 Dec 2. DOI:10.1002/14651858.CD005149.pub4