Topical Corticosteroid Therapy in Recalcitrant Chronic Rhinosinusitis

Glucocorticoids are a cornerstone in the treatment of chronic rhinosinusitis (CRS). Intranasal corticosteroid sprays are consistently recommended as a first-line treatment for CRS in published clinical practice guidelines, evidence-based reviews, and multidisciplinary and international consensus statements; and short courses of oral steroids can be a useful adjunct for symptomatic CRS refractory to topical steroids and saline rinses [1–8]. Daily nasal steroid sprays are also a standard part of long-term, postoperative medical maintenance regimens that are designed to prevent or delay the relapse of sinus disease after surgery. Meta-analyses have shown that intranasal corticosteroids administered via a breath actuated dry-powder inhaler device, nasal spray, or drop can decrease symptom severity and reduce polyp burden in CRS [9–11]. However, nasal steroid sprays alone may be inadequate for symptom control in the treatment of CRS. Up to half of patients may not achieve adequate symptom control with an appropriate medical therapy protocol involving a 3-month, twice-daily regimen of nasal steroid sprays and saline rinses, a ≥ 3-week course of systemic antibiotics, and a 21-day oral steroid taper [12]. Medically refractory CRS veritably represents a major health issue, with patients failing medical therapy reporting a similar health-related quality of life to those with end-stage renal disease requiring dialysis [13] and experiencing mean annual productivity costs greater than patients with diabetes, severe asthma, and chronic migraine [14].