Managing chronic rhinosinusitis in adults

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Commentary by Carl Philpott, Clinical Senior Lecturer, Norwich Medical School and Honorary Consultant Ear, Nose and Throat Surgeon and Rhinologist, James Paget University Hospital:

“The evidence presented by Rudmik et al. (2015) confirms the conclusions in the European Position Paper on Rhinosinusitis and Nasal Polyps (2012), but doesn’t add any new evidence or recommendations. This is not surprising because there have been no new RCTs in that time for chronic rhinosinusitis. Although open label and non-randomised series have been reported, any publications since 2012 have been themselves meta-analyses. As such, this systematic review supports the current recommendations to treat people who have chronic rhinosinusitis with topical steroids and nasal irrigation, and review treatment after 4 weeks.

“Practice variation in the UK is high. Longitudinal data from the Clinical Practice Research Datalink (CPRD) show that 1% of UK adults receive treatment for chronic rhinosinusitis from their GP each year, averaging 4 GP visits (Gulliford et al. 2014). These people receive multiple medications, with 91% receiving an antibiotic prescription. The recent ENT-UK commissioning guideline (Royal College of Surgeons of England 2013) does not recommend routine antibiotic use for chronic rhinosinusitis in primary care, but GPs often prescribe repeated courses (Akkerman et al. 2005), which may cause resistance.

“There is growing interest in the immune-modulating effects of macrolide antibiotics in chronic airway inflammatory disease. Low-dose, long-term macrolides are being prescribed in chronic rhinosinusitis for their effect on immune response and not primarily as antibacterial agents (Cervin and Wallwork 2007). Some evidence exists for longer term antibiotic use in secondary care, but this evidence is from 2 small conflicting RCTs (Wallwork et al. 2006 and Videler et al. 2011), resulting in a call for further larger trials (Piromchai et al. 2011). Recently some Clinical Commissioning Groups (CCGs) have insisted on a 3 month trial of macrolide antibiotics before people with chronic rhinosinusitis can be referred to secondary care (Soni-Jaiswal et al. 2015), despite the fact that no high-level evidence is available to support this approach.

“Hospital Episode Statistics show that 1 in 3 people with chronic rhinosinusitis attending ear, nose and throat clinics in England are considered not to have responded adequately to current medical treatment and are considered for surgery. However, insufficient evidence is available to define the role of surgery, which has contributed to a 5-fold variation in UK intervention rates (Royal College of Surgeons of England 2013). Symptom duration before surgery varies from under 1 to over 10 years (Hopkins et al. 2015a, Hopkins et al. 2015b). If surgery is less effective than continued medical therapy, patients may be exposed to unnecessary risks and morbidity. If surgery is better, current variation reflects suboptimal patient care.”
Original languageEnglish
TypeNICE Eyes on Evidence - Commentary
Media of outputWeb page
Publication statusPublished - 2016


  • Sinusitis

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