Acute rhinosinusitis and systemic corticosteroids
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* Kingsley N. Ukwaja

I read with interest the *CMAJ* article by Venekamp and colleagues,1 but I disagree with the authors’ findings that suggest systemic corticosteroid monotherapy had no clinically important benefit in acute rhinosinusitis. The proportion of patients with resolution of facial pain or pressure on day 7 was 62.5% in the prednisolone group and 55.8% in the placebo group (absolute risk difference 6.7%). Studies with possible clinical importance have 95% confidence intervals (CIs) that include the value of the minimal clinically important difference (MCID) and a MCID greater than the point estimate of the efficacy.2 Based on this, the 95% CI (−7.9% to 21.2%) obtained for the point estimate included both the point estimate (6.7%) and the MCID used for the study (20%).

Also, the proportion of patients with resolution of severe facial pain or pressure on day 7 was significantly higher among those receiving prednisolone compared with those receiving placebo (absolute risk difference 10.6%, 95% CI 1.0% to 20.2%). Furthermore in Table 2, which shows the proportion of patients with resolution of symptoms on day 7, the prednisolone group shows a tendency toward an overall beneficial effect compared with placebo.1

One reason why the full effect of systemic corticosteroids cannot be elicited from the study is lack of patient selection. The Infectious Diseases Society of America guidelines distinguish clinically between acute bacterial/viral rhinosinusitis and acute rhinosinusitis due to other causes based on illness pattern and duration.3 There was no attempt to identify patients in the sample who might benefit from other treatment approaches. It is possible that the short-term benefits are higher among those with acute rhinosinusitis due to other causes compared with patients with acute bacterial rhinosinusitis who might require antibiotic therapy.3 A previous guideline suggests that systemic corticosteroids be reserved for those with nasal polyps, severe nasal swelling due to inflammation of the mucous membrane, or for whom other treatment approaches have failed.4

I thank the authors for the study, but I believe the clinical importance of systemic corticosteroids for treating acute rhinosinusitis should not completely be discarded until we identify the subgroups of patients who will benefit from them.

## References

1.  Venekamp RP, Bonten MJM, Rovers MM, et al. Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial. CMAJ 2012;184:E751–7.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTg0LzE0L0U3NTEiO3M6NDoiYXRvbSI7czoyMToiL2NtYWovMTg1LzEvNjIuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  Man-Son-Hing M, Laupacis A, O’Rourke K, et al. Determination of the clinical importance of study results: a review. J Gen Intern Med 2002;17:469–76.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1046/j.1525-1497.2002.11111.x&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=12133163&link_type=MED&atom=%2Fcmaj%2F185%2F1%2F62.1.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000176548900011&link_type=ISI) 

3.  Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137(Suppl):1–31.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NToic3BvdG8iO3M6NToicmVzaWQiO3M6NzoiMTM3LzEvMSI7czo0OiJhdG9tIjtzOjIxOiIvY21hai8xODUvMS82Mi4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Slavin RG, Spector SL, Bernstein IL, et al. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol 2005;116(Suppl):13–47.