-
The Cochrane Database of Systematic... Apr 2016This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Nasal saline irrigation is commonly used to improve patient symptoms.
OBJECTIVES
To evaluate the effects of saline irrigation in patients with chronic rhinosinusitis.
SEARCH METHODS
The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 9); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 30 October 2015.
SELECTION CRITERIA
Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing saline delivered to the nose by any means (douche, irrigation, drops, spray or nebuliser) with (a) placebo, (b) no treatment or (c) other pharmacological interventions.
DATA COLLECTION AND ANALYSIS
We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation and discomfort. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.
MAIN RESULTS
We included two RCTs (116 adult participants). One compared large-volume (150 ml) hypertonic (2%) saline irrigation with usual treatment over a six-month period; the other compared 5 ml nebulised saline twice a day with intranasal corticosteroids, treating participants for three months and evaluating them on completion of treatment and three months later. Large-volume, hypertonic nasal saline versus usual care One trial included 76 adult participants (52 intervention, 24 control) with or without polyps.Disease-specific HRQL was reported using the Rhinosinusitis Disability Index (RSDI; 0 to 100, 100 = best quality of life). At the end of three months of treatment, patients in the saline group were better than those in the placebo group (mean difference (MD) 6.3 points, 95% confidence interval (CI) 0.89 to 11.71) and at six months there was a greater effect (MD 13.5 points, 95% CI 9.63 to 17.37). We assessed the evidence to be of low quality for the three months follow-up and very low quality for the six months follow-up. Patient-reported disease severity was evaluated using a "single-item sinus symptom severity assessment" but the range of scores is not stated, making it impossible for us to determine the meaning of the data presented.No adverse effects data were collected in the control group but 23% of participants in the saline group experienced side effects including epistaxis. General HRQL was measured using SF-12 (0 to 100, 100 = best quality of life). No difference was found after three months of treatment (low quality evidence) but at six months there was a small difference favouring the saline group, which may not be of clinical significance and has high uncertainty (MD 10.5 points, 95% CI 0.66 to 20.34) (very low quality evidence). Low-volume, nebulised saline versus intranasal corticosteroids One trial included 40 adult participants with polyps. Our primary outcome of disease-specific HRQL was not reported. At the end of treatment (three months) the patients who had intranasal corticosteroids had less severe symptoms (MD -13.50, 95% CI -14.44 to -12.56); this corresponds to a large effect size. We assessed the evidence to be of very low quality.
AUTHORS' CONCLUSIONS
The two studies were very different in terms of included populations, interventions and comparisons and so it is therefore difficult to draw conclusions for practice. The evidence suggests that there is no benefit of a low-volume (5 ml) nebulised saline spray over intranasal steroids. There is some benefit of daily, large-volume (150 ml) saline irrigation with a hypertonic solution when compared with placebo, but the quality of the evidence is low for three months and very low for six months of treatment.
Topics: Administration, Intranasal; Adrenal Cortex Hormones; Adult; Chronic Disease; Humans; Hypertonic Solutions; Nasal Polyps; Nasal Sprays; Quality of Life; Randomized Controlled Trials as Topic; Rhinitis; Sinusitis; Sodium Chloride; Therapeutic Irrigation; Time Factors
PubMed: 27115216
DOI: 10.1002/14651858.CD011995.pub2 -
Antibiotics (Basel, Switzerland) Sep 2018Most antibiotics are prescribed in primary care, and commonly for respiratory tract infections (RTIs). Narrow-spectrum phenoxymethylpenicillin is the antibiotic of... (Review)
Review
Most antibiotics are prescribed in primary care, and commonly for respiratory tract infections (RTIs). Narrow-spectrum phenoxymethylpenicillin is the antibiotic of choice for RTIs in the Scandinavian countries, while broader spectrum amoxicillin is used in most other European countries. This review summarizes the knowledge of the effect of phenoxymethylpenicillin versus amoxicillin for infections treated in ambulatory care. We searched PubMed/Medline and Embase for trials comparing the clinical effect of phenoxymethylpenicillin and amoxicillin. The Norwegian Knowledge Centre for the Health Services' checklist was used to assess risk of bias. In total, 1687 studies were identified, and 18 of these fulfilled the inclusion criteria. One additional study was found as a reference. The randomized controlled trials revealed no significant differences in clinical effect in acute sinusitis (three RCTs), GAS tonsillitis (11 RCTs) and Lyme borreliosis (two RCTs). One RCT on community-acquired pneumonia found amoxicillin to be superior, while the results were conflicting in the two RCTs on acute otitis. The results suggest that non-Scandinavian countries should consider phenoxymethylpenicillin as the treatment of choice for RTIs because of its narrower spectrum. More studies should be conducted on the clinical effect of phenoxymethylpenicillin versus amoxicillin for acute otitis and lower RTIs.
PubMed: 30181520
DOI: 10.3390/antibiotics7030081 -
The Journal of Laryngology and Otology Feb 2018Without the release of histamines, patients with rhinosinusitis may not benefit from antihistamines. Additionally, anticholinergic effects may do more harm than good.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Without the release of histamines, patients with rhinosinusitis may not benefit from antihistamines. Additionally, anticholinergic effects may do more harm than good. This study aimed to investigate the effectiveness of antihistamines in treating rhinosinusitis.
METHODS
An electronic search was performed. Randomised controlled trials comparing antihistamines with either placebo or other treatments for patients with rhinosinusitis were selected.
RESULTS
Two studies (184 patients) met the inclusion criteria. Loratadine decreased nasal obstruction in allergic rhinitis patients with acute rhinosinusitis (mean difference = -0.58; confidence interval = -0.85 to -0.31, p < 0.01), but had no benefit on total symptom score (mean difference = -1.25; confidence interval = -2.77 to 0.27, p = 0.11), or rhinorrhoea symptoms (mean difference = -0.06; confidence interval = -0.37 to 0.25, p = 0.71).
CONCLUSION
There is limited evidence to support the use of antihistamines in treating rhinosinusitis. The number of included studies in this systematic review is limited. Antihistamines may relieve nasal obstruction in allergic rhinitis patients with acute rhinosinusitis.
Topics: Histamine Antagonists; Humans; Loratadine; Randomized Controlled Trials as Topic; Rhinitis, Allergic; Sinusitis; Treatment Outcome
PubMed: 28901282
DOI: 10.1017/S002221511700192X -
BJGP Open 2021Antibiotic overprescribing is a major concern that contributes to the problem of antibiotic resistance.
BACKGROUND
Antibiotic overprescribing is a major concern that contributes to the problem of antibiotic resistance.
AIM
To assess the effect on antibiotic prescribing in primary care of telehealth (TH) consultations compared with face-to-face (F2F).
DESIGN & SETTING
Systematic review and meta-analysis of adult or paediatric patients with a history of a community-acquired acute infection (respiratory, urinary, or skin and soft tissue). Studies were included that compared synchronous TH consultations (phone or video-based) to F2F consultations in primary care.
METHOD
PubMed, Embase, Cochrane CENTRAL (inception-2021), clinical trial registries and citing-cited references of included studies were searched. Two review authors independently screened the studies and extracted the data.
RESULTS
Thirteen studies were identified. The one small randomised controlled trial (RCT) found a non-significant 25% relative increase in antibiotic prescribing in the TH group. The remaining 10 were observational studies but did not control well for confounding and, therefore, were at high risk of bias. When pooled by specific infections, there was no consistent pattern. The six studies of sinusitis - including one before-after study - showed significantly less prescribing for acute rhinosinusitis in TH consultations, whereas the two studies of acute otitis media showed a significant increase. Pharyngitis, conjunctivitis, and urinary tract infections showed non-significant higher prescribing in the TH group. Bronchitis showed no change in prescribing.
CONCLUSION
The impact of TH on prescribing appears to vary between conditions, with more increases than reductions. There is insufficient evidence to draw strong conclusions, however, and higher quality research is urgently needed.
PubMed: 34497096
DOI: 10.3399/BJGPO.2021.0106 -
American Journal of Rhinology & Allergy May 2021RARS is a challenging clinical phenomenon that affects many patients, and diagnostic criteria for this condition are not fully characterized in the literature.
BACKGROUND
RARS is a challenging clinical phenomenon that affects many patients, and diagnostic criteria for this condition are not fully characterized in the literature.
OBJECTIVE
To examine diagnostic criteria for recurrent acute rhinosinusitis (RARS).
STUDY DESIGN
Systematic review.
METHODS
Cochrane, PubMed (MEDLINE), clinicaltrials.gov, EMBASE, Google Scholar, and Web of Science databases were queried for articles related to RARS dating from 1990 to present, according to PRISMA statement guidelines. Full text articles pertinent to the diagnostic criteria of RARS were included in this review. Inclusion criteria included articles specifically addressing RARS; studies with 3 or more patients; and articles in English.
RESULTS
A total of 1022 titles/abstracts potentially related to RARS were identified. Of these, sixty-nine full texts were selected for review, and 22 of these ultimately met inclusion criteria. The level of evidence was generally low. Studies and guidelines have used many different definitions for RARS diagnosis over the years based on symptomatology, physical examination, nasal endoscopy, imaging, and laboratory domains. Clinically important RARS has been defined most commonly as 4 or more discrete episodes of ARS per year, but this frequency is typically based on expert opinion. Additionally, radiologic anatomic associations such as concha bullosa, accessory maxillary os, and narrowed infundibular distance may be associated with RARS. Endoscopic visualization and imaging are sometimes used to confirm the presence of sinus disease during exacerbations of RARS, but there is variability in this practice.
CONCLUSION
The diagnostic definition for RARS has developed over time and is currently based on low level 4 and 5 evidence. Because of the migratory definition of RARS, comparing inter-study results of RARS management remains difficult, and future studies should aim to follow current expert guidelines on diagnostic criteria of RARS.
Topics: Acute Disease; Humans; Recurrence; Retrospective Studies; Rhinitis; Sinusitis
PubMed: 32954839
DOI: 10.1177/1945892420956871 -
European Archives of... May 2016The aim of this systematic review was to synthesize the results of original studies assessing antibiotic efficacy at different time points after initiating treatment in... (Review)
Review
The aim of this systematic review was to synthesize the results of original studies assessing antibiotic efficacy at different time points after initiating treatment in patients with a moderate probability of acute bacterial rhinosinusitis. We searched the Cochrane library for systematic reviews on the efficacy of antibiotic treatment in patients with acute rhinosinusitis (ARS). Only randomized controlled trials (RCTs) that compared treatment of any antibiotic with placebo were included. The synthesis of the results of six RCTs showed a benefit of antibiotic treatment compared to placebo for the rate of improvement after 3 [pooled odds ratio (OR) 2.78 (95 % confidence interval (CI) 1.39-5.58)] and 7 [OR 2.29 (95 % CI 1.19-4.41)] days after initiation in patients with symptoms and signs of ARS lasting for 7 or more days. After 10 days [pooled OR 1.36 (95 % CI 0.66-2.90)], improvement rates did not differ significantly between patients treated with or without antibiotics. Compared to placebo, antibiotic treatment relieves symptoms in a significantly higher proportion of patients within the first days of treatment. Reporting an overall average treatment efficacy may underestimate treatment benefits in patients with a self-limiting illness.
Topics: Acute Disease; Anti-Bacterial Agents; Female; Humans; Male; Probability; Randomized Controlled Trials as Topic; Rhinitis; Sinusitis; Treatment Outcome
PubMed: 25597034
DOI: 10.1007/s00405-015-3506-z -
Pediatrics May 2024Acute sinusitis is one of the leading causes of antibiotic prescriptions in children. No recent systematic reviews have examined the efficacy of antibiotics compared... (Meta-Analysis)
Meta-Analysis
CONTEXT
Acute sinusitis is one of the leading causes of antibiotic prescriptions in children. No recent systematic reviews have examined the efficacy of antibiotics compared with placebo.
OBJECTIVE
We sought to determine if antibiotics are superior to placebo in the treatment of acute sinusitis in children.
DATA SOURCES
Medline and Embase were searched from their origin to July 2023.
STUDY SELECTION
We considered randomized placebo-controlled studies focusing on the treatment of acute sinusitis. In all studies, symptoms were present for <4 weeks and subjects were <18 years of age.
DATA EXTRACTION
Two authors independently extracted the data. We pooled data primarily using fixed-effects models.
RESULTS
Analysis of 6 included studies showed that antibiotic treatment reduced the rate of treatment failure by 41% (with a risk ratio of 0.59; 95% confidence interval 0.49-0.72) compared with placebo. There was substantial heterogeneity between the studies (I2 = 69.7%), which decreased substantially when the 1 study with a high risk of bias was removed (I2 = 26.9%). Children treated with antibiotics were 1.6 times more likely to have diarrhea than those who were not treated with antibiotics (risk ratio = 1.62, 95% confidence interval 1.04-2.51).
LIMITATIONS
A small number of studies were eligible for inclusion. Included studies differed in their methodology.
CONCLUSIONS
In children with clinically diagnosed acute sinusitis, antibiotics significantly reduced the rate of treatment failure compared with placebo. However, given the favorable natural history of sinusitis, our results could also support close observation without immediate antibiotic treatment.
Topics: Humans; Anti-Bacterial Agents; Sinusitis; Child; Acute Disease; Randomized Controlled Trials as Topic; Treatment Failure; Adolescent
PubMed: 38646685
DOI: 10.1542/peds.2023-064244 -
International Forum of Allergy &... Aug 2022Although nasal saline treatments are widely used in treating acute rhinosinusitis (ARS), the evidence in adult patients is inconclusive. Our objective was to assess the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Although nasal saline treatments are widely used in treating acute rhinosinusitis (ARS), the evidence in adult patients is inconclusive. Our objective was to assess the add-on benefits of saline treatment in adults with ARS.
METHODS
Literature searches were performed (updated May 9, 2021). Randomized, controlled trials studying the effects of nasal saline treatment in adults with ARS were included. Data were pooled for meta-analysis. Outcomes were composite symptoms score (CSS), disease-specific quality-of-life (DS-QoL) score, individual symptom score, endoscopy score, saccharin transit time, cure rate, days to resolution, and adverse events.
RESULTS
Eleven studies (718 patients) were included in our investigation. Nasal discharge was the only symptom improved (standardized mean difference [SMD], -0.36; 95% confidence interval [CI], -0.66 to -0.05]. Saline as an add-on treatment brought no benefit to CSS and DS-QoL score at both time-points (3-10 days and at the end of the study). Other outcomes also showed no benefits with use of saline, including endoscopy score, saccharin transit time, cure rate, days to resolution, and adverse events. Subgroup analyses showed improvement in viral ARS patients for CSS (SMD, -0.60; 95% CI, -1.12 to -0.08) and DS-QoL score (mean difference, -15.90; 95% CI, -31.78 to -0.02), and also in patients using high-volume saline (SMD, -0.42; 95% CI, -0.78 to -0.06).
CONCLUSION
Nasal saline as an add-on treatment improved rhinorrhea. There was no improvement in CSS and DS-QoL, except among the subgroup of viral ARS patients using high-volume saline. There were no differences in adverse events between the saline and non-saline treatments.
Topics: Acute Disease; Adult; Chronic Disease; Humans; Quality of Life; Rhinitis; Saccharin; Saline Solution; Sinusitis; Sodium Chloride
PubMed: 34971301
DOI: 10.1002/alr.22957 -
The Laryngoscope Jan 2015To systematically assess the prevalence of bacterial infection in adults with acute rhinosinusitis (ARS). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES/HYPOTHESIS
To systematically assess the prevalence of bacterial infection in adults with acute rhinosinusitis (ARS).
METHODS
Electronic databases were systematically searched for relevant studies published up to June 2012.
RESULTS
Twenty-nine articles, evaluating a total of 9,595 patients with a clinical diagnosis of ARS, were included in the study. Of these, 14 (48%) studies required radiographic confirmation of sinusitis, one study (3%) required evidence of purulence, 10 studies (35%) required both for inclusion in the study population, and four studies (14%) required neither. The random effects model estimate of prevalence of bacterial growth on all cultures was 53.7% (CI 48.4%-59.0%), ranging from 52.5% (CI 46.7%-58.3%) in studies requiring radiographic confirmation of sinusitis to 61.1% (CI 54.0%-68.1%) in studies requiring neither radiographic evidence nor purulence on exam. Studies that obtained cultures from antral swab had a prevalence of bacterial growth of 61.0% (CI 54.7%-67.2%), whereas those utilizing endoscopic meatal sampling had a prevalence of 32.9% (CI 19.0%-46.8%).
CONCLUSIONS
Few studies evaluate the recovery of bacteria via culture in adults with a diagnosis of ABRS or ARS based on clinical criteria alone. With radiographic and/or endoscopic confirmation, antral puncture and endoscopically guided cultures produce positive bacterial cultures in approximately one-half of patients. Opportunities exist to improve diagnostic accuracy for bacterial infection in ARS.
Topics: Acute Disease; Adolescent; Adult; Aged; Bacterial Infections; Bacteriological Techniques; Cross-Sectional Studies; Endoscopy; Female; Humans; Male; Middle Aged; Radiography; Rhinitis; Sinusitis; Young Adult
PubMed: 24723427
DOI: 10.1002/lary.24709 -
The British Journal of General Practice... Jul 2019The overall clinical impression ('clinical gestalt') is widely used for diagnosis but its accuracy has not been systematically studied. (Meta-Analysis)
Meta-Analysis
BACKGROUND
The overall clinical impression ('clinical gestalt') is widely used for diagnosis but its accuracy has not been systematically studied.
AIM
To determine the accuracy of clinical gestalt for the diagnosis of community-acquired pneumonia (CAP), acute rhinosinusitis (ARS), acute bacterial rhinosinusitis (ABRS), and streptococcal pharyngitis, and to contrast it with the accuracy of clinical decision rules (CDRs).
DESIGN AND SETTING
Systematic review and meta-analysis of outpatient diagnostic accuracy studies in ambulatory care.
METHOD
PubMed and Google were searched for studies in outpatients that reported sufficient data to calculate accuracy of the overall clinical impression and that used the same reference standard. Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2), and measures of accuracy calculated using bivariate meta-analysis.
RESULTS
The authors identified 16 studies that met the inclusion criteria. The summary estimates for the positive (LR+) and negative likelihood ratios (LR-) were LR+ 7.7, 95% confidence interval (CI) = 4.8 to 11.5, and LR- 0.54, 95% CI = 0.42 to 0.65 for CAP in adults, LR+ 2.7, 95% CI = 1.1 to 4.3 and LR- 0.63, 95% CI = 0.20 to 0.98 for CAP in children, LR+ 3.0, 95% CI = 2.1 to 4.4 and LR- 0.37, 95% CI = 0.29 to 0.46 for ARS in adults, LR+ 3.9, 95% CI = 2.4 to 5.9 and LR- 0.33, 95% CI = 0.20 to 0.50 for ABRS in adults, and LR+ 2.1, 95% CI = 1.6 to 2.8 and LR- 0.47, 95% CI = 0.36 to 0.60 for streptococcal pharyngitis in adults and children. The diagnostic odds ratios were highest for CAP in adults (14.2, 95% CI = 9.0 to 21.0), ARS in adults (8.3, 95% CI = 4.9 to 13.1), and ABRS in adults (13.0, 95% CI = 5.0 to 27.0), as were the C-statistics (0.80, 0.77, and 0.84 respectively).
CONCLUSION
The accuracy of the overall clinical impression compares favourably with the accuracy of CDRs. Studies of diagnostic accuracy should routinely include the overall clinical impression in addition to individual signs and symptoms, and research is needed to optimise its teaching.
Topics: Acute Disease; Clinical Decision Rules; Community-Acquired Infections; Humans; Odds Ratio; Pharyngitis; Pneumonia; Rhinitis; Sensitivity and Specificity; Sinusitis; Streptococcal Infections
PubMed: 31208974
DOI: 10.3399/bjgp19X704297