Oral antifungal therapy for chronic rhinosinusitis and its subtypes: a systematic review

The objective of the evidence base review was to systematically evaluate the literature to elucidate the potential role of oral antifungal therapy in management of chronic rhinosinusitis (CRS) and its subtypes.

Articles for inclusion were identified by query of appropriate search terms in the PubMed database. The articles were reviewed independently by 2 authors and assigned an evidence level. The composite outcome data was reviewed to determine the impact of oral antifungals in CRS.

The search yielded 356 abstracts for review, retrieved 60 articles for full review, and incorporated 28 studies in this report. The majority of literature included level 4 (15) and level 5 (12) studies. One study met criteria for level 1 evidence. Most common disease entity studied was allergic fungal rhinosinusitis in 19 series; the most common antifungals reported were itraconazole and ketoconazole in 19 and 6 studies, respectively. Subjective parameters were assessed in 12 (42.8%) studies; overall, 64 (78%) of 82 patients reported symptom resolution or improvement. Objective parameters were reported in 6 (21.4%) studies, including improvement in endoscopic findings (3), CT imaging (3), reduction in oral steroid usage (1), and less revision surgery (2). Median length of follow-up was 14.7 months (3-60).

The composite data suggests a potential beneficial effect of oral itraconazole and ketoconazole in patients with CRS and its subtypes. However, majority of the studies are uncontrolled case series, confounded by non-validated outcome variables. Randomized controlled trials are required to better elucidate their role in CRS.