Systemic Corticosteroids in the Management of Sinonasal Disease: An Evidence-Based Expert Review

Chronic rhinosinusitis (CRS) is a prevalent, heterogeneous inflammatory disease associated with significant morbidity. Systemic corticosteroids (SCS) are commonly prescribed for their anti-inflammatory effects, but cumulative exposure carries risks, including metabolic, cardiovascular, and skeletal complications. Despite widespread use, evidence-based guidance on optimal indications, timing, and duration of SCS in CRS remains inconsistent.

An evidence-based review was performed using MEDLINE, EMBASE, and Cochrane databases (2013-2023). Studies were screened and categorized into two primary groups: CRS with (CRSwNP) or without (CRSsNP) nasal polyps. Within CRSwNP, evidence was subcategorized by indication, including (1) polyp size reduction, (2) olfactory dysfunction, (3) comorbid disease, and (4) perioperative use, encompassing pre- and postoperative SCS administration. The CRSsNP category included studies evaluating SCS in non-polypoid disease, with or without comorbidities. Recommendations were graded according to evidence quality and the balance of benefit versus harm.

Short courses of SCS provide consistent, short-term improvements in nasal polyp size, nasal congestion, and olfactory function in CRSwNP, but benefits wane within weeks unless followed by intranasal corticosteroids. Preoperative SCS improves intraoperative visualization, though comparable nonsteroidal techniques exist. Routine postoperative SCS are not supported, showing no meaningful advantage over topical therapy. No additional benefit was seen in comorbid subgroups. Evidence in CRSsNP is limited, with possible benefit only in early disease or select medically managed cases. Repeated use contributes to cumulative toxicity.

SCS have a narrow, time-limited role in CRS. Stewardship should emphasize optimized topical therapy, appropriate sinus surgery, and biologics to minimize systemic steroid exposure.