Survey of Local and Systemic Corticosteroids Use in Adults with Chronic Rhinosinusitis with Nasal Polyps in Chile

Abstract

Introduction

Local and systemic corticosteroids have long been the mainstay in the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP), although there is no universally accepted prescription modality. A survey was conducted in Chile to determine the current prescription of topical and systemic corticosteroids in adult patients with CRSwNP.

Objective

To describe the use of local and systemic corticosteroids in adult patients with CRSwNP prescribed by otolaryngologists in Chile.

Material and Method

A cross-sectional study. A self-administered online survey was conducted among active members of the Chilean Society of Otorhinolaryngology, with 104 participating professionals.

Results

In CRSwNP, the most frequently prescribed topical corticosteroid was mometasone (69.2%) in the form of a daily intranasal spray. Nasal lavage is frequently indicated as an adjunctive treatment. The majority of respondents considered local adverse effects of local steroids to be minimal and systemic adverse effects to be infrequent. Prednisone is the most commonly used systemic corticosteroid (86.5%), especially in short bursts during exacerbations. However, there is heterogeneity in duration, dose, and route of administration. In surgery, systemic corticosteroids are used to optimize outcomes and reduce complications.

Conclusion

The treatment of chronic rhinosinusitis with nasal polyps combines a medical and surgical approach. Topical corticosteroids are essential according to multiple international guidelines. The use of systemic corticosteroids should be rational, assessing risks and benefits. Given the heterogeneity of the results obtained in this study regarding steroid prescription, the development of clinical guidelines to standardize the rational use of topical and systemic corticosteroids in Chile should be considered.

Introduction

Chronic rhinosinusitis with nasal polyps is a chronic inflammatory disorder characterized by significant negative impact of symptoms on quality of life. Although its precise pathogenesis remains incompletely elucidated, accumulating evidence supports a multifactorial model encompassing genetic susceptibility, environmental exposures, epithelial barrier dysfunction, and aberrant type 2–skewed immune responses.^1–3 The condition frequently coexists with comorbidities such as asthma, allergic rhinitis, and aspirin-exacerbated respiratory disease, underscoring its systemic inflammatory underpinnings.^1–6

The management of CRSwNP entails an integrated medical and surgical approach tailored to disease severity and patient-specific factors. Nasal saline irrigations and intranasal corticosteroids (INCS) represent the mainstay of first-line therapy. In patients with moderate-to-severe disease who exhibit an inadequate response to topical treatment, short courses of systemic corticosteroids are commonly employed to achieve more rapid control of inflammatory exacerbations.¹ Surgical intervention is reserved for individuals in whom medical therapy fails to secure satisfactory disease control. Endoscopic sinus surgery aims to re-establish ventilation and mucociliary clearance of the paranasal sinuses, thereby enhancing the penetration and efficacy of subsequent topical therapies.^1,3 More recently, biologic agents targeting key inflammatory pathways have emerged as an effective therapeutic option in carefully selected patients, particularly those with type 2–predominant, eosinophilic, or allergic endotypes and persistent disease despite prior surgical management.⁷

INCS are considered first-line medical therapy for CRSwNP because of their beneficial effects on symptom control, reduction of polyp size, and prevention of postoperative recurrence.⁸ First-generation INCS include beclomethasone dipropionate, triamcinolone acetonide, and budesonide, while second-generation INCS include ciclesonide, fluticasone furoate, fluticasone propionate, and mometasone furoate. Currently, there is insufficient evidence to suggest superiority of a specific agent in terms of efficacy. However, in clinical practice, mometasone and fluticasone formulations are often preferred for long-term use due to their very low systemic bioavailability (<1%).^9,10

Systemic corticosteroids may be employed as adjunctive medical therapy or administered prior to considering surgery; however, their use in clinical practice is far from standardized. Considerable heterogeneity persists among clinicians with regard to indications, dosing regimens, and treatment duration, reflecting the absence of unequivocal guidance and shared prescribing paradigms.¹¹

Although the optimal dose and duration of therapy remain to be clearly defined, short courses of oral corticosteroids (7–21 days), administered with or without concomitant INCS therapy, have been shown to provide transient symptomatic relief and to reduce polyp size.³ Furthermore, perioperative administration of systemic corticosteroids has been reported to temporarily optimize the surgical field.¹²

With respect to safety, short courses of oral corticosteroids employed in the management of CRSwNP are generally effective; however, their use is not devoid of clinically relevant adverse effects. The most frequently reported events include insomnia, mood disturbances, and gastrointestinal discomfort. In patients with diabetes mellitus, systemic corticosteroid therapy may precipitate elevations in blood glucose levels, thereby necessitating careful glycemic monitoring and, where appropriate, adjustment of hypoglycemic agents or insulin regimens.^13,14 Importantly, increasing cumulative annual exposure to systemic corticosteroids has been associated with a heightened risk of metabolic complications, reduced bone mineral density with consequent osteoporosis, and cardiovascular events. These considerations underscore the need to balance therapeutic efficacy against the potential burden of systemic toxicity, particularly in patients requiring repeated treatment courses.¹⁵

Although international evidence-based recommendations exist regarding the rational use of local and systemic corticosteroids, including the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS),¹ the Spanish Society of Otorhinolaryngology guidelines (SEORL-CCC),³ and the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS),^16,17 there is no universally accepted systemic steroid prescription protocol. Clinical practice is characterized by significant heterogeneity regarding steroid type, dose, and duration.^11,18,19

Currently, there are no descriptive studies from Chile or Latin America that analyze the rational use of corticosteroids in CRSwNP according to international evidence-based recommendations.

Objective

To describe the use of local and systemic corticosteroids in adult patients with chronic rhinosinusitis with nasal polyps (CRSwNP) prescribed by otorhinolaryngologists in Chile.

Methodology

A cross-sectional study was conducted using a survey entitled “Modified Use of Corticosteroids in Patients with CRSwNP” (Table 1). The questionnaire was based on the survey published by De Corso et al, 2022.¹¹ This self-administered questionnaire was distributed online through the Google Forms platform and shared with otorhinolaryngologists and otorhinolaryngology residents who are members of the Chilean Society of Otorhinolaryngology (SOCHIORL).

Table 1.

“Survey on Corticosteroid Use in Patients with Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)” Modified

Variable	Range/Levels
Sex	Male; Female
Age	>18 years [18–99]
Career Stage	Resident; <5 years of experience; 5–15 years of experience; >15 years of experience
Practice Setting	Public Hospital; University Hospital; Armed Forces Hospital; Occupational Health/Social Security Hospital; Other Public Health System; Private Healthcare Center
Most frequently prescribed intranasal corticosteroid	Budesonide; Mometasone; Fluticasone furoate; Fluticasone propionate; Other
Preferred method of local corticosteroid administration	Nasal spray aerosol; Nasal drops; Nasal irrigations; Others
Combination of local corticosteroids with saline irrigation	Yes, same time of day; Yes, different times of day; Only in selected cases; No
Time to first follow-up after initiation of local corticosteroids	1 month; 2 months; 3 months; 3–6 months; 6–12 months; Other
Frequency of local corticosteroid administration	Daily; Alternate days; Alternate weeks; 15 days on/15 days off; Alternate months; Others
Adherence to local corticosteroids within 3 months	>90%; 70–90%; 50–70%; 30–50%; <30%
Agreement with safety of prolonged local corticosteroid use	Strongly agree; Partially agree; Neither agree nor disagree; Partially disagree; Strongly disagree
Aspects considered when prescribing topical corticosteroids	Application technique; Duration/frequency; Body position; Administration schedule; Timing relative to irrigation; Others
Most common systemic side effect of prolonged local corticosteroid use	Glucose metabolism alterations; Bone metabolism alterations; Mood changes; Increased appetite; Insomnia; Hypertension; Adrenal suppression; Others; No systemic effects
Most common local side effect of prolonged local corticosteroid use	Epistaxis; Nasal pain; Craniofacial pain/headache; Hyposmia; Nasal dryness; Increased intraocular pressure; Cataract; Nasal crusting; Septal perforation; Mucosal atrophy; No local effects; Others
Contraindications for local corticosteroid use	Risk of epistaxis; Hypertension; Glaucoma; Cataracts; Diabetes; Immunosuppression; Herpes simplex; None; Others
Strategies to reduce adverse effects of local corticosteroids	Correct administration technique; Discontinue ≥10 days/month; Alternate-week administration; Alternate-day administration; Adjunctive nasal medications; None; Other
Discontinuation of local corticosteroids before surgery	No; Yes, 1 week before; Yes, 1 month before; Yes, 3 months before; Other
Initiation of local corticosteroids after surgery	Immediate/post-packing removal; According to mucosal recovery; 1 week; 15 days; 1 month; 1–3 months; 6 months; Only if recurrence; Others
Local corticosteroid prescribed during pregnancy	Budesonide; Mometasone; Fluticasone furoate; Fluticasone propionate; Other; Do not prescribe
Most frequently prescribed systemic corticosteroid	Prednisone; Prednisolone; Methylprednisolone; Deflazacort; Hydrocortisone; Betamethasone; Triamcinolone; Others
Preferred route of systemic corticosteroid administration	Oral; Intramuscular; Intravenous; Oral/Intramuscular; Do not use systemic corticosteroids
Indication for short-course oral corticosteroids	Any exacerbation; ≤2 cycles/year; ≤3 cycles/year; Monthly for 5 days; Monthly for 7 days; Other
Typical systemic corticosteroid dose (prednisone equivalent)	60 mg/day; 40 mg/day; 20 mg/day; 10 mg/day; 5 mg/day; Weight-based dosing; Other
Duration of short-course systemic corticosteroids	<5 days; 5–10 days; 10–15 days; 15–20 days; 20–25 days; 25–30 days; Other
Adherence to oral systemic corticosteroids	>90%; 70–90%; 50–70%; 30–50%; <30%
Use of depot systemic corticosteroids	Never; Considered but not used; Routine use; During exacerbations; Rapid symptom control; Poor response to oral corticosteroids/surgery not feasible
Use of systemic corticosteroids before surgery	No; Yes, always; Depending on severity; Only recurrence/complications; Others
Benefits of preoperative systemic corticosteroids	Reduced bleeding; Improved visualization; Reduced inflammatory changes; Reduced operative time; No benefits
Adverse effects observed with systemic corticosteroids	Gastroesophageal reflux; Increased appetite; Mood changes; Insomnia; Anxiety; Cataracts; Glaucoma; Hypertension; Hyperglycemia/diabetes; Infections; Adrenal suppression; Osteoporosis; None; Others
Reasons for discontinuing systemic corticosteroids	Never; Osteoporosis; Hyperglycemia/diabetes; Hypertensive crisis; Dyslipidemia/weight gain; Gastritis/ulcer; Cataracts/glaucoma; Anxiety/depression/sleep disorders; Other reasons
Management of recurrences in patients at risk from systemic corticosteroids	Avoid systemic corticosteroids; Minimal doses; Low mineralocorticoid activity corticosteroids; Strict monitoring; Increase local corticosteroids; Alternative medications; Others

The survey consisted of 31 questions divided into three sections (Table 1): sociodemographic data, use of local corticosteroids, and use of systemic corticosteroids. The questionnaire was simplified and adapted to the local clinical context. A content validation with full agreement was conducted by a group of Chilean otorhinolaryngologists to ensure clarity of the questions and an appropriate response time. Minor adjustments were subsequently made to ensure adequate instrument validation. The final questionnaire is reported in supplementary material.

The survey was distributed via Email between November 2024 and January 2025 and a census recruitment was carried out. A system was implemented to prevent duplicate responses while preserving participant anonymity. Confidentiality of all collected opinions and responses was strictly maintained. This survey was completely anonymous, with no collection of personal data or identifiers. Prior to starting the survey, all participants were informed on the website about the purpose of the clinical research, as well as the voluntary and confidential nature of their participation, which did not require personal data. To provide consent and prevent duplicate entries, participants were required to verify their Email addresses. In accordance with Article 2 of Chilean Law No. 19,628, this study does not constitute the processing of sensitive or personal data.

Descriptive and statistical analyses were performed using STATA software version 16.1 (StataCorp, TX, USA). Factor variables (see Table 1 for details) were described using absolute and relative frequencies, while age was analyzed using measures mean+-SD. All responses were mandatory and there were no missing data.

Results

Sample Profile

Out of a total of 405 active society members, 104 responses were obtained (25.67%). Of the respondents, 65.4% were male and 34.6% female. The mean age was 45.2 years (range: 26–80 years; SD = 13.5).

Regarding professional experience, 36.5% were otorhinolaryngologists with more than 15 years of clinical practice, 28.8% had 6–15 years of experience, 27.9% had less than 5 years of experience, and 6.7% were residents.

In terms of workplace setting, 82.7% reported working in the private healthcare system and 66.3% in at least one public healthcare hospital. Additionally, 13% worked in university hospitals and 4.9% in other types of healthcare institutions (Table 2).

Table 2.

Sociodemographic Data

Career Stage	Female	Male	Total
ENT with >15 years of clinical practice experience	12	26	38
ENT with 5–15 years of clinical practice experience	10	20	30
Resident or ENT with <5 years of clinical practice experience	14	22	36
Total	36	68	104

Use of Local Corticosteroids

The most frequently prescribed local corticosteroid (LCS) for CRSwNP treatment was mometasone (69.2%), followed by fluticasone (24%) and budesonide (6.7%). Additionally, 98.1% of respondents prescribed daily corticosteroid therapy (Figure 1).

Figure 1.

In your clinical practice, which intranasal corticosteroid do you prescribe most frequently in the treatment of patients with CRSwNP?.

In terms of administration method, 94.1% preferred intranasal spray, 3.8% corticosteroids delivered through nasal irrigation, and 1.9% nasal drops. Perceived treatment adherence at 3 months was estimated to be between 70–90% by 51.9% of respondents, between 50–70% by 27.9%, and greater than 90% by only 17.3%. (Figure 2) In pregnant patients, 60.6% prescribed budesonide, 24% mometasone, 5.7% fluticasone, and 9.6% reported not prescribing any medication.

Figure 2.

In your clinical experience, what percentage of patients adhere to local corticosteroid therapy within 3 months?

A total of 93.3% of respondents strongly agreed that prolonged use of local corticosteroids is associated with minimal local side effects and few or no systemic side effects. To optimize INCS prescription, 93.3% considered correct device application technique essential, 68.3% considered administration after nasal irrigation important, 60.5% emphasized duration and frequency of spray use, and 49% highlighted patient body position during administration. To minimize local adverse effects, 88.5% emphasized patient education on correct administration technique, and 26% preferred adjunctive therapies such as hyaluronic acid or nasal emollients.

Systemic adverse effects were considered generally absent by 90.3% of respondents. The most commonly reported local adverse effects were epistaxis (58.6%), nasal dryness (25.9%), and nasal crusting (5.7%), while 4.8% reported no local adverse effects. Potential contraindications most frequently identified were risk of epistaxis (50%) and glaucoma (29.8%), while 32.6% considered that there are no contraindications for INCS use.

In the perioperative setting of endoscopic sinus surgery (ESS), 97.1% prescribed INCS until the day of surgery, while 2% recommended discontinuation one week prior. For postoperative initiation, 31.7% prescribed INCS immediately postoperatively or after nasal packing removal, 24% at 1 week postoperatively, 16.3% according to mucosal healing, and 13.5% at 2 weeks postoperatively.

Use of Systemic Corticosteroids

The most common route of administration was oral (88.5%), followed by intramuscular (6.7%), and combined oral or intramuscular depending on clinical scenario (3.8%) (Figure 3) Systemic corticosteroid use was reported as follows: 86.5% of respondents prescribed prednisone, 9.6% betamethasone, and 1.9% deflazacort and 2% others drugs (Figure 4).

Figure 3.

Which Type of administration do you prefer for systemic corticosteroids?

Figure 4.

In your clinical experience, which systemic corticosteroid do you prescribe most frequently in patients with CRSwNP?

For short oral steroid bursts, 45.2% prescribed them during exacerbations without exceeding two courses per year, 34.6% limited use to three courses per year, and 18.3% prescribed them whenever exacerbations occurred regardless of number.

With respect to daily systemic steroid dosing (using prednisone as reference), 54.8% prescribed according to patient weight, 17.3% prescribed 40 mg daily, 14.4% prescribed 60 mg daily, 6.7% prescribed 20 mg daily, and 6.7% reported other dosing regimens. Treatment duration varied, with 67.3% prescribing systemic steroids for 5–10 days, 11.5% for less than 5 days, 7.6% for 10–15 days, and 13.5% reporting other durations (Figure 5). Adherence was estimated to be above 90% by 74.8% of respondents, between 70–90% by 22.3%, and other adherence levels were reported by 2.9%.

Figure 5.

If it is necessary to prescribe a short course of systemic corticosteroids for exacerbations or recurrences in CRSwNP, what dose do you usually prescribe? Prednisone as reference.

Depot systemic corticosteroid use showed variability: 50% reported never using them, 15.3% had considered their use, and 34.7% reported using them depending on patient clinical condition.

Preoperative systemic corticosteroid use before ESS was reported as routine by 42.3% of respondents, while 36.5% prescribed them according to disease severity, and 13.4% never prescribed them. In terms of perceived benefits, 59.6% reported reduced intraoperative bleeding, 56.7% improved endoscopic visualization, 51.9% reduced anatomical inflammatory changes, and 32.7% reduced operative time.

Adverse effects most frequently reported included insomnia (51%), hyperglycemia (48%), gastroesophageal reflux (40.4%), hypertension (31.7%), anxiety (26%), mood changes (13.5%), and glaucoma (7.7%), while 17.3% reported no adverse effects. Treatment discontinuation occurred mainly due to hyperglycemia (39.4%), while 32.7% reported never discontinuing treatment. Other reasons included psychiatric symptoms (18.3%), gastrointestinal symptoms (17%), ophthalmologic symptoms (8.7%), and other causes (5.7%).

In high-risk patients, management strategies included preference for alternative therapies such as antihistamines or antileukotrienes (40.4%), increasing INCS dosing (28.8%), prescribing systemic corticosteroids under strict monitoring (28.8%), selecting corticosteroids with lower mineralocorticoid activity (26.9%), and absolute avoidance of systemic corticosteroids (20.1%).

Discussion

Currently, neither Chile nor Latin America have established national or regional clinical guidelines, and there is a lack of descriptive studies evaluating the use of local and systemic corticosteroids in the management of CRSwNP. To our knowledge, this is the first study in Latin America specifically designed to evaluate prescribing patterns of local and systemic corticosteroids in the management of CRSwNP.

According to the results of this study, most physicians reported using local corticosteroids as first-line therapy, with high prescription rates of mometasone (69.2%) and fluticasone (24%), administered daily and preferably using intranasal spray devices (94.1%). These findings are consistent with international clinical guideline recommendations, including EPOS, AAO-HNS, SEORL-CCC, the Canadian Society of Otolaryngology (CSO), and the Australasian Society of Clinical Immunology and Allergy (ASCIA).^{1,3,15,16,20,21} These guidelines consistently prioritize second-generation corticosteroids such as mometasone and fluticasone due to their high local efficacy and very low systemic bioavailability (<1%).^1,3,16,21

One relevant finding was the low perceived long-term adherence to therapy, with only 17.3% of respondents estimating adherence above 90% at 3 months. This suggests the need to strengthen patient education regarding device application technique, the importance of prior nasal irrigation, and active clinical follow-up. Notably, the POLINA guideline from the Spanish Society of Otorhinolaryngology emphasizes the correct use of intranasal corticosteroids, including patient education regarding spray angle, head position, and treatment continuation beyond initial symptomatic improvement, factors also highlighted by participants in the present study.³

Systemic corticosteroid use showed greater heterogeneity. Although most respondents reported using oral prednisone (86.5%) and oral administration as the main route (88.5%), significant variability was observed regarding dosing strategy (fixed dosing versus weight-based adjustment), treatment duration (5–15 days), and annual cycle frequency, ranging from restricted use to administration during every exacerbation.

These practices contrast with EPOS and ASCIA recommendations, which warn about the cumulative systemic adverse effects of repeated corticosteroid use and recommend limiting therapy to 2–3 short courses per year under strict risk–benefit assessment.^1,21 The POLINA guideline similarly discourages systematic use without individualized clinical evaluation.³

In this study, 18.3% of respondents reported prescribing systemic corticosteroids during every exacerbation, which may represent a risk of cumulative overexposure with documented clinical consequences such as hyperglycemia (48%), insomnia (51%), and gastrointestinal symptoms (40.4%), adverse effects also reported by participants in our sample.

One of the most relevant findings of this study is that 34.6% of respondents reported having used depot corticosteroids in the treatment of chronic rhinosinusitis with nasal polyps, and 15.3% have even considered it at some point. Although this therapeutic approach is not included in the analyzed clinical guidelines, a systematic review by Tamene et al (2023) suggested that depot corticosteroids may provide longer therapeutic effects with potentially fewer adverse effects in CRSwNP patients.²² However, the quality of evidence is low, and despite potential short-term symptom control benefits, current evidence is insufficient to support routine use compared with currently validated therapies.

Regarding perioperative corticosteroid use, 42.3% of respondents reported always prescribing systemic corticosteroids prior to surgery, while 36.5% prescribed them depending on disease severity. These findings are consistent with evidence supporting their role in reducing intraoperative bleeding, improving endoscopic visualization, and optimizing the surgical field.^1,12 However, it should be noted that available evidence is not robust and is largely based on small or non-controlled studies.

Clinical guidelines emphasize the importance of reintroducing intranasal corticosteroids immediately after nasal packing removal.^1,3,15 In this study, only 31.7% of respondents reported following this practice, which could potentially limit postoperative treatment effectiveness.

Importantly, Chile currently lacks national clinical guidelines or consensus recommendations for CRSwNP management. This may partly explain the observed heterogeneity in medical management, particularly regarding systemic corticosteroid use. Unlike countries such as Spain, Canada, the United States, and Australia, where structured and accessible consensus guidelines exist, therapeutic decisions in Chile are largely dependent on individual clinical judgment and likely influenced by local drug availability.

Given the adverse effect profile of systemic corticosteroids and the risk of heterogeneous prescribing practices, the development of standardized national recommendations is essential to regulate rational corticosteroid use. These guidelines should include clear recommendations regarding steroid selection, dosing and duration, perioperative indications, management in high-risk populations (eg, diabetes, hypertension, glaucoma, psychiatric disorders), as well as structured follow-up protocols and patient education strategies.

Limitations

Among study limitations, the cross-sectional design and response rate of 25.67% introduce potential self-selection bias. We originally aimed for 198 participants that would imply a 5% error for categorical variables estimations²³ Additionally, it was not possible to determine sample representativeness due to confidentiality of reference population data.

Future studies should include prospective designs and evaluation of clinical outcomes associated with different therapeutic regimens. Furthermore, research could explore the relationship between academic training, use of international guidelines, and adherence to quality standards in corticosteroid prescribing.

Conclusions

The results of this survey highlight relevant aspects regarding the use of local and systemic corticosteroids in the management of CRSwNP. Similar prescribing patterns were observed for local corticosteroids in terms of steroid selection, dosing regimens, and method of administration. In contrast, a more heterogeneous pattern was observed in the use of systemic corticosteroids, particularly regarding dosing strategies, treatment duration, and the maximum number of annual treatment cycles.

The findings of this research help to understand the prescription of corticosteroids among ENTs and could be a tool for the development of national clinical guidelines and/or standardized recommendations in Chile to promote the rational and evidence-based use of local and systemic corticosteroids in the management of patients with chronic rhinosinusitis with nasal polyps.

Funding Statement

No funding was received.

Data Sharing Statement

All the data are available in the paper and the Supplementary Materials File.

Ethics Statement

According to Article 2 of Chilean Law No. 19,628, our study is exempt from informed consent and ethical approval by an Ethics Committee or Institutional review board because no personal data was collected or processed.

Author Contributions

D.N.: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data curation, Writing – original draft, Writing – review and editing, Visualization, Project administration. C.V.: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Writing – original draft, Writing – review and editing, Supervision. G.S.: Methodology, Validation, Investigation, Resources, Writing – original draft, Writing – review and editing, Visualization. C.D.: Methodology, Validation, Formal analysis, Writing – original draft, Writing – review and editing. E.N.: Methodology, Validation, Writing – original draft, Writing – review and editing. G.O.: Methodology, Validation, Writing – original draft, Writing – review and editing. A.L.: Methodology, Validation, Writing – original draft, Writing – review and editing. M.J.R.: Methodology, Formal analysis, Writing – original draft, Writing – review and editing. R.M.: Methodology, Writing – review and editing. D.S.: Resources, Data curation, Writing – original draft, Writing – review and editing. V.G.: Data curation, Writing – original draft, Writing – review and editing. E.D.C.: Methodology, Formal analysis, Data curation, Writing – original draft, Writing – review and editing, Supervision. All authors gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

Constanza Valdés reports Honoraria from Sanofi, GSK. María Jesús Rojas-Lechuga reports Grants or contracts from Instituto de Salud Carlos III, Hospital Clínic de Barcelona; Meeting/travel support from Aural. Ramón Moreno-Luna reports Consulting fees from GSK, SANOFI; Data safety/advisory board participation in European Rhinologic Society The authors declare no other conflicts of interest.