Corticosteroid Confusion: Evidence lacking for most conditions, panelists say

The catch, he said, is one study, included in the AAO-HNS guidelines, that has given many otolaryngologists concern about the safety of steroid use in this setting.

The 2008 study, which included 215 pediatric patients, found an increased risk of postoperative bleeding in children treated with steroids during tonsillectomy (JAMA. 300(22):2621-2630). “When we looked at this study, it gave a lot of us pause because many of us are using steroids, and the question is whether steroids actually put our children at risk for postoperative hemorrhage,” he said.

Because of the confusion and concern generated by this study, Dr. Hartnick and his colleagues are conducting a study looking primarily at the risk of bleeding with steroid use in tonsillectomy. To date, the study has accrued 285 patients out of a goal of 320 patients. “We are looking at all levels of bleeding,” he said, “and hope to have an answer soon.”

Peritonsillar Abscess, Infectious Mononucleosis, Sinus Surgery

Judith Lieu, MD, assistant professor of otolaryngology-head and neck surgery at Washington University in St. Louis, Mo., walked participants through some of the evidence on steroids for peritonsillar abscess, infectious mononucleosis and sinus surgery.

Citing a study (J Laryngol Otol. 2004;118(6):439) that showed that a single intravenous dose of dexamethasone in patients with peritonsillar abscess reduced fever, aided in a return to normal swallowing, reduced trismus and decreased number of days in the hospital, she emphasized that the protocol used in this Turkish study differed from that typically used in the U.S. Before she could recommend steroid use in this setting, she said, a study is needed that more closely mirrors what is done in the U.S.

For infectious mononucleosis, Dr. Lieu focused on an updated Cochrane Review (Cochrane Database System Rev. 2011;(4):DOI:CD004402) that included seven randomized trials, including over 300 children and young adults, and evaluated the safety and efficacy of steroids. The study did not recommend the use of steroids in these patients based on insufficient evidence on symptom control. One major problem with the study, she said, was the exclusion of patients with airway obstruction.

Based on this study, steroids would not be recommended, she said, adding, “However, the main concern for most otolaryngologists is airway compromise, and that particular outcome has not been studied.”

Finally, Dr. Lieu discussed a number of studies that looked at topical and systemic steroids for perioperative and postoperative functional endoscopic sinus surgery (FESS). (See “Studies of Steroid Use and FESS,”)