For David R. Friedland, MD, PhD, professor and vice-chair of otolaryngology and communications sciences at the Medical College of Wisconsin in Milwaukee, making initial oral steroid use optional is problematic, particularly when this practice is coupled with the other initial treatment that the panel rated as optional: hyperbaric oxygen (statement nine).
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June 2012“For the most part, hyperbaric oxygen is not used in the United States, and, for the most part, initial use of oral steroids is commonly used in this country,” he said. “To give those two treatments equal weight in a guideline is ignoring current practice and is not acknowledging the health care system in this country.”
The inclusion of hyperbaric oxygen as optional initial therapy was also highlighted by two other sources weighing in on these guidelines. John C. Li, MD, an otologist, neurotologist and otolaryngologist in private practice in Jupiter, Fla., said that he was surprised by the inclusion of hyperbaric oxygen because it is not commonly available and can be very expensive. He has seen costs billed to insurance companies as high as $2,300 per session.
“I personally have not had much luck with hyperbaric oxygen therapy,” Dr. Li added, noting that he no longer uses it based on the poor cost-benefit ratio.
Similarly, Lorne S. Parnes, MD, professor of otolaryngology at the University of Western Ontario, London Health Sciences Centre, London, Ontario, said that “emphasizing hyperbaric oxygen therapy was a disservice, as it is extremely costly and not available in most centers.” He also said it was an oversight of the guidelines panel to leave out a recommendation on the use of combined oral and IT corticosteroid therapy as an initial treatment.
Dr. Chandrasekhar acknowledged that hyperbaric oxygen is not widely used in the U.S., is not approved by the U.S. Food and Drug Administration for use as initial steroid therapy for SHL and is very costly. However, she said that it was included as optional initial therapy for SHL in these guidelines because of its wide use outside the U.S. and evidence from trials that support its use.
According to Dr. Stachler, no one expected to find support for hyperbaric oxygen as an initial option for treatment, but the evidence from overseas could not be ignored.
Salvage Intratypanic Steroids
According to Dr. Friedland, statement nine, which recommends the use of intratympanic (IT) steroids as salvage, is questionable. It doesn’t make sense to say that initial therapy with oral steroids is optional but that IT steroids as salvage is recommended, he said.