“Biologically, it is not consistent. Why would a steroid work a month later and not immediately?” he said. He added that his main contention is the different level of ratings given, with the weaker optional rating for initial steroid use and the stronger recommended rating for IT salvage steroids. He questioned the strength of the evidence for IT steroids, saying that the evidence is “extremely poor.”
Explore this issue:June 2012
“The issue I have for this particular recommendation is that most of the studies that showed an effect or improvement with IT salvage steroids only showed an improvement of about 12 decibels on average,” he said. “I don’t think that is clinically significant to warrant such a strong recommendation for using IT salvage steroids for treatment of [sudden hearing loss].”
He also emphasized that the use of IT steroids as salvage is not current standard practice, which means that the guidelines, if followed, will change current practice. He cautioned that this may be a difficult recommendation for private practitioners to follow because many are not trained in or comfortable with using IT steroids, or for those who are not able to get adequate preparations.
Dr. Chandrasekhar, who said that others have also expressed concern over the perceived inconsistency between the statement that initial oral steroid use is optional but salvage IT steroids are recommended, said the guidelines are evidence-based and that readers need to read the guidelines from a scientific perspective.
“The data is very compelling for salvage IT steroids,” she said. “This makes sense clinically. The reality is we see people all the time who come to us after they’ve received a treatment for a diagnosis they don’t have, or who have received insufficient steroid treatment or who have not responded to appropriate treatment, and then we treat with salvage IT.”
She also said that offering IT steroids is well within the parameters of what general otolaryngologists do and emphasized that she trains many otolaryngologists every year in the use of this procedure during her course on sudden hearing loss at the annual AAO-HNS meeting. Otolaryngologists who are not comfortable doing this procedure or those who don’t have access to the necessary preparations can refer patients to a trained specialist, she said.
In addition, she said that discussion of this option is recommended based on the current evidence, but nothing in the guidelines prevents any physician from exercising his or her educated, clinical judgment.