04 March 2010

But ... steroids fix everything!

RCentor has an interesting article on Sore Throats and Pharyngitis over at MedRants.  He writes:
There is a new trend in pharyngitis that has taken hold amongst emergency physicians – the use of steroids to provide symptom relief.
I too have noticed this, and I completely agree with Dr Centor that while this is a highly effective treatment, it needs to be used with some caution.  For our practice, this has been pushed by the ENTs.   It has been our experience that when we see someone with a really bad sore throat or even with a peritonsillar abscess, 100% of the time the instruction from the ENTs has been to administer steroids.  While the data is underwhelming (pain relief on average six hours quicker with steroids), the truth is that for a really bad case of tonsillitis, steroids work.  I'm not meaning the average case of strep, mind you, but rather the muffled-voice cases where the patient is so bad that they can't take any fluids and you are worried about the integrity of their airway.  You give these cases a whopping dose of whatever steroid you like and BAM, like magic the tonsils shrink down and the patient feels a million times better.

How can we ER docs -- suckers for immediate gratification -- possibly be expected to resist such a magical therapy?

Dr Centor worries about masking complications of pharyngitis (specifically his pet disease Lemierre's); I worry more about masking the more common complications -- like the peritonsillar abscess.  Let me recount a cautionary tale.  A couple of years ago, on an Wednesday evening shift, I saw a young man with a peritonsillar abscess.  It was pretty obvious on exam, but the patient looked OK.  A CT confirmed the presence of a small-to-medium sized abscess which would need to be drained surgically.  In our ER, this is usually done by the ENT surgeons -- though we ER docs are trained to drain them, it's just worked out that ENT has been deemed to "own" throat pus, the lucky duckys.  So I call the ENT and we reviewed the CT together. Unfortunately, he was unable to come in and do the procedure in a timely manner.  I forget why, maybe he was in a big case at the other hospital, but it was a legitimate reason.  So we agreed that since the patient looked good (meaning specifically his airway was in no jeopardy) that I would give him a dose of steroids and the ENT would drain it in the office first thing in the morning.

Seemed reasonable.

So I was surprised to see the patient back in the ER at 8AM on Friday with persistent and worsening symptoms.  He had not had the I&D of the abscess! I called the ENT guy, who explained that he had in fact seen the patient as planned, but the swelling in his throat had gone down so dramatically that he decided the drainage of the abscess was no longer necessary.  This is not as insane as it sounds.  It can be hard to really tell the difference between pus and a phlegmon on a CT scan, and while pus needs to see the light of day, a phlegmon will often resolve when treated with antibiotics and steroids.  But this was pretty clearly an abscess on the scan, so he should have drained it when he saw the patient.

Ultimately it was a happy ending -- the surgeon came in and took excellent care of the patient and he did fine.  But the point raised by Dr Centor is apt: in this case the surgeon deluded himself that the pus had gone away based on the steroid effect, and the patient wound up with a delayed operation.  This is a case, bear in mind, where the abscess had already been diagnosed.  What happens when the abscess is missed or not apparent on the initial presentation?  You treat with steroids, the patient shows initial improvement, and then gets worse again later.  While it's true that peritonsillar abscess have a very low morbidity and mortality, it's not zero.  If we start indiscriminately giving steroids to patients with pharyngitis, will we wind up seeing more abscesses or worse complications?  Or is it possible that steroid treatment will reduce the inflammation and resolve early phelgmons resulting in fewer abscesses?  I don't know.  More research is needed, but it's going to be difficult to get good data on this, given that the development of complications from exudative pharyngitis is an uncommon event, and even more uncommon to develop complications after the initial presentation.  It seems like all of my peritonsillar abscesses are diagnosed on the initial presentation -- it's rare to see someone with an abscess who had already been on antibiotics.

So how do I approach this?  I do give steroids for some cases of pharyngitis, but only bad cases where a) I am comfortable that there is no surgical pathology and b) the patient has excellent follow-up and is reliable or c) the patient is being admitted.  It's a great tool, but one to be used with caution, in my view.

And I'm gratified to see that Dr Centor agrees with me.  As he should.

5 comments:

  1. I've been seeing a lot of orders for nebulized lidocaine lately for cough/throat pain.

    ReplyDelete
  2. Seen some scary rebound from racemic epinephrine too.

    ReplyDelete
  3. There is an article that has been passed around by our ENTs regarding using steroid + abx + toradol for abscess as an alternative to drainage. It require good OP followup in case of treatment failure, but it seems to work.

    In my world, only ENTs drain them and we don't have coverage and no one will accept our transfers (turns out that the basic ENT curriculum doesn't have a section on EMTALA). So medical management seems to be a good choice for us.

    ReplyDelete
  4. Shadow interesting post. For what it is worth I'll share my practice:

    At my very rural ED we see a ton of peritonsillar abscesses (on the order of 1 every 2-3 shifts). We also do not have any ENT (our pts have to fly 400 miles to see ENT unless it is one of 2 very special days every quarter when they are on site). As such I drain a lot of these on my own. (in case your interested I use an 18 gauge needle with a protector guard so it can only go in about 1 cm - my record is 18 ml of pus). I usually find that most people have significant enough trismus that I can't even get a good view initially. As such I usually start them off with Morphine 5 mg, 1-2 L of NS, and clinda 900mg. After reading an article about steroids in pharyngitis about 2 yrs ago and talking to ENT, I have now added Decadron 10 mg to this initial cocktail. Anecdotally I have seen excellent results. Typically about 1 hr after the "cocktail" I can return to the room and get a much better view. This usually results in a subsequent aspiration. If anything looks more abdnormal than a typical peritonsillar abscess or the pt looks toxic then they get a CT and I talk with ENT. These pts tend to have more swelling, extension to the the skin, and/or torticollis. They also generally tend to be children. We have only had access to CT over the last year or so so this is actually a new addition to my practice. Most of the pts I aspirate I send out and have them followup with PCP or the ER in 8 hrs. At that point some may need a repeat dose of clinda or simply a change to orals. I may also elect to use Bicillin at initial visit but most of these pts seem to already have been treated with bicillin/Pen VK before they see me.

    This is unlikely to be a national standard of care, but it is certainly our local standard and it has worked well for us. It has kept our ENTs happy (they are a precious resource in our neck of the woods) and we have not had any bad outcomes. I should stress though that we are very selective and anything that seems iffy gets scanned and sent. I have sent 2 such cases to ENT in the last 2 weeks, a 9yo and 3yo. Furthermore I do not routinely use steroids for simple pharyngitis. I will use it on occasion if a pt has such discomfort that they can not drink and are clearly dehydrated. I'd love to hear any feedback.
    As always excellent posting, please keep it up.

    ReplyDelete