Medicolegal Considerations Regarding Steroid Use in Otolaryngology: A Review of the Literature

Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians

OBJECTIVE

To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders.

DATA SOURCES

PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines.

REVIEW METHODS

A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings.

CONCLUSIONS

Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss.

IMPLICATIONS FOR PRACTICE

Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

Complications of Corticosteroid Therapy: A Comprehensive Literature Review

Relevance to Patient Care and Clinical Practice: Corticosteroids are among the most prescribed medications, particularly during the COVID-19 era. The literature has clearly highlighted the dangers of prolonged, high-dose corticosteroid use, which is important for clinicians to consider before treating patients in their clinical practices. Objective: The objective of this article is to review the literature on complications of corticosteroid use, review corticosteroid pharmacokinetics, and provide an updated reference on risks associated with corticosteroid therapy, especially at higher doses. Data Sources: A conventional literature search of PubMed was conducted without restrictions on publication date. Search terms included "corticosteroids," "avascular necrosis," "gastrointestinal bleeding," and "complications." Study Selection and Data Extraction: Pertinent systematic review/meta-analyses and randomized controlled trials were reviewed for study inclusion. Data Synthesis: Corticosteroids were associated with complications including avascular necrosis, gastrointestinal bleeding, myocardial infarction, heart failure, cerebrovascular events, diabetes mellitus, psychiatric syndromes, ophthalmic complications, tuberculosis reactivation, and bacterial sepsis. Increased daily and cumulative doses were associated with increased excess risk of complications. Cumulative doses greater than 430 mg prednisone equivalent were shown to increase the excess risk of avascular necrosis, with progressively higher rates with higher doses. Risk of gastrointestinal bleeding was significantly increased with corticosteroid usage in the in-patient but not out-patient setting. Conclusion: Since corticosteroids have been associated with the aforementioned severe complications and frequent medicolegal malpractice claims, counseling and informed consent should be performed when prescribing moderate-high dosages of corticosteroids. Further research is needed to characterize the long-term effects of corticosteroid usage in COVID-19 patients.