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 ); 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 called 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 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.