Oral Steroids No Help in Sinus Infections?

Media outlets such as Fox News reported yesterday that oral steroids do not help with sinus infections. This claim is based on a small study of 174 patients with clinical symptoms of an acute sinus infection and given either 30 milligrams per day of prednisolone or placebo pills for one week. Of note, antibiotics were not given.

No significant difference in symptom resolution was found.

Now why would one even think to give oral steroids for sinusitis in the first place?

Steroids decrease inflammation and swelling which theoretically would allow for the sinuses to drain more easily and effectively therefore expediting sinusitis resolution.

Also, there have been studies that suggest steroid nasal sprays do help with resolve sinusitis to a certain extent.

Keep in mind that steroids are NOT antibiotics and do not kill the germs that cause an infection. Furthermore, many viral upper respiratory infections are misdiagnosed as sinus infections.

What this study suggests is that at least for acute sinusitis, oral steroids alone do not help resolve an acute sinus infection.

HOWEVER, keep in mind that oral steroids have been shown to help with nasal polyps and chronic sinus infections when given in the setting of antibiotics and sinus surgery.


Source:
Oral steroid doesn't clear up sinus infections. Fox News 8/7/12

References:
Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial. CMAJ August 7, 2012 First published August 7, 2012, doi: 10.1503/cmaj.120430

Chronic rhinosinusitis: epidemiology and medical management. J Allergy Clin Immunol. 2011 Oct;128(4):693-707; quiz 708-9. Epub 2011 Sep 3.

Treatment outcomes and predictors for systemic steroids in nasal polyposis. Acta Otolaryngol. 2012 Jun;132 Suppl 1:S82-7.

Intranasal Corticosteroids in Management of Acute Sinusitis: A Systematic Review and Meta-Analysis Ann Fam Med May/June 2012 vol. 10 no. 3 241-249

TV Show SMASH Portrays Ivy With Vocal Issues

In last night's episode (Episode 106: Chemistry) of the new hit TV drama SMASH, the main character Ivy who plays Marilyn Monroe in the show developed laryngitis that affected her ability to sing clearly, especially in the high registers. However, her speaking voice did sound normal.

To treat this condition, she was given prednisone which did help her voice, but suffered unfortunate side effects of mood lability, hallucinations, insomnia, etc.

Did the show accurately portray what actually happens in real life?

Yes...

Laryngitis

Ivy probably did suffer laryngitis, but more in the sense of pre-nodule formation (otherwise known as vocal cord swelling) from vocal overuse given how much singing she has been doing. With such "pre-nodule" formation, the singer is able to sound perfectly normal when talking, but suffers from pitch breaks and onset delays in the high range, especially when singing quietly. Watch a video and audio demonstrating this phenomenon.

I should also point out that this problem is also under-recognized by medical professionals including ENTs... When such singer/patients with vocal cord swelling present complaining of hoarseness, they sound normal... talk normal... and for all intensive purposes seem to be making up their perceived raspy voice.

A simple test to demonstrate vocal cord swelling is to have the singer sing a song at a high pitch (octave above middle C), but to sing the song very quietly. I typically have patients sing Happy Birthday. Listen for any vocal quality problems.

Even though the vocal issue is only in the high range, for professional (and amateur) singers, such "minor" vocal raspiness is a HUGE problem. Consider this... if this patient is singing a solo for a performance where there's several hundred people in the audience... it's hard enough to sing a solo just from nervousness. Now add the concern that you have no idea what your voice is going to do in that one part of the song where it goes high. Confidence is key to a good performance and with an undependable voice, confidence is lost and the performance overall suffers.

Prednisone

Is prednisone really as good as the show suggests? Yes... including the side effects, though they did stretch the side effects some.

Typically steroids provide almost immediate (within 4-12 hours) resolution of vocal cord swelling and inflammation. Problem is, it only works for a short period of time.

I typically prescribe decadron rather than prednisone as I feel it works faster, better, and more reliably than prednisone. I also prescribe it judiciously.

Judiciously means I prescribe it if there's a single major concert or single audition that is very important to the singer. I typically prescribe a single large dose to be taken the night before.

If it is a singer who is undergoing a series of auditions over a short period of time, I may prescribe a week long course of steroids to maintain its good effects.

The USUAL common side effects are reflux, insomnia, mood lability, and jitteriness. However, for those who are sensitive to medications can suffer many of the side effects experienced by Ivy.

NOW... for the problem with steroids beyond the side effects... Its effects are temporary and the better way of treating vocal cord swelling is behavioral changes as one can't just keep prescribing steroids indefinitely. It is much like giving morphine to a football player to mask the pain of a sprained ankle so he can still keep playing football. MORE vocal injury can occur while taking the steroids!

With steroids, I usually also recommend restricted voice use (strict voice use is even better). What this means is talk ONLY when you MUST talk and with low energy if you do. NO social talking, no whispering, no yelling, no raising voice, etc. Strict voice rest is when you are not even talking at all.

Also, work with a singing voice therapist.

New Webpage on Facial Paralysis

Our office has produced a new webpage on the evaluation and management of facial paralysis without any other symptoms.

Click here to read more about this condition.