Oral corticosteroid use and the risk of developing avascular necrosis; a large retrospective review

INTRODUCTION

The risk of adverse events, specifically avascular necrosis (AVN), associated with corticosteroid use is not well reported. The aim of this study was to evaluate the prevalence of AVN among patients with prior oral corticosteroid administration.

METHODS

An institutional database query recognized 113,734 adult patients with oral corticosteroid administration between 2006 and May 2017. A temporal query performed on this cohort determined that 789 had a diagnosis of AVN following oral corticosteroids. A retrospective review was performed on this cohort. Data collected included demographics, co-morbidities, date of initial oral corticosteroid exposure, and time-to-diagnosis of AVN. Records without radiographic confirmation of AVN were excluded from analysis. Patients with cumulative lifetime dosages greater than 10,000 mg prednisone were excluded from analysis.

RESULTS

789 patients with oral corticosteroid use prior to diagnosis of AVN were identified. 572 patients were excluded due to insufficient documentation of oral corticosteroid dosage, no radiographic evidence supporting the diagnosis of AVN, insufficient data confirming the temporal relationship between oral corticosteroids and AVN, and/or a cumulative dosing of > 10,000 mg prednisone. This left 217 patients included in the analysis. The mean duration of use prior to diagnosis of AVN was 219 (± 374) days and mean cumulative dose was 3314 (± 2908) mg prednisone-equivalents. Mean time between diagnosis of AVN and onset of pathologic fracture was 379 (± 1046) days.

CONCLUSION

For patients receiving low cumulative doses of oral corticosteroids, corticosteroids pose a small risk of development of AVN. More studies are required to better characterize risk. This article is protected by copyright. All rights reserved.

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

OBJECTIVE

To review the literature on corticosteroid use and provide recommendations on patient counseling and/or consent to promote judicious prescribing and reduce the incidence of corticosteroid-related lawsuits.

METHOD

A conventional literature search of PubMed on corticosteroid-related medicolegal cases was undertaken. Search terms included "medicolegal," "otolaryngology," and "adrenocorticosteroids." A medical subjects headings search with the keywords "adrenal cortex hormones" and "jurisprudence" was also performed.

RESULTS

Corticosteroids have been reported as the third most frequent medication involved in malpractice claims, oftentimes leading to disproportionately costly payments. The most common specialties found to be involved in corticosteroid related medicolegal cases included dermatology (12%), primary care (10%), and neurologists or neurosurgeons (6%). The most common complications encountered were avascular necrosis (39%), changes in mood (16%), infection (14%), and vision changes (14%). Only a few cases corticosteroid-related litigation regarding otolaryngologists were identified. More frequent causes for otolaryngology claims were intraoperative complications, deficits in diagnoses, and failures or delays in treatment. Three medicolegal pitfalls regarding corticosteroid use were identified from this review included: (1) insufficient advising, (2) lack of or incomplete informed consent, and (3) the significance of the patient-physician relationship.

CONCLUSION

Despite the scarcity of corticosteroid-related medicolegal literature pertaining to otolaryngologists, corticosteroids are one of the most widely prescribed medications in the field of otolaryngology and have been shown to have a high rate of medical malpractice claims in medicine. Counseling and consenting the patient, as well as developing a strong physician-patient relationship, are integral processes in addressing any adverse effects occurring during therapy, and may also help to decrease the incidence and success of litigation against otolaryngologists.

Topical Steroid Drops for the Treatment of Sinus Ostia Stenosis in the Postoperative Period

Background

Chronic oral steroid use causes significant morbidity, including osteoporosis, immunosuppression, and adrenal insufficiency. Refractory chronic rhinosinusitis patients often take repeated oral steroid courses to treat polypoid disease or sinus ostia stenosis. This study evaluated topical steroid drop efficacy in treating recurrent sinus ostia stenosis in the postoperative period.

Methods

The 5-year single institution experience with topical steroid drop use after endoscopic sinus surgery (ESS) was evaluated by retrospective review. Patients were included if they began topical dexamethasone ophthalmic, prednisolone ophthalmic, or ciprofloxacin/dexamethasone otic intranasally (used off-label) within 3 months after ESS. Outcomes (i.e., ostia patency, oral steroid use, revision surgery, and complications) were assessed for a 6-month period after steroid drop initiation.

Results

Thirty-six patients met inclusion criteria. Forty-four surgeries were performed during the study period; 67 sides were treated postoperatively with topical steroid drops. In 86.6% of cases, steroid drops were used to treat frontal ostium stenosis or frontal recess edema; 93.2% of surgeries were revision procedures. Sixty-four percent of sinuses were treated successfully with topical steroid drops, 14.9% remained stable, and 20.9% failed. Reasons for failure included persistent/worsening edema, scarring, or noncompliance. Ten patients (27.8%) required oral steroids and 4 patients (6%) underwent revision surgery during the study period. One case of adrenal suppression occurred.

Conclusion

Topical steroid drops are beneficial in preventing sinus ostia stenosis in the postoperative period and may decrease the propensity toward repeated oral steroid therapy. This is particularly noteworthy in this challenging cohort, largely composed of revision frontal sinus surgery patients.

Hydrocortisone relieves the immediate post-operative scrotal edema after inguinal varicocelectomy: A prospective clinical trial

This study aimed to assess the effect of a single IM injection of hydrocortisone succinate in relieving the immediate post-varicocelectomy scrotal edema. In all, 117 patients with grades II and III varicocele who developed post-varicocelectomy scrotal edema were randomly classified into group A (n = 59) that received a single IM hydrocortisone sodium succinate injection plus ordinary post-operative treatment and Group B (n = 58), which received the post-operative treatment alone. All patients were followed up to assess; changes in scrotal edema, the day of return to work and emergence of complications. Post-operative scrotal edema was assessed using a scrotal edema rating grades (SERG = 0-3) score. In group A, scrotal edema disappeared 1 day after steroid injection in 33 patients (55.9%), and after 2 days in the remaining 26 patients (44.1%), and all patients were returned to work within 5-7 days. In group B, the edema remained large in 36 patients (62.1%), moderate in 22 patients (37.9%), and disappeared after 9-12 days; and those patients returned to work within 11-13 days. It is concluded that a single IM hydrocortisone injection could be effective to reduce the immediate post-operative scrotal edema after inguinal varicocelectomy without obvious side effects.

Intratympanic Steroids for Idiopathic Sudden Sensorineural Hearing Loss

Objectives:

We undertook to evaluate the effectiveness of intratympanic (IT) steroid injections for treating idiopathic sudden sensorineural hearing loss (ISSHL) by performing a retrospective case series study in a private otology practice.

Methods:

A total of 21 eligible patients with ISSHL were included. We defined ISSHL as a hearing loss of 20 dB or more at at least 3 consecutive audiometric frequencies that develops within 72 hours or less and cannot be attributed to any commonly identifiable cause of sudden hearing loss. Three IT injections of 0.4 mL of 62.5 mg/mL methylprednisolone solution were administered 1 week apart. The end point for the study was a clinically significant change in audiometric values, with a positive response determined to be a 10-dB or greater improvement in the 4-tone pure tone average and/or a 15% or greater improvement in the word discrimination score. Audiometric data were recorded just before therapy and 1 week after the last IT treatment. The potentially confounding variables recorded included age, sex, “prompt treatment” (defined as treatment within 14 days from onset), concurrent or prior treatment with oral steroids, and severity of hearing loss.

Results:

The overall response rate to the IT steroid protocol was 67% (14 of 21 patients), with a 95% confidence interval of 43% to 85%. Backward stepwise logistic regression identified “prompt treatment” as the only variable that significantly affected the outcome. The response rate of the “prompt treatment” cohort was 91% (10 of 11 patients), with a 95% confidence interval of 59% to 100%.

Conclusions:

These findings support the use of IT steroids as an early intervention in the treatment of ISSHL.

Does systemic steroid deficiency affect inner ear functions?

PURPOSE

Today corticosteroids are employed for the treatment of various inner ear disorders. In this study we have investigated probable changes in hearing functions resulting from a deficiency of systemic steroid secretions.

MATERIALS AND METHODS

Twenty four healthy female rats were used in our study, allocated into three groups (medical adrenalectomy, medical adrenalectomy+dexamethasone, no treatment). Audiological evaluations were conducted at the beginning of the study and on days 7, 14 and 21. Blood samples were taken at the beginning and at the end of the study and blood corticosterone levels were determined.

RESULTS

While there were no significant differences between the basal, 7th, 14th and 21st day DPOAE values of group 1, their ABR threshold values showed significant increases. In group 2, there were no significant differences between the basal, 7th, 14th and 21st day DPOAE values. ABR thresholds of group 2 showed significant increases on days 7 and 14 as compared to their basal values, but there were no significant differences between the 21st day and basal ABR threshold values. There were no significant differences between the basal cortisol levels of the three groups. The mean cortisol level of group 1 on day 21 was found to be significantly lower than those of groups 2 and 3.

CONCLUSION

The results of the study demonstrated that there were no significant changes in DPOAE values with the cessation of cortisol secretion, while there was a progressive increase in ABR thresholds, which could be overcome with cortisone replacement.

Dexamethasone eluting cochlear implant: Histological study in animal model

OBJECTIVE

New cochlear implant (CI) designs and developments in implantation techniques have revolutionized the management of hearing loss. However, cochlear implantation still has some disadvantages, such as its potential to initiate an inflammatory response that may lead to further hair cell damage. Recent topics of investigation have been the effect of glucocorticoids on inflammatory tissue response reduction, glucocorticoid dosage levels, and drug-delivery methods. In the present study, dexamethasone delivery via a drug-eluting CI was evaluated histologically through assessing inflammatory cell infiltration.

METHODS AND MATERIALS

Thirty healthy, adult male guinea pigs were included and randomly assigned to one of three surgical groups that underwent cochleostomy of the basal turn. The experimental group (Group 1) of 12 animals were implanted with a dexamethasone-loaded silicone elastomer shaped like a CI electrode. The primary control group (Group 2) of 12 animals were implanted with a simple CI (non-eluting). A second control group (Group 3) of six animals underwent cochleostomy only. Inflammatory responses were compared between groups by evaluating inflammatory cell infiltration in inner-ear specimens at days 3 and 13.

RESULTS

The Mann‐Whitney test revealed reduction in most of the inflammatory indices in Group 1 compared with Group 2. This was significant for fibrocyte, macrophage, and giant cell infiltration at day 3 as well as lymphocyte, macrophage infiltration, and capillary formation at day 13.

CONCLUSION

This study showed some attenuation in inflammatory response following insertion of a dexamethasone-eluting CI, suggesting that it could be a route for local drug delivery into the cochlea.

Corticosteroid therapy for hearing and balance disorders

This review addresses the current status of steroid therapies for hearing and vestibular disorders and how certain misconceptions may be undermining the efficacy in restoring normal ear function, both experimentally and clinically. Specific misconceptions addressed are that steroid therapy is not effective, steroid-responsive hearing loss proves an underlying inflammatory problem in the ear, and steroids only have application to the hearing disorders listed below. Glucocorticoid therapy for hearing and balance disorders has been employed for over 60 years. It is recommended in cases of sudden hearing loss, Meniére's disease, immune-mediated hearing loss, and any vestibular dysfunction suspected of having an inflammatory etiology. The predominant steroids employed today are dexamethasone, prednisone, prednisolone, and methylprednisolone. Despite years of use, little is known of the steroid responsive mechanisms in the ear that are influenced by glucocorticoid therapy. Furthermore, meta-analyses and clinical study reviews occasionally question whether steroids offer any benefit at all. Foremost in the minds of clinicians is the immune suppression and anti-inflammatory functions of steroids because of their efficacy for autoimmune hearing loss. However, glucocorticoids have a strong binding affinity for the mineralocorticoid (aldosterone) and glucocorticoid receptors, both of which are prominent in the ear. Because the auditory and vestibular end organs require tightly regulated endolymph and perilymph fluids, this ion homeostasis role of the mineralocorticoid receptor cannot be overlooked in both normal and pathologic functions of the ear. The function of the glucocorticoid receptor is to provide anti-inflammatory and antiapoptotic signals by mediating survival factors.

Effect of intratympanic dexamethasone, memantine and piracetam on cellular apoptosis due to cisplatin ototoxicity

OBJECTIVE

This study aimed to contribute to the literature on the prevention and treatment of ototoxicity due to various drugs and chemicals.

MATERIAL AND METHODS

This study compared the histological effects of intratympanic dexamethasone, memantine and piracetam on cellular apoptosis due to cisplatin ototoxicity, in 36 rats.

RESULTS

Dexamethasone and memantine had significant effects on the stria vascularis, organ of Corti and spiral ganglion (p < 0.05). Although piracetam decreased the apoptosis rate, this effect was not statistically significant (p > 0.05).

CONCLUSION

Dexamethasone and memantine were found superior to piracetam in reducing apoptosis due to cisplatin ototoxicity. Further studies of this subject are needed, incorporating electron microscopy and auditory brainstem response testing.

What rhinologists and allergists should know about the medico-legal implications of corticosteroid use: a review of the literature

BACKGROUND

Corticosteroids are a mainstay of treatment in the management of sinonasal inflammatory disease. Despite their common use, many practitioners are not well versed in their potential complications or the medico-legal ramifications of their use. The objectives of this review were to outline the existing data of the medico-legal implications of oral steroids.

METHODS

An OVID database search of the terms "corticosteroids OR adrenal cortex hormones" AND "medico-legal OR malpractice OR jurisprudence OR expert testimony OR informed consent" was performed. This search was then narrowed to English language articles and the titles and abstracts were searched for relevance.

RESULTS

The OVID search identified 178 articles. This search was then narrowed, resulting in 9 articles that were relevant and included in the current review. Five articles involved database reviews of litigation associated with medications. Steroids were found to be a common medication associated with litigation and the cost of the litigation involving steroid use can be very high. Common themes associated with the litigation include poor communication and lack of informed consent regarding steroid use. Several additional articles addressed single cases and many addressed lawsuit prevention.

CONCLUSION

Lawsuits associated with steroids are disproportionately costly and most of the allegations stem from a lack of informed consent over the use of steroids. Open dialogue with patients is the key to informed consent. Ideally, clinicians should discuss the rationale for steroid use, and the risks, expected benefits, and alternatives of the steroid therapy. Document this discussion and consider providing educational material for the patient to read and review.

Intratympanic injection of dexamethasone: time course of inner ear distribution and conversion to its active form

HYPOTHESIS

Intratympanically injected dexamethasone 21-phosphate is converted to its active form dexamethasone in the inner ear and follows the distribution of the glucocorticoid receptor.

BACKGROUND

Although dexamethasone is routinely delivered intratympanically for hearing loss, we know little of its inner ear pharmacokinetics. Dexamethasone 21-phosphate is the pharmaceutical compound available for injection, but it must be converted to its biologically active form (dexamethasone) to bind to the glucocorticoid receptor. Therefore, the current study was conducted to determine the time course of dexamethasone 21-phosphate movement from the middle ear into the inner ear, its conversion to dexamethasone, and the distribution of both forms relative to the glucocorticoid receptor.

METHODS

BALB/c mice were injected intratympanically with the prodrug dexamethasone 21-phosphate and inner ears collected at postinjection times ranging from 5 minutes to 7 days. Ears were immunohistochemically stained for dexamethasone 21-phosphate, dexamethasone, and the glucocorticoid receptor.

RESULTS

Both forms of dexamethasone were seen in the inner ear within 15 minutes, reaching their highest staining intensity at 1 hour. Neither drug was seen after 24 hours. The strongest staining occurred in the spiral ligament, organ of Corti, spiral ganglion, and vestibular sensory epithelia. Distribution of the drug paralleled locations of the glucocorticoid receptor except in the stria vascularis marginal cells, which stained heavily for the receptor but not the drug.

CONCLUSION

Dexamethasone rapidly travels from the middle ear into the inner ear and converts to its active form. The drug distribution follows that of the glucocorticoid receptor. However, it probably has little impact on ear tissues after 24 hours.

Local Dexamethasone Therapy Conserves Hearing in an Animal Model of Electrode Insertion Trauma-Induced Hearing Loss

HYPOTHESIS

The progressive loss of hearing that develops after electrode insertion trauma (EIT) can be attenuated by local dexamethasone (DXM) therapy.

BACKGROUND

Hearing loss (HL) that develops after cochlear implant EIT occurs in two stages in laboratory animals, that is, an immediate loss followed by a progressive loss. Direct infusion of DXM into the guinea pig cochlea can attenuate both ototoxin- and noise-induced HL.

MATERIALS AND METHODS

Auditory-evoked brainstem responses (ABRs) of guinea pigs were measured for 4 frequencies (i.e., 0.5, 1, 4, and 16 kHz) before, immediately after, and more than 30 days post-EIT for experimental (EIT,EIT + artificial perilymph, and EIT + DXM) and for the contralateral unoperated cochleae of each group. An electrode analog of 0.14-mm diameter was inserted through a basal turn cochleostomy for a depth of 3 mm and withdrawn. DXM in artificial perilymph was delivered immediately post-EIT into the scala tympani via a miniosmotic pump for 8 days.

RESULTS

The ABR thresholds of EIT animals increased progressively post-EIT. Contralateral unoperated cochleae had no significant changes in ABR thresholds. Immediately post-EIT, that is, Day 0, the DXM-treated animals exhibited a significant HL at 1, 4, and 16 kHz, but this HL was no longer significant by Day 30 compared with contralateral control ears.

CONCLUSION

The results from immediate local treatment of the cochlea with DXM in an animal model of EIT-induced HL suggest a novel therapeutic strategy for hearing conservation by attenuating the progressive HL that can result from the process of electrode array insertion during cochlear implantation.

Glucocorticoid impact on cochlear function and systemic side effects in autoimmune C3.MRL-Faslpr and normal C3H/HeJ mice

Glucocorticoids are effective in reversing hearing loss, but their severe side effects limit long term management of many ear disorders. A clearer understanding of these side effects is critical for prolonged therapeutic control of hearing and vestibular dysfunction. Therefore, this study characterized the impact of the glucocorticoid prednisolone on cochlear dysfunction and systemic organ systems in C3.MRL-Fas(lpr) autoimmune mice and their normal C3H/HeJ parent strain. Following 3 months of treatment, autoimmune mice had better auditory thresholds and improved hematocrits, anti-nuclear antibodies, and immune complexes. Steroid treatment also lowered body and spleen weights, both of which rise with systemic autoimmune disease. Steroid treatment of the normal C3H/HeJ mice significantly elevated their blood hematocrits and lowered their body and spleen weights to abnormal levels. Thus, systemic autoimmune disease and its related hearing loss in C3.MRL-Fas(lpr) mice are steroid-responsive, but normal hemopoiesis and organ functions can be significantly compromised. This mouse model may be useful for studies of the detrimental side effects of steroid treatments for hearing loss.

Mineralocorticoid receptor mediates glucocorticoid treatment effects in the autoimmune mouse ear

The standard treatment for many hearing disorders is glucocorticoid therapy, although the cochlear mechanisms involved in steroid-responsive hearing loss are poorly understood. Cochlear dysfunction in autoimmune mice has recently been shown to be controlled with the mineralocorticoid aldosterone as effectively as with the glucocorticoid prednisolone. Because aldosterone regulates sodium, potassium, and other electrolyte homeostasis, this implied the restoration of hearing with the mineralocorticoid was due to its impact on cochlear ion transport, particularly in the stria vascularis. This also suggested glucocorticoids may be controlling hearing recovery in part through their binding to the mineralocorticoid receptor in addition to their glucocorticoid receptor-mediated anti-inflammatory and immunosuppressive functions. Therefore, the aim of the present study was to better delineate the role of the mineralocorticoid receptor in steroid control of hearing in the autoimmune mouse. Spironolactone, a mineralocorticoid receptor antagonist, was administered to MRL/MpJ-Fas(lpr) autoimmune mice in combination with either aldosterone or prednisolone to compare their hearing and systemic disease with mice that received either steroid alone. ABR thresholds showed either aldosterone or prednisolone alone preserved hearing in the mice, but spironolactone prevented both steroids from maintaining normal cochlear function. This suggested both steroids are preserving hearing through the mineralocorticoid receptor within the ear to regulate endolymph homeostasis. The spironolactone treatment did not block normal glucocorticoid receptor-mediated immune-suppression functions because mice receiving prednisolone, either with or without spironolactone, maintained normal body weights, hematocrits, and serum immune complexes. Thus, reducing systemic autoimmune disease was not sufficient to control hearing if mineralocorticoid receptor-mediated functions were blocked. It was concluded the inner ear mineralocorticoid receptor is a significant target of glucocorticoids and a factor that should be considered in therapeutic treatments for steroid-responsive hearing loss.

Dexamethasone inner ear perfusion by intratympanic injection in unilateral Ménière's disease: a two-year prospective, placebo-controlled, double-blind, randomized trial

OBJECTIVE

To investigate the efficacy of dexamethasone inner ear perfusion by intratympanic injection in hearing loss, tinnitus, aural fullness, and vertigo in the treatment of unilateral Ménière's disease and compare it with the control group.

STUDY DESIGN AND SETTING

A prospective, randomized, double-blind study with 2-year follow-up comparing changes secondary to dexamethasone inner ear perfusion versus placebo consisting of saline solution.

PATIENTS

Twenty-two patients having definite Ménière's disease as outlined by the 1995 American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium. All the patients were older than 18 years of age and were not receiving any other form of treatment with steroids for their Ménière's disease.

METHOD

Five consecutive daily intratympanic injections of dexamethasone or placebo to the involved ear.

RESULTS

In the dexamethasone group at 2-year follow-up, complete control of vertigo (class A) was achieved in 9 of 11 patients (82%) and substantial control of vertigo (class B) in the remaining 2 patients (18%.) In the control group only 7 of 11 patients (64%) finished the 2-year follow-up because in the other 4 patients (36%) we had to give another treatment for the continuing vertigo and thus they were classified as failure (class F.) From the 7 patients who have finished the follow-up of 2 years in the control group, 4 patients (57%) achieved class A, 2 patients (29%) achieved class C, and 1 patient (14%) class F.

CONCLUSIONS

Dexamethasone (4 mg/mL) inner ear perfusion in a group of patients with unilateral Ménière's disease (Shea's stage III) showed 82% of complete control of vertigo over placebo (57%). There was also a subjective improvement in tinnitus (48%), hearing loss (35%), and aural fullness (48%) in the dexamethasone group compared with 20%, 10%, and 20% respectively in the control group.

Understanding the nasal airway: principles and practice

LEARNING OBJECTIVES

After studying this article, the reader should be able to: 1. Describe the soft-tissue, cartilaginous, and bony anatomy of the nose. 2. Describe the anatomy and function of the nasal valves. 3. Discuss the governing physiologic principles responsible for airflow dynamics. 4. Discuss the various functions of the nose. 5. Demonstrate an appropriate evaluation of the nasal airway. 6. Discuss the differential diagnosis of nasal obstruction. 7. Discuss appropriate management options for nasal airway obstruction. The nose is a complex, multifunctional organ that requires respect and understanding from the rhinoplasty surgeon. The etiologic and pathologic characteristics of each patient's nasal airway problem determine the treatment of the nasal airway. Frequently, medical management is sufficient without operative intervention. Recent advances have shown that nasal valves in airway patency may play a more important role than the septum. The rhinoplasty surgeon's understanding of the anatomy and physiology of the nasal airway, along with the causes of obstruction, can pave the way for a proper evaluation and appropriate management of nasal airway problems. Lack of understanding can result in misdiagnosis and mismanagement. This article outlines current concepts of medical and surgical management of nasal airway problems and discusses in detail the key concepts and principles in the practical management of the nasal airway.

A review of perioperative corticosteroid use in dentoalveolar surgery

OBJECTIVES

Dental surgeons are often advised to use corticosteroids during and after third molar removal and other dentoalveolar surgery to reduce postsurgical edema, but recommendations for use are rarely accompanied by definitive guidance regarding the type of steroid, dosage, or duration of administration. Many regimens in use appear to be based on anecdotal information from articles in the 1960s and 1970s and might be subtherapeutic. Few regimens have been updated with data from more recent studies, and well-designed comparison studies are lacking.

STUDY DESIGN

In this article, the literature from the past 30 years is reviewed, meaningful findings are highlighted, and available data are used as a basis for formulating interim clinical recommendations for corticosteroid use pending the emergence of more evidence-based data. A meta-analysis of data was not performed.

RESULTS

Recent data suggest that perioperative corticosteroid regimens should be administered in higher doses and for longer durations than recommended in the past and should be started before surgery for optimum benefit.

CONCLUSIONS

Based on the literature review, interim recommendations for the use of corticosteroids are proposed, including dosages and regimens that appear rational for oral, intramuscular, or intravenous corticosteroid administration before and after extractions and other dentoalveolar surgery. These largely empiric recommendations might require adjustment when evidence-based data become available in future studies. There is a great need for well-designed clinical research to further evaluate protocols for corticosteroid use.

Transtympanic dexamethasone application in Ménière's disease: an alternative treatment for intractable vertigo

The aetiology of Ménière's disease still remains unknown and its therapy is therefore empirical. As a result of immunological abnormalities demonstrated, steroids are commonly used in Ménière's disease. The place of topical steroids is still controversial. In this investigation topical dexamethasone is applied for three months through a ventilation tube in patients with intractable vertigo. The results showed that this treatment controls vertigo in 72 per cent of cases. No patient was worse than before treatment. Only in 17 per cent of the patients was there an increase in hearing level. When compared to the reports which used only tympanostomy tubes, this procedure seems to have a placebo effect with minimal harmful effects. It appears that transtympanic dexamethasone application is a good alternative to vestibular nerve section. Topical treatment may be sufficient in most patients. Systemic treatment may be used in patients where topical treatment fails.

The Medical Management of Rhinosinusitis

The management of rhinosinusitis depends on a number of variables related to the duration and severity of symptoms in the individual patient. Furthermore acute rhinosinusitis is managed differently than chronic rhinosinusitis. Because a variety of conservative and pharmacologic interventions are available, the physician can find it difficult to develop a cohesive and logical approach to treatment. An understanding of the pathophysiology, microbiology, and natural history of rhinosinusitis is necessary to formulate the best treatment plan for the individual patient.