Role of Steroids in otolaryngology

Dr T Balasubramanian

Introduction

Corticosteroids are small lipophilic molecules

These molecules readily diffuse across cell membrane into the cytoplasm

Inside the cytoplasm these molecules bind to the corticosteroid receptors present there.

The steroid-receptor complex acts on transcription factors

Action of steroid-receptor complex

This activated complex acts on transcription proteins found inside the cytoplasm

Causes a reduction in the amount of inflammatory cytokines secreted by the cell

Reduces the cells response to inflammation

Due to this complex mechanism of action there is a time delay between the administration of the drug and its clinical activity

Time delay of 3 hours is common

Intravenous steroids

Useful during emergencies

One hour is gained when the drug is administered intravenously

Drugs with minimal mineralocorticoid effect is preferred

Methylprednisolone / Dexamethasone are preferred as intravenous steroids

Oral steroids

Used in patients who need long term administration of the drug

Prednisolone is preferred to prednisone (prodrug)

Prednisone needs to be metabolised in the liver into its active metabolites

Dexamethasone is the most potent oral steroid with very negligible mineralocorticoid effect

Depo injections - IM

Methyl prednisolone acetate is commonly used

Its effect on the hypothalamic-pituitary-adrenal axis lasts for 3 weeks

Usually administered once in 3 weeks intramuscularly

Minimum plasma concentration after depo injection lasts for 3-4 weeks

Intranasal steroids

Intranasally adeministered steroid should be lipophilic

First pass metabolism is avoided

Very low dose is enough for local effect reduced systemic toxicity

On administration 50% of the drug stays in the non ciliated anterior part of the nose while the other 50% is in the posterior ciliated columnar portion of the nasal cavity

Intranasal steroid (contd)

Fluticasone propionate commonly used. Highly lipophilic and has a large tissue distribution volume

Beclamethasone dipropionate / budesonide are less lipophilic and hence are rapidly absorbed into the circulation when applied as topical spray

Spray administered in aqueous forms are better than aerosols.

Topical application is effective on itching and sneezing

Systemic application is better for blockage / anosmia

Nasal topical steroids indications

Allergic rhinitis

Vasomotor rhinitis

Nasal polyposis

Management of rhinitis medicamentosa

Idiopathic rhinitis

Systemic steroids

Oral

Parenteral

Depo (intramuscular)

Systemic steroids indications

Angioneurotic oedema

Acute allergic rhinitis

Drug anaphylaxis

Acute sensorineural hearing loss (sudden deafness)

Treatment of acute hyposmia / anosmia

Acute stridor before tracheostomy

Acute epiglottitis

Croup

Systemic steroids indications (contd)

Otitis externa to reduce external canal inflammatory oedema

Bells palsy

Nasal sarcoidosis

Wegners granulomatosis

Thankyou

Steroid ear drops

Used to treat eczematous conditions of the skin lining fo external canal

Used in the treatment of myringitis granulosa

Can be used to reduce middle ear mucosal oedema in active middle ear infections with central perforation

Long term use can cause atrophy of the skin lining of the external ear canal

Intranasal steroid (contd)

Topical steroids when used on hyper reactive nose can cause increased sneezing

Reassurance is a must and the drug should not be stopped

Dry nasal mucosa / crusts / blood stained discharge seen in patients on long term nasal steroid therapy

Prolonged usage may cause increased risk of cataract and osteoporosis