Discussion
In sore throat patients, adjuvant dexamethasone resulted in a high
proportion of patients reporting sufficient response. Additionally, of
all the symptoms, cough was significantly negatively associated with
treatment response. Patients presenting with less cough tended to
experience higher sore throat resolution. There was no incidence of
infection complications in patients. This new treatment strategy seems
to be effective and safe.
The criteria for treatment outcome evaluation in the present study was
different from those of other studies, as previous studies usually
established clinical outcomes as complete resolution at 24 or 48 hours
[17]. A recent randomized trial for
elucidating the efficacy of dexamethasone without immediate antibiotic
use showed that 22.6% and 35.4% of patients in the dexamethasone group
experienced complete resolution at 24 and 48 hours, respectively, with a
risk ratio (RR) of 1.28 at 24 hours and 1.31 at 48 hours
[15]. A meta-analysis including both
adults and children reported a RR of complete pain resolution of 3.2 at
24 hours and 14 % pain reduction by corticosteroids at 24 hours
[14]. However, the criteria of
clinical outcomes in this study was divided into three groups:
non-responder, partial responder, and responder, because the study never
aimed to compare the effects with or without steroid, but to describe
the response according to the adjuvant steroid. Additionally, although
only 2 (5%) of the patients in this study experienced complete
resolution at 24 hours, 30 (75.0%) reported with an NRS of 2, 3, or 4
at 24 hours. Since a less than 4 NRS score generally indicates mild
symptoms, the response in this study was enough to prove the efficacy of
dexamethasone [18].
In the present study, cough was negatively associated with the response
to corticosteroid treatment. After reviewing the symptoms in the medical
record, patients with cough were stratified into two categories: those
with intermittent cough, especially during sleep at night, and those
with persistent cough, regardless of the specific condition. When we
analyzed the treatment response according to the degree of cough, there
was a significant difference in sore throat resolution between cough
type. Although this result has not been evaluated in detail by other
studies, we had a few hypotheses for the reason of the association
between cough and treatment response. Several mechanisms are responsible
for cough reflexes in the course of pharyngitis
[19-21]. Corticosteroids suppress
pro-inflammatory mediators, which could have decreased cough induced by
these mediators [22]. However,
steroid use might have been insufficient for the inhibition of
persistent cough resulting from inflammation-induced nerve injury
[23]. We believe that further studies
can help elucidate this mechanism.
Because this study was retrospective, antibiotic use was decided by the
clinician. Although several studies showed that most adults with sore
throat do not need antibiotics, they are usually offered to adult sore
throat patients [7]. Antibiotic use
can reduce the incidence of suppurative complications and provide
additional benefits to some patients with bacterial infections
[24]. However, a recent study
demonstrated that steroid use without immediate antibiotic use could
improve sore throat symptom recovery
[15]. Also, several studies have
reported viruses as the cause of purulent or large tonsils in most
patients
[24,25].
The rapid streptococcal antigen test was unavailable at the primary
clinics in which the present study was conducted and most of the
included patients had a modified Centor score of 2 or 3. Therefore,
almost all patients in this study were treated with immediate or delayed
antibiotics due to the fear of bacterial tonsillitis. To reduce
antibiotic use for sore throat, the evidence for adjuvant steroids
should be collected continually and made widely known.
This study had several limitations. First, the small sample size could
make its results less significant and might have prevented adverse event
detection. However, we had 100% of the sore throat score data and
collected information on variable symptoms, treatment options, and signs
upon physical examination, to aid our search for prognostic factors by
applying these variables to the multivariate model. Secondly, the
included patients were all young men without comorbidity. There have
been no studies that recruited patients with comorbidities
[14,17].
Since corticosteroid-induced infection complications may be more common
in patients with comorbidities, uncertainty remains about the
prescribing of steroids to those presenting in primary clinics. Thus,
future studies in patients with comorbidities are needed. Despite these
limitations, the study has many strengths. To the best of our knowledge,
this is the first study to evaluate the benefits of oral corticosteroids
for Korean sore throat patients. We also analyzed the prognostic factor
associated with treatment response, which could help in the selection of
a target group of patients who would benefit from this treatment
strategy, reducing unnecessary corticosteroid use.