On shift: Start with airway assessment, analgesia and oral intake. Nebulized steroids have no established routine role in uncomplicated acute pharyngitis.
What the trial showed
The 2025 three-centre Oman RCT compared single-dose nebulized dexamethasone, budesonide and saline in patients older than five years. Of 200 randomized patients, 163 completed 24-hour follow-up.
- Primary endpoint: Table 2 reports complete symptom resolution at 24 hours in 20% with dexamethasone, 17% with budesonide and 9% with placebo. Neither comparison was statistically significant; confidence intervals were wide.
- Earlier relief: Steroid groups reported pain relief roughly one to one-and-a-half hours sooner (overall three-group p=0.003). Clinical importance remains uncertain.
- Other outcomes: No significant differences were detected in 48-hour pain improvement, reattendance/admission or absenteeism. Minor adverse effects occurred; uncommon harms cannot be excluded.
Attrition and imprecision weaken certainty; equivalence was not tested. The published methods and registry differ on budesonide dose and nebulized volume; the abstract and tables also contain inconsistent estimates. This is not a treatment protocol.
Keep oral-steroid evidence separate
In a separate adult primary-care trial, one 10 mg oral dexamethasone dose did not significantly improve complete resolution at 24 hours. At 48 hours, resolution was 35.4% versus 27.1% with placebo. This modest benefit cannot be used to rank oral and nebulized treatment.
Guidance differs: BMJ Rapid Recommendations make a weak recommendation for a single oral dose through shared decision-making, while NICE does not recommend corticosteroids for acute sore throat. Discuss potential benefit and individual risk rather than making steroids automatic or prescribing repeated courses.
A practical ED approach
- Escalate red flags: Stridor, respiratory distress, drooling, trismus, muffled voice or neck swelling require assessment for airway compromise or deep-neck infection. Do not delay escalation for a trial of nebulization. RCH guidance.
- Treat pain and dehydration: Use paracetamol or, if suitable, ibuprofen; encourage fluids and reassess swallowing. Inability to maintain intake or worsening systemic illness warrants reassessment. NICE NG84.
- Use antibiotics selectively: Do not treat viral pharyngitis with antibiotics. Follow local testing and rheumatic-fever-risk guidance. CDC recommends treating confirmed group A streptococcal infection and backing up a negative rapid antigen test with culture in symptomatic children older than three years. CDC guidance.
Sources
Al Atbi AY, Al Khalasi U, Al Atbi A, et al. Nebulized glucocorticoids for acute pharyngitis. CJEM. 2025;27:543–550. Trial registration: NCT04027322.
For earlier systemic-steroid evidence: Wing et al., 2010 systematic review. These studies do not provide a direct route comparison.
