Letter to the Editor: The Role of Corticosteroids in Pediatric Ludwig’s Angina

Ludwig’s angina, a fulminant cellulitis of the submandibular and sublingual spaces, remains a critical emergency in pediatric patients due to its propensity for rapid airway obstruction and systemic complications. ¹ While rare, up to one-third of cases occur in children, often arising from dental infections, trauma, or immunocompromised states. ² The cornerstone of management—prompt airway stabilization, intravenous antibiotics (eg, penicillin with metronidazole or clindamycin), and surgical drainage—is well-established. ³ However, the adjunctive use of corticosteroids to mitigate inflammation and edema remains contentious, particularly in children, where evidence is sparse and clinical decisions rely heavily on extrapolated adult data. ⁴ This gap in pediatric-specific guidance warrants urgent attention.

A 2020 narrative review by Patel et al examining corticosteroids in Ludwig’s angina included 31 patients, predominantly adults (median age 43 years), with dexamethasone as the most-frequently-administered steroid. ⁴ The majority received steroids alongside antibiotics and surgical intervention, with reported reductions in inflammatory markers, shorter hospital stays, and no major complications attributed to steroid use. ⁴ Mechanistically, corticosteroids inhibit pro-inflammatory cytokines and reduce vascular permeability, potentially alleviating airway-compromising edema. ⁵ However, pediatric data are limited to isolated case reports. For instance, in a case series of 12 children with Ludwig’s angina, non of whom required tracheostomy, all were administered dexamethasone before the induction of general anesthesia. ⁶ Conversely, children treated without steroids reported similar outcomes, raising questions about necessity. ⁷ While short-course steroids (eg, 0.1-0.3 mg/kg/day dexamethasone for 1-3 days) are generally safe in children, concerns persist regarding immunosuppression, delayed infection resolution, or masking of sepsis, particularly in younger or immunocompromised cohorts. ⁸ Notably, the Royal Australian College of General Practitioners emphasizes that brief steroid courses (<7 days) rarely cause adrenal suppression or long-term sequelae in acute pediatric settings. ⁸ Still, the absence of randomized trials or consensus guidelines leaves clinicians navigating uncharted territory. ⁴

The stakes are undeniably high: Delayed airway intervention in Ludwig’s angina carries mortality rates of 5% to 10%. ⁹ Corticosteroids may offer a critical window to stabilize the airway before definitive surgical management, particularly in resource-limited settings or during transfer to tertiary care. ⁴ Yet, their role must be balanced against potential risks. For example, in a retrospective study, pediatric population has more ICU admission,compared to adults. ¹⁰ This underscores the need for nuanced, case-by-case decisions. Factors such as disease severity, comorbidities, and response to initial antibiotics should guide therapy. ³ Multidisciplinary collaboration—between otolaryngologists, intensivists, and pediatricians—is paramount to optimize outcomes. ²

Prospective studies are urgently needed to address this evidence gap. Randomized controlled trials comparing steroid-augmented regimens to standard care in pediatric Ludwig’s angina could clarify efficacy, optimal dosing, and duration. ⁴ Until then, clinicians must weigh limited adult data, pediatric case evidence, and institutional protocols. ⁷ Registries or multicenter collaborations may accelerate insights, given the condition’s rarity. In conclusion, while corticosteroids hold promise as an adjunct in severe pediatric Ludwig’s angina, their use should be judicious, reserved for high-risk cases, and accompanied by rigorous monitoring. Prioritizing pediatric research will ensure evidence-based stewardship of this potentially-life-saving intervention.