> Table of Contents > Laryngitis
Laryngitis
Hugh Silk, MD, MPH, FAAFP
Sheila O. Stille, DMD
Anne M. Barnard, MD
image BASICS
DESCRIPTION
  • Laryngitis is the inflammation, erythema, and edema of the mucosa of the larynx and/or vocal cords characterized by hoarseness, loss of voice, throat pain, coughing, and often a negative impact on a person's quality of life and daily activities
  • There is a range of severity, but most cases are acute and are associated with viral upper respiratory infection, irritation, or acute vocal strain.
  • System(s) affected: pulmonary; ears, eyes, nose, throat (ENT)
  • Synonym(s): acute laryngitis; chronic laryngitis; croup or laryngotracheitis (in children)
EPIDEMIOLOGY
  • Predominant age: affects all ages
  • Children more susceptible than adults due to increased risk of symptomatic inflammation from smaller airways
  • Predominant sex: male = female
Incidence
Common
Prevalence
Common
ETIOLOGY AND PATHOPHYSIOLOGY
  • Misuse or abuse of voice
  • Infectious
    • Viral: influenza A, B; parainfluenza; adenovirus; coronavirus; rhinovirus; human papillomavirus; cytomegalovirus; varicella-zoster virus; herpes simplex virus; respiratory syncytial virus; coxsackievirus
    • Fungal: uncommon, but thought to be underdiagnosed, potentially accounting for up to 10% of presentations in both immunocompromised and immunocompetent patients; risk factors include recent antibiotic or inhaled corticosteroid use (1): histoplasmosis, blastomycosis, Coccidioides, Cryptococcus, and Candida
    • Bacterial: (uncommon): &bgr;-hemolytic streptococcus, Streptococcus pneumoniae, Haemophilus influenzae, tuberculosis (TB), leprosy, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydophila pneumoniae
    • Secondary syphilis if left untreated
    • Leprosy (in 30-55% of those with leprosy, larynx is affected; tropical and warm countries)
  • Irritants
    • Inhalation of irritating substances (e.g., air pollution, cigarette smoke)
    • Aspiration of caustic chemicals
    • Gastroesophageal reflux disease (GERD)/laryngopharyngeal reflux disease (LPRD)
    • Excessively dry environment
    • Allergy exposures (including pollens)
  • Anatomic
    • Aging changes: muscle atrophy, loss of moisture in larynx, and bowing of vocal cords
    • Vocal cord nodules/polyps (“singer's nodes”)
    • Local cancer
  • Iatrogenic: inhaled steroids such as those used to treat asthma; surgical injury; endotracheal intubation injury
  • Idiopathic
  • Neuromuscular disorder (e.g., myasthenia gravis); stroke
  • Rheumatoid arthritis
  • Trauma (e.g., blunt or penetrating trauma to neck)
RISK FACTORS
  • Acute:
    • Upper respiratory tract infection
    • Voice overuse—excess talking, singing, or shouting
    • Pneumonia
    • Influenza
    • Lack of immunization for pertussis or diphtheria
    • Immunocompromised
    • Recent endotracheal intubation or local surgery
  • Chronic:
    • Allergies
    • Chronic rhinitis/sinusitis
    • Voice abuse
    • GERD/LPRD (rare) (2,3)[A]
    • Smoking: primary or secondhand
    • Excessive alcohol use
    • Stroke
    • Constant exposure to dust or other irritants such as chemicals at workplace; environmental pollution
    • Medications: inhaled steroids, anticholinergics, antihistamines, anabolic steroids (4)[B]
Geriatric Considerations
May be more ill, slower to heal
Pediatric Considerations
  • Common in this age group
  • Consider congenital/anatomic causes.
GENERAL PREVENTION
  • Avoid overuse of voice (voice training is helpful for vocal musicians/public speakers).
  • Influenza virus vaccine is suggested for high-risk individuals.
  • Quit smoking, and avoid secondhand smoke.
  • Limit or avoid alcohol/caffeine/acidic foods.
  • Control GERD/LPRD.
  • Maintain proper hydration status.
  • Avoid allergens.
  • Wear mask around chemical/environmental irritants.
  • Good hand washing (infection prevention)
COMMONLY ASSOCIATED CONDITIONS
  • Viral pharyngitis
  • Diphtheria (rare): Membrane can descend into the larynx.
  • Pertussis: larynx involved as part of the respiratory system
  • Bronchitis
  • Pneumonitis
  • Croup, epiglottitis, in children
image DIAGNOSIS
PHYSICAL EXAM
  • Head and neck exam, including airway patency, cervical nodes; cranial nerve exam
  • Visualization of the larynx: preferably with a flexible or rigid endoscope, or with an indirect mirror examination as a screening technique to dictate further appropriate testing (6)
  • Note quality of voice (i.e., hoarse, breathy, wet, “hot potato like,” asthenic [weak], strained).
DIFFERENTIAL DIAGNOSIS
  • Diphtheria
  • Vocal nodules or polyps
  • Laryngeal malignancy
  • Thyroid malignancy
  • Upper airway malignancy
  • Epiglottitis
  • Pertussis
  • Laryngeal nerve trauma/injury
  • Foreign body (in children)
  • Autoimmune (rheumatoid arthritis) (7)
DIAGNOSTIC TESTS & INTERPRETATION
  • Rarely needed
  • WBCs elevated in bacterial laryngitis
  • Viral culture (seldom necessary)
Follow-Up Tests & Special Considerations
  • Barium swallow, only if needed for differential diagnosis
  • CT scan if foreign body suspected
Diagnostic Procedures/Other
  • Fiber-optic or indirect laryngoscopy: looking for red, inflamed, and occasionally hemorrhagic vocal cords; rounded edges and exudate (Reinke edema)
  • Consider otolaryngologic evaluation and biopsy: laryngitis lasting >2 weeks in adults with history of smoking or alcohol abuse to rule out malignancy
  • P.591

  • pH probe (24-hour): no difference in incidence of pharyngeal reflux as measured by pH probe between patients with chronic reflux laryngitis and healthy adults (8)[C]
  • Strobovideo laryngoscopy for diagnosis of subtle lesions (e.g., vocal cord nodules or polyps)
image TREATMENT
  • Limited but good evidence that treatment beyond supportive care is ineffective.
  • Antibiotics appear to have no benefit, as etiologies are predominantly viral (9)[A].
  • Corticosteroids in severe cases of laryngitis to reduce inflammation such as croup
  • May need voice training, if voice overuse
  • Nebulized epinephrine reduces croup symptoms 30 minutes posttreatment; evidence does not favor racemic epinephrine or L-epinephrine, or IPPB over simple nebulization. Racemic epinephrine reduces croup symptoms at 30 minutes, but effect lasts only 2 hours (10)[A].
GENERAL MEASURES
  • Acute:
    • Usually a self-limited illness lasting <3 weeks and not severe
    • Antibiotics of no value (9)[A]
    • Avoid excessive voice use, including whispering.
    • Steam inhalations or cool-mist humidifier
    • Increase fluid intake, especially in cases associated with excessive dryness.
    • Avoid smoking (or secondhand exposure).
    • Warm saltwater gargles
  • Chronic:
    • Symptomatic treatment as above
    • Voice therapy (for patients with intermittent dysphagia and vocal abuse)
    • Smoking cessation
    • Reduction or cessation of alcohol intake
    • Occupational change or modification, if exposure-driven
    • Allergen avoidance
    • Consider discontinuing offending medication.
  • Reflux laryngitis: Elevate head of bed, diet changes, other antireflux lifestyle change management; proton pump inhibitors
MEDICATION
Usually none
First Line
  • Analgesics
  • Antipyretics (rare)
  • Cough suppressants
  • Throat lozenges
  • Plenty of fluids
Second Line
  • Inhaled corticosteroids (consider only if allergy induced)
  • Oral corticosteroids: only if urgent need in adults (presenter, singer, actor)
  • Oral corticosteroids: Evidence of benefit has been studied with single-dose dexamethasone in children ages 6 months to 5 years for moderate-severity croup; reduces symptoms within 6 hours, reduces hospitalizations, hospital length of stay, and revisits to office (11)[A].
  • Standard of care is to prescribe proton pump inhibitors for chronic laryngitis if GERD or LPRD is suspected; however, evidence suggests only a modest benefit, if any (12, 13)[C].
  • Treat nonviral infectious underlying causes.
  • Candidal laryngitis:
    • Mild cases: oral antifungal (fluconazole)
    • Amphotericin B or echinocandin can be given in life-threatening cases.
ISSUES FOR REFERRAL
  • Immediate emergency ENT referral for patients with stridor or respiratory distress
  • ENT referral for persistent symptoms (>2 to 3 weeks) or concern for foreign body
  • Consider otolaryngologic evaluation and biopsy for laryngitis lasting >2 weeks in adults, especially in those with history of smoking or alcohol abuse to rule out malignancy.
  • Consider GI consult to rule out GERD/LPRD.
SURGERY/OTHER PROCEDURES
  • Vocal cord biopsy of hyperplastic mucosa and areas of leukoplakia if cancer or TB is suspected
  • Removal of nodules or polyps if voice therapy fails
COMPLEMENTARY & ALTERNATIVE MEDICINE
The following, although not well studied, have been recommended by some experts:
  • Barberry, black currant, echinacea, eucalyptus, German chamomile, goldenrod, goldenseal, warmed lemon and honey, licorice, marshmallow, peppermint, saw palmetto, slippery elm, vitamin C, zinc
image ONGOING CARE
PATIENT EDUCATION
  • Educate on the importance of voice rest, including whispering.
  • Provide assistance with smoking cessation.
  • Help the patient with modification of other predisposing habits or occupational hazards.
PROGNOSIS
Complete clearing of the inflammation without sequelae
REFERENCES
1. Merati AL. Acute and chronic laryngitis. In: Flint PW, Haughey BH, Lund VL, et al, eds. Cummings otolaryngology head and neck surgery. 5th ed. Philadelphia, PA: Mosby Elsevier, 2010.
2. Hawkshaw MJ, Pebdani P, Sataloff RT. Reflux laryngitis: an update, 2009-2012. J Voice. 2013;27(4):486-494.
3. Hom C, Vaezi MF. Extraesophageal manifestations of gastroesophageal reflux disease. Gastroenterol Clin North Am. 2013;42(1):71-91.
4. Ray S, Masood A, Pickles J, et al. Severe laryngitis following chronic anabolic steroid abuse. J Laryngol Otol. 2008;122(3):230-232.
5. Gallivan GJ, Gallivan KH, Gallivan HK. Inhaled corticosteroids: hazardous effects on voice—an update. J Voice. 2007;21(1):101-111.
6. Tulunay OE. Laryngitis—diagnosis and management. Otolaryngol Clin North Am. 2008;41(2):437-451.
7. Hamdan AL, Sarieddine D. Laryngeal manifestations of rheumatoid arthritis. Autoimmune Dis. 2013;2013:103081.
8. Johnson DA. Medical therapy of reflux laryngitis. J Clin Gastroenterol. 2008;42(5):589-593.
9. Reveiz L, Cardona AF. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev. 2015;(5):CD004783.
10. Bjornson C, Russell KF, Vandermeer B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2013;(10):CD006619.
11. Russell KF, Liang Y, O'Gorman K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011;(1):CD001955.
12. Wood JM, Athanasiadis T, Allen J. Laryngitis. BMJ. 2014;349:g5827.
13. Kim JH, Sung IK, Hong SN, et al. Is the proton pump inhibitor test helpful in patients with laryngeal symptoms? Dig Dis Sci. 2013;58(6);1663-1667.
Codes
&NA;
ICD10
  • J04.0 Acute laryngitis
  • J37.0 Chronic laryngitis
  • J04.2 Acute laryngotracheitis
Clinical Pearls
&NA;
  • Laryngitis is usually self-limited and needs only comfort care. Standard treatment is voice rest.
  • Refer to ENT for direct visualization of vocal cords for prolonged laryngitis.
  • Corticosteroids have some benefits for children with moderately severe croup.
  • Voice training useful for chronic