Laryngitis

Background

• Laryngitis is inflammation of the laryngeal mucosa with resulting dysphonia (hoarse voice or air-wasting/breathiness), and pain or discomfort in the anterior neck.
• Acute laryngitis is usually caused by upper respiratory infection, but laryngitis (acute or chronic) can also develop due to other etiologies, including trauma (physical or phonotrauma) or chronic inflammatory conditions.
• Risk factors for acute laryngitis include:
  • occupational use of voice as found in:
    • singers
    • actors/performers
    • teachers
  • smoking
  • snoring or mouth breathing
  • sleep apnea
  • immunocompromised status

Evaluation

• Laryngitis typically presents with dysphonia (hoarseness of voice which may be in the form of a strained voice, weak voice, or aphonia [no voice]) as well as signs and symptoms, including:
  • dysphagia
  • odynophagia
  • dry, sore, itchy throat
  • globus pharyngeus (feeling of lump in the throat)
  • chronic dry cough
  • frequent throat clearing
  • laryngeal edema and erythema on endoscopic exam
  • stridor or shortness of breath due to airway compromise in severe cases
• Perform a general head and neck exam, paying careful attention to the oral cavity, oropharynx, and neck, to assess for:
  • airway patency
  • mucosal alterations
  • mucous and purulent secretions
  • mass lesions
• Vocal assessment should be performed using a grading scale that can be used to assess voice change and quality over time.
• Perform laryngoscopy if:
  • symptoms persist > 3 weeks or others are present
  • other indications are present, including stridor (requires emergency referral), recent surgery to the neck or recurrent laryngeal nerve, recent endotracheal intubation, radiation therapy to the neck, history of smoking, weight loss, dysphagia or odynophagia, or otalgia
• In patients with suspected reflux laryngitis who fail to respond to optimal combined antireflux treatment, consider additional testing depending on symptoms.
  • Consider modified barium swallow testing or videofluoroscopic assessment of swallowing if solid food dysphagia, gagging, or choking is present.
  • Consider esophagogastroscopy if symptoms are dyspeptic (bloating, burping, or food-triggered).
  • Consider pH monitoring to detect acid reflux.
• Biopsy is not typically performed for diagnosis of laryngitis, but biopsy and culture of an abnormal lesion may help rule out nodules, polyps, premalignant or malignant lesions, or chronic inflammatory and infectious etiologies.

Management

• Significant stridor and dyspnea rarely occur, but may suggest upper airway obstruction requiring emergency tracheotomy or intubation.
• Treatment of acute laryngitis is usually conservative and may include:
  • vocal hygiene, including:
    • voice rest
    • humidification
    • local lubrication and systemic hydration
    • lifestyle factors to improve vocal health
  • Use of antibiotics:
    • Do not routinely use antibiotics to treat hoarseness (Strong recommendation).
    • Indications for antibiotics may include persistent fever (> 48 hours), purulent sputum, and membrane formation, or other findings associated with a serious condition (such as acute epiglottitis, tuberculosis, syphilis, or actinomycosis).
  • Corticosteroids are generally not indicated for patients with laryngitis. Corticosteroids are usually indicated for children with croup.
  • Antifungal agents are used for patients with fungal laryngitis. Specific choice depends on the causative organism.
• Acute laryngitis may be treated in the primary care setting, but consider referral to an otolaryngologist for patients with symptoms persisting > 2-3 weeks.
• In addition to vocal hygiene, treatment of chronic laryngitis varies by underlying condition.
  • Treatment of allergic laryngitis requires removal or avoidance of triggering antigens.
  • Treatment of reflux laryngitis may vary depending on the etiology of reflux, but several overlapping therapies are commonly used, including:
    • physical reflux barriers, such as oral administration of antacid liquid to coat the stomach (such as sucralfate)
    • dietary and behavioral modification, such as dietary avoidance of foods that are acidic or otherwise irritative, or that may stimulate gastric acid production and reflux
    • liquid alginate preparations or H2 receptor antagonists (can be used in combination with proton pump inhibitors in patients with symptoms refractory to treatment)
    • proton pump inhibitors (PPIs) once or twice daily:
      • PPIs are commonly used for the treatment of gastroesophageal reflux disease, but many patients with laryngopharyngeal symptoms fail to improve with PPIs
      • optimal time to take PPIs is reported to be 30 minutes before a meal
      • optimal duration of treatment is uncertain; PPIs should only be prescribed for a defined period due to potential for adverse effects.