Laryngitis

para>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

DIAGNOSIS

HISTORY

Hoarseness, throat tickling, dry cough, and rawness
Dysphonia (abnormal-sounding voice)
Constant urge to clear the throat
Possible fever
Malaise
Dysphagia/odynophagia
Regional cervical lymphadenopathy
Stridor or possible airway obstruction in children (5)[C]
Cough may be worse at night in children.
Hemoptysis
Laryngospasm or sense of choking
Allergic rhinitis/rhinorrhea/postnasal drip (PND)
Occupation or other reasons for voice overuse
Smoking history
Blunt or penetrating trauma to neck
GERD/LPRD

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
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)

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 post-treatment; 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

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 ‚

COMPLICATIONS

Chronic hoarseness ‚

REFERENCES

11 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, 2010.22 Hawkshaw ‚ MJ, Pebdani ‚ P, Sataloff ‚ RT. Reflux laryngitis: an update, 2009 " “2012. J Voice. 2013;27(4):486 " “494.33 Hom ‚ C, Vaezi ‚ MF. Extraesophageal manifestations of gastroesophageal reflux disease. Gastroenterol Clin North Am. 2013;42(1):71 " “91.44 Ray ‚ S, Masood ‚ A, Pickles ‚ J, et al. Severe laryngitis following chronic anabolic steroid abuse. J Laryngol Otol. 2008;122(3):230 " “232.55 Gallivan ‚ GJ, Gallivan ‚ KH, Gallivan ‚ HK. Inhaled corticosteroids: hazardous effects on voice " ”an update. J Voice. 2007;21(1):101 " “111.66 Tulunay ‚ OE. Laryngitis " ”diagnosis and management. Otolaryngol Clin North Am. 2008;41(2):437 " “451.77 Hamdan ‚ AL, Sarieddine ‚ D. Laryngeal manifestations of rheumatoid arthritis. Autoimmune Dis. 2013;2013:103081.88 Johnson ‚ DA. Medical therapy of reflux laryngitis. J Clin Gastroenterol. 2008;42(5):589 " “593.99 Reveiz ‚ L, Cardona ‚ AF. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev. 2015;(5):CD004783.1010 Bjornson ‚ C, Russell ‚ KF, Vandermeer ‚ B, et al. Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2013;(10):CD006619.1111 Russell ‚ KF, Liang ‚ Y, O 'Gorman ‚ K, et al. Glucocorticoids for croup. Cochrane Database Syst Rev. 2011;(1):CD001955.1212 Wood ‚ JM, Athanasiadis ‚ T, Allen ‚ J. Laryngitis. BMJ. 2014;349:g5827.1313 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

ICD10

J04.0 Acute laryngitis
J37.0 Chronic laryngitis
J04.2 Acute laryngotracheitis
J05.0 Acute obstructive laryngitis [croup]

ICD9

464.00 Acute laryngitis without mention of obstruction
476.0 Chronic laryngitis
464.20 Acute laryngotracheitis without mention of obstruction
464.4 Croup

SNOMED

45913009 Laryngitis (disorder)
29951006 Chronic laryngitis
6655004 Acute laryngitis
71186008 Croup (disorder)
64375000 Acute laryngotracheitis (disorder)

CLINICAL PEARLS

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

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