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Laryngitis

- 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.

para>May be more ill, slower to heal ‚

Pediatric Considerations

‚

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 severeAntibiotics of no value (9)[A]Avoid excessive voice use, including whispering.Steam inhalations or cool-mist humidifierIncrease fluid intake, especially in cases associated with excessive dryness.Avoid smoking (or secondhand exposure).Warm saltwater gargles
  • Chronic:Symptomatic treatment as aboveVoice therapy (for patients with intermittent dysphagia and vocal abuse)Smoking cessationReduction or cessation of alcohol intakeOccupational change or modification, if exposure-drivenAllergen avoidanceConsider 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