Laryngitis, Emergency Medicine

Basics

Description

Inflammation of the mucosa of the larynx
The most common cause is viral upper respiratory infection
Peaks parallel epidemics of individual viruses
Most common during late fall, winter, early spring

Etiology

Viral upper respiratory infections most common in acute laryngitis:
- Influenza A and B
- Parainfluenza types 1 and 2
- Adenovirus
- Coronavirus
- Coxsackievirus
- Respiratory syncytial virus
- Measles
- Rhinovirus
Bacterial infections much less common:
- ²-Hemolytic streptococcus
- Streptococcus pneumoniae
- Haemophilus influenzae (HiB)
- Moraxella catarrhalis
- Bordetella pertussis
- Diphtheria
- Tuberculosis
- Syphilis
- Leprosy
Laryngopharyngeal reflux (LPR) from gastroesophageal reflux disease (GERD) (especially in adults)
Fungal infections (often associated with inhaled steroid use or immunocompromise)
Allergic
Voice abuse or misuse
Inhalation or ingestion of caustic substances or other irritants
Autoimmune (rheumatoid arthritis, relapsing polychondritis, Wegener granulomatosis, or sarcoidosis)
Trauma
Idiopathic

Acute spasmodic laryngitis (spasmodic croup)
More likely to be infectious.
- Consider HiB, diphtheria, etc., if not immunized
Consider foreign body

Diagnosis

Signs and Symptoms

History

Hoarseness
Abnormal-sounding voice
Throat swelling
Throat tickling
Feeling of throat rawness
Constant urge to clear the throat
Cough
Fever
Malaise
Dysphagia

Physical Exam

Regional lymphadenopathy
Stridor in infants
Hoarse voice
Pharyngeal erythema, exudates, and/or edema
Asymmetrical breath sounds in case of foreign body

Essential Workup

Acute laryngitis:
- In most cases, the history and inspection of the throat suffice to distinguish between infectious and noninfectious laryngitis:
  - Infectious laryngitis usually lasts about 7 " 10 days.
- Have increased suspicion for epiglottitis in persons who have not had HiB vaccine
Chronic laryngitis (>3 wk):
- The workup should be directed toward chronic infections, GERD, neurologic disorders, and tumors
- Visualization of the larynx should be performed but may not need to be done in the ED
- The patient should be referred to an ear " nose " throat specialist for further workup

Diagnosis Tests & Interpretation

Lab

Blood tests are not generally indicated:
- An elevated WBC count is not a reliable way to distinguish between bacterial and viral illness
Throat culture:
- Indicated when exam suggests a bacterial infection such as significant exudate in the throat or on the vocal folds

Imaging
Soft-tissue neck films:

Rarely indicated because fiberoptic laryngoscopy provides a more comprehensive assessment
Mostly used if epiglottitis or foreign body suspected, though high-risk patients should not be sent to radiology

Diagnostic Procedures/Surgery
Fiberoptic laryngoscopy:

Red, inflamed vocal cords, with rounded edges
Occasionally hemorrhage or exudates
Endolaryngeal pus is more common in bacterial laryngitis than viral
Demonstration of laryngeal pseudomembrane to distinguish diphtheria from other infectious forms of laryngitis

Differential Diagnosis

Asthma
Epiglottitis
Esophageal reflux
Vocal nodules
Laryngeal or thyroid malignancy
Croup/laryngotracheobronchitis
Foreign-body inhalation or other trauma

Treatment

Pre-Hospital

Supportive care and ambulance transport are not generally indicated

Stridor can mean obstruction of the laryngeal or tracheal parts of the airway, particularly in children
An otolaryngologist should evaluate laryngitis after trauma to the neck
Beware of esophageal injuries in laryngitis associated with caustic ingestions
If there are signs of respiratory distress, epiglottitis should be suspected:
- Transport sitting up
- Provide supplemental oxygen
- Intubation may be difficult or impossible and should only be attempted in patients in extremis

Initial Stabilization/Therapy

Stabilization is only required if the patient shows signs of respiratory distress:

The patient should be managed for epiglottitis
Supplemental oxygen via a nonrebreather mask
Orotracheal intubation when time permits in the OR
The neck should be prepped and the equipment ready for a surgical airway

Ed Treatment/Procedures

Antibiotics are not 1st-line therapy in adults with acute laryngitis:
- In a systematic review of randomized controlled trials investigating the use of antibiotics vs. placebo, antibiotics offered no objective improvement in symptoms over placebo
Vocal rest (avoid whispering, as it promotes hyperfunctioning of the larynx):
- If patient must speak, use a soft sighing voice
Humidified air
Increase fluid intake
Analgesics
Smoking cessation
Symptoms usually resolve in 7 " 10 days, if viral cause
Use of inhaled steroids for laryngitis is controversial and not part of current best practices.

Medication

Depends on cause of laryngitis.

Mucolytics like guaifenesin if related to upper respiratory infection or allergy
Acetaminophen or NSAIDs for symptomatic relief if associated with viral syndrome
Proton pump inhibitors for GERD-related laryngitis:
- Esomeprazole magnesium: 20 " 40 mg (peds: 10 mg for patients 1 " 11 yr) PO daily
- Omeprazole: 20 mg PO BID
Diflucan for candidal laryngitis
If caused by croup: Dexamethasone (0.6 mg/kg) PO or IM 1
Antihistamines can dry out the vocal cords, make it harder to clear secretions and exudate
Cochrane Review found no benefit in using antibiotics to treat acute laryngitis
- Antibiotics may be considered in high-risk patients or in cases where a positive Gram stain and culture has been obtained

Follow-Up

Disposition

Admission Criteria

Tuberculous laryngitis:
- Highly contagious requiring isolation
Signs of epiglottitis, respiratory distress, neck trauma, or anaphylaxis
Respiratory compromise

Discharge Criteria
Most patients with uncomplicated laryngitis can be discharged if they have no difficulty breathing and are able to keep adequately hydrated.
Issues for Referral
Refer patients with chronic laryngitis to otolaryngologist. Patients with >3 wk of laryngitis without obvious benign cause should be evaluated with laryngoscopy to rule out more serious conditions such as carcinoma.

Follow-Up Recommendations

With otolaryngology if not improved in 2 " 3 wk
With primary care or gastroenterology if symptoms of GERD

Pearls and Pitfalls

Most acute laryngitis is of viral origin
- Antibiotics likely with no benefit
Consider life-threatening causes of altered phonation such as epiglottitis
Laryngitis not associated with upper respiratory infection may be related to GERD
Patients with chronic or nonresolving laryngitis should follow up with otolaryngologist

Additional Reading

Behrman RE, Kliegman R, Jenson H, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: WB Saunders; 2007.
Dworkin JP. Laryngitis: Types, causes, and treatments. Otolaryngol Clin North Am. 2008;41:419 " 436.
Heidelbaugh JJ, Gill AS, Van Harrison R, et al. Atypical presentations of gastroesophageal reflux disease. Am Fam Physician. 2008;78:483 " 488.
Mehanna HM, Kuo T, Chaplin J, et al. Fungal laryngitis in immunocompetent patients. J Laryngol Otol. 2004;118:379 " 381.
Reveiz L, Cardona AF, Ospina EG. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev. 2007;(2):CD004783.

Codes

ICD9

464.00 Acute laryngitis without mention of obstruction
464.01 Acute laryngitis with obstruction
476.0 Chronic laryngitis
034.0 Streptococcal sore throat
464.0 Acute laryngitis

ICD10

J04.0 Acute laryngitis
J05.0 Acute obstructive laryngitis [croup]
J37.0 Chronic laryngitis
B95.5 Unspecified streptococcus as the cause of diseases classified elsewhere

SNOMED

45913009 Laryngitis (disorder)
195684009 acute haemophilus influenzae laryngitis (disorder)
29951006 Chronic laryngitis
408669002 Acute laryngitis with obstruction (disorder)
441551009 Viral laryngitis
85083002 Streptococcal laryngitis (disorder)

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