Acute Laryngitis


Article Author:
Gunjan Gupta


Article Editor:
Kunal Mahajan


Editors In Chief:
Rhonda Coffman
Lindsay Iverson
Heather Templin


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
11/22/2018 12:52:47 PM

Introduction

Laryngitis refers to inflammation of the larynx and can present in both acute and chronic form.[1] Acute Laryngitis is a mild and self-limiting condition that typically lasts for a period of 3 to 7 days. If this condition lasts for over 3 weeks, then it is termed as chronic laryngitis. The acute form of laryngitis is more common among both.

Etiology

The etiology for acute laryngitis can be classified as infectious and non-infectious. The infectious form is more common and usually follows the upper respiratory tract infection. To begin with, it is usually viral but soon bacterial agents supervene. Viral agents include Rhinovirus, Parainfluenza virus, Respiratory Syncytial virus, coronavirus, adenovirus, influenza virus. Coxsackievirus and HIV may be potential causes among immunocompromised individuals. Most commonly encountered bacterial organisms are Streptococcus pneumoniae, H.influenzae, and Moraxella catarrhalis. Exanthematous fevers like measles, chickenpox and whooping cough are also associated with acute laryngitis. Laryngitis caused by fungal infection is also common but frequently remains undiagnosed. This usually occurs secondary to use of inhaled corticosteroids or recent antibiotic use. trains causing fungal laryngitis includehHistoplasma, blastomyces, candida, cryptococcus and coccidioides

The non-infectious form is due to vocal trauma, allergy, gastroesophageal reflux disease, use of asthma inhalers, environmental pollution, smoking and thermal or chemical burns of the larynx.

In addition, the patients with rhinitis are more prone to develop laryngitis.

Epidemiology

Acute laryngitis usually affects individuals aged 18 to 40 years of age. However, it may be seen in children as young as  3 years of age or above. Accurate figures regarding the incidence of acute laryngitis remain unknown as this condition remains unreported most of the times. Since its a self-limiting disease, significant morbidity and mortality are not encountered.

Pathophysiology

An acute form of laryngitis resolves within 2 weeks. Infectious form is characterized by congestion of larynx in early stages. As the healing stage begins, white blood cells invade at the site of infection to remove the pathogens. This process enhances vocal cord edema and affects vibration adversely. As the edema progresses phonation threshold pressure increases. Generation of adequate phonation pressure becomes difficult, and the patient develops hoarseness. Sometimes edema is so marked that it becomes impossible to generate adequate phonation pressure. In such a situation, the patient develops frank aphonia.

Vocal Trauma induced acute laryngitis usually occurs following excessive screaming or singing. This results in damage to the outer layer of the vocal fold. However, repeated episodes may cause fibrosis and scarring at a later stage. 

History and Physical

Initial symptoms are those of upper respiratory tract infection and include fever, cough, sore throat and rhinorrhoea. Following this,  acute laryngitis sets in. Symptoms are usually abrupt in onset and get worsened over two or three days. These include:

  • Change in quality of voice, in later stages there may be a complete loss of voice (aphonia).
  • Discomfort and pain in the throat, particularly after talking.
  • Dysphagia, odynophagia
  • Dry irritating cough which worsens at night.
  • General symptoms of dryness of throat, malaise, and fever.

Diagnosis can usually be made based on history.

Local Examination of larynx further confirms the diagnosis. Indirect examination of the airway with a mirror and direct examination with a flexible nasolaryngoscope is used for examination. Laryngeal appearances vary with the severity of the disease. In the early stages there is erythema and edema of the epiglottis, aryepiglottic folds, arytenoids, and ventricular bands, but vocal cords, in contrast, are normal and white, betraying the degree of hoarseness the patient has. As the disease progresses, vocal cords also turn red and edematous. The subglottic region may also get involved. Sticky secretions may also be seen between vocal cords and interarytenoid region. In case of vocal abuse, submucosal hemorrhage may also be seen in vocal cords.

Evaluation

Diagnosis is usually made clinically only. Fiberoptic or indirect laryngoscopy further confirms the diagnosis.  Stroboscopy reveals asymmetry, aperiodicity, and reduced mucosal wave pattern. Further imaging or laboratory studies are not required. Rarely, if the patient has exudate in the oropharynx or vocal cords, culture may be sent.

Treatment / Management

Treatment is often supportive in nature and depends on the severity of laryngitis.

  • Voice rest: This is the single most important factor. Use of voice during laryngitis results in incomplete or delayed recovery. Complete voice rest is recommended although it is impossible to achieve. If the patient needs to speak, soft sighing speech is best.
  • Steam Inhalation: Inhaling humidified air enhances moisture of upper airway and helps in removal of secretions and exudates.
  • Avoidance of irritants: Smoking and alcohol should be avoided. Smoking delays prompt resolution of the disease process
  • Dietary modification: dietary restriction is recommended for patients with gastroesophageal reflux disease. This includes avoiding caffeinated drinks, spicy food items, fatty food, chocolate, peppermint. Another important lifestyle modification is avoidance of late meals. The patient should have meals at least 3 hours before sleeping. The patient should drink plenty of water.
  • Medications: Antibiotics prescription for an otherwise healthy patient with acute laryngitis is currently unsupported; however for high-risk patients and patients with severe symptoms antibiotics may be given. Some authors recommend narrow-spectrum antibiotics only in presence of identifiable gram stain and culture.

fungal laryngitis can be treated by use of oral antifungal. Treatment is usually required for three weeks period and may be repeated if needed.

Mucolytics like guaifenesin may be used for clearing secretions.

Certain authors also recommend the use of osmolyte ecotine containing oral and throat sprays.

In addition to lifestyle and dietary modification gastroesophageal reflux disease-related laryngitis is treated with antireflux medications. Antacid medications that suppress the acid production such as H2 receptor and proton pump blocking agents are highly effective against gastroesophageal reflux. Among all these groups, proton pump inhibitors are found to be most effective.

Prevailing data do not support the prescription of antihistaminics or oral corticosteroids for treating acute laryngitis.

Differential Diagnosis

This includes spasmodic dysphonia, reflux laryngitis, chronic allergic laryngitis, epiglottitis or coryza.

Prognosis

As this is a self-limiting condition, it carries a good prognosis. If patient sticks to above-mentioned therapy, the prognosis for recovery to a premorbid level of phonation is excellent.

Enhancing Healthcare Team Outcomes

Acute laryngitis is a self limiting condition. Voice rest is recommended. (Level 1) Antihistaminics and oral steroids have no role in treatment. (Level 1)


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Acute Laryngitis - Questions

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A patient is seen with symptoms of an upper respiratory tract infection. Upon examination, erythema, edema, and irregular contour of the vocal folds are noted. No exudate or vocal fold hemorrhages are noted. Acute laryngitis is diagnosed. Which of the following is an appropriate choice for management of this condition?



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A 30-year-old female who is a professional lecturer presents with a complaint of a cold and cough for 5 days and a change in the quality of her voice for 3 days. Local examination of the larynx reveals congested vocal cords. The diagnosis of acute laryngitis is made. What is the treatment of choice for this condition?



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A 40-year-old male is diagnosed with gastroesophageal reflux-induced laryngitis. The treating provider gives him certain advice regarding lifestyle modification. All of the following are true regarding lifestyle modification for gastroesophageal reflux-induced laryngitis except which one?



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A 25-year-old male who is a professional singer presents to an otolaryngologist with a change in the quality of his voice for 6 days. He also gives a history of a common cold 1 week ago. On local examination, the arytenoids, epiglottis, and aryepiglottic folds are congested. The vocal cords, however, appear normal. Which of the following regarding the diagnosis and management of this disease is true?



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A 17-year-old male who is a professional singer consults an otolaryngologist for hoarseness of voice, throat pain, and cough for 5 days. Laryngeal examination reveals congested and edematous vocal cords. What is the most likely diagnosis?



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Acute Laryngitis - References

References

Jaworek AJ,Earasi K,Lyons KM,Daggumati S,Hu A,Sataloff RT, Acute infectious laryngitis: A case series. Ear, nose,     [PubMed]

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