Acute Laryngitis

Practice Essentials

Laryngitis is one of the most common conditions identified in the larynx. Laryngitis, an inflammation of the larynx, manifests in both acute and chronic forms.

Acute laryngitis has an abrupt onset and is usually self-limited. If a patient has symptoms of laryngitis for more than 3 weeks, the condition is classified as chronic laryngitis. The etiology of acute laryngitis includes vocal misuse, exposure to noxious agents, or infectious agents leading to upper respiratory tract infections. The infectious agents are most often viral but sometimes bacterial.

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This view depicts the larynx of a 62-year-old woman with an intermittent history of exudative acute laryngitis that was treated conservatively. Courte....

Rarely, laryngeal inflammation results from an autoimmune condition such as rheumatoid arthritis, relapsing polychondritis, Wegener granulomatosis, or sarcoidosis. A case report showed a 2-year-old intubated patient who was given activated charcoal for poisoning, resulting in obstructive laryngitis. This unusual case demonstrates the myriad potential etiologies of acute laryngitis.

Chronic laryngitis, as the name implies, involves a longer duration of symptoms; it also takes longer to develop. Chronic laryngitis may be caused by environmental factors such as inhalation of cigarette smoke or polluted air (eg, gaseous chemicals), irritation from asthma inhalers, vocal misuse (eg, prolonged vocal use at abnormal loudness or pitch), or gastrointestinal esophageal reflux. Vocal misuse results in an increased adducting force of the vocal folds with subsequent increased contact and friction between the contacting folds. The area of contact between the folds becomes swollen. Vocal therapy has the greatest benefit in the patient with chronic laryngitis.

Although acute laryngitis is usually not a result of vocal abuse, vocal abuse is often a result of acute laryngitis. The underlying infection or inflammation results in a hoarse voice. Typically, the patient exacerbates the dysphonia by misuse of the voice in an attempt to maintain premorbid phonating ability.

Workup

No laboratory studies are necessary in acute laryngitis. If the patient has an exudate in the oropharynx or overlying the vocal folds, a culture may be taken.

Direct fiberoptic or indirect laryngoscopy may be performed to provide a view of the larynx. This examination reveals redness and small dilated vasculature on the inflamed vocal folds.

Analysis of vocal fold movement reveals asymmetry and aperiodicity with reduced mucosal waves and incomplete vibratory closure. The propagation of the mucosal wave is also reduced.

Management

The following measures can help to lessen the intensity of laryngitis as the patient waits for the condition to resolve:

• Inhaling humidified air promotes moisture of the upper airway, helping to clear secretions and exudate
• Complete voice rest is suggested, although this recommendation is nearly impossible to follow; if the patient must speak, soft sighing phonation is best; avoidance of whispering is best, as whispering promotes hyperfunctioning of the larynx
• Prevailing data do not support the use of antihistamines and corticosteroids

The treatment for gastroesophageal reflux disease (GERD)–related laryngitic conditions includes dietary and lifestyle modifications, as well as antireflux medications. Antacid medications that suppress acid production, such as H2-receptor and proton pump blocking agents, are highly effective against gastroesophageal reflux. Of the various classes of medicines available to treat GERD, the proton pump inhibitors are the most effective.^[1]

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Pathophysiology

Acute laryngitis is an inflammation of the vocal fold mucosa and larynx that lasts less than 3 weeks. When the etiology of acute laryngitis is infectious, white blood cells remove microorganisms during the healing process. The vocal folds then become more edematous, and vibration is adversely affected. The phonation threshold pressure may increase to a degree that generating adequate phonation pressures in a normal fashion becomes difficult, thus eliciting hoarseness. Frank aphonia results when a patient cannot overcome the phonation threshold pressure required to set the vocal folds in motion.

The membranous covering of the vocal folds is usually red and swollen. The lowered pitch in laryngitic patients is a result of this irregular thickening along the entire length of the vocal fold. Some authors believe that the vocal fold stiffens rather than thickens. Conservative treatment measures, as outlined below, are usually enough to overcome the laryngeal inflammation and to restore the vocal folds to their normal vibratory activity.

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Epidemiology

Frequency

United States

The exact prevalence of acute laryngitis is not reported because many patients often use conservative measures to treat their inflammation rather than seek medical consultation. Symptoms of an upper respiratory tract infection often accompany the disease; thus, patients are accustomed to managing their own treatment. Nevertheless, laryngitis is one of the most common laryngeal pathologies.

A study by Bhattacharyya suggested that annually about 1% of children in the United States are effected by voice or swallowing problems, with laryngitis being a common diagnosis in these cases. Using the 2012 National Health Interview Survey, the study found that an estimated 839,000 children in the United States (1.4%) reported a voice problem in the 12 months preceding the survey, with 53.5% of these youngsters having been given a diagnosis for it, the most prevalent being laryngitis (16.6%) and allergies (10.4%).^[2]

A retrospective study by Roy et al indicated that among elderly members of the US population (those over age 65 years) who saw a primary care physician or otolaryngologist, acute and chronic laryngitis were among the most frequent laryngeal/voice disorder diagnoses, along with nonspecific dysphonia and benign vocal fold lesions. The study, which was based on information from a national administrative database, also found that among the elderly, women had greater odds of developing acute laryngitis than did men.^[3]

A study by Benninger et al found that between 2008 and 2012, an increase in dysphonia diagnoses in the US population (from 1.3% to 1.7%) was accompanied by an associated rise in acute laryngitis diagnoses.^[4]

Mortality/Morbidity

Because acute laryngitis is usually self-limited and treated with conservative measures, significant morbidity and mortality are not encountered. Patients who develop acute laryngitis from an infectious etiology rather than vocal trauma may ultimately injure their vocal folds. The deficient voice production in patients with acute laryngitis may result in application of a greater adduction force or tension to compensate for the incomplete glottic closure during an acute laryngitic episode. This tension further strains the vocal folds and decreases voice production, ultimately delaying return of normal phonation.

In 1997, Ng conducted a study of the aerodynamic and acoustic characteristics of acute laryngitis.^[5] His study demonstrated that across the 5 vowels, the fundamental frequency values were lower in patients with acute laryngitis than in patients with a normal voice. The authors concluded that acute laryngitis changes the vocal fold mass, resulting in a reduction of the fundamental frequency; other authors have anecdotally corroborated this finding.^[6]

Patients with acute laryngitis have an increased open quotient value. This indicates that the patient's vocal folds are open longer, and less time is spent in the closed position, which contributes to the hoarseness and breathiness of the voice.

Laryngitis has a significant economic impact. Over the economic burden, pharmaceutical costs were approximately 30% of such costs.^[7]

Age

Studies have demonstrated that, usually, acute laryngitis affects individuals aged 18-40 years. Children, a category not included in the above study, are clinically observed with acute laryngitis when aged 3 years and older.

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History

In addition to symptoms of an upper respiratory tract infection (ie, fever, cough, rhinitis), the patient also experiences dysphonia or a hoarse voice. A hoarse voice is defined as one that has the components of breathiness and tension.^[5] These symptoms are consistent with laryngitis and are not specific for acute or chronic laryngitis. Patients with laryngitis may also experience odynophonia, dysphagia, odynophagia, dyspnea, rhinorrhea, postnasal discharge, sore throat, congestion, fatigue, and malaise.^[8] The patient's vocal symptoms usually last 7-10 days. If symptoms persist longer than 3 weeks, a workup for chronic laryngitis should be performed.

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Physical

As Postma indicates, the diagnosis of acute laryngitis may be made solely based on the history and symptoms; thus, visual examination of the larynx is not always imperative. Certainly, if seen by an otolaryngologist, the patient would have a thorough examination of the head and neck, involving visual inspection of the larynx. Delay in referral to an otolaryngologist for 3 weeks may be acceptable for a primary care physician. However, an otolaryngologist should perform a laryngoscopy in a patient with hoarseness without delay in order to avoid missing other pathologies, such as cancer, vocal nodules, or papillomas.

Other than findings of a common upper respiratory tract infection, the patient may appear healthy.

Indirect examination of the airway with a mirror or direct examination with a flexible nasolaryngoscope reveals erythema and edema of the vocal folds, secretions, and irregularities of the surface contour of the vocal folds. Note the presence of normal vocal fold mobility and the absence of airway obstruction.

In a case series of seven patients who underwent strobovideolaryngoscopy before and after developing acute laryngitis, Jaworek et al found that although during the episode of laryngitis, the expected erythema, edema, cough, and dysphonia were present, five of the patients also displayed new masses. However, all signs returned to their prelaryngitis state with conservative management.^[9]

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Causes

Infection (usually viral upper respiratory tract infection), including with the following, can cause acute laryngitis^[8] :

• Rhinoviruses
• Parainfluenza viruses
• Respiratory syncytial virus
• Adenoviruses
• Influenza viruses
• Measles virus
• Mumps virus
• Bordetella pertussis
• Varicella-zoster virus

Other causes of acute laryngitis include the following:

• Gastroesophageal reflux disease (GERD)
• Environmental insults (pollution)
• Vocal trauma
• Use of asthma inhalers

A report notes herpes simplex virus as another viral etiology.^[10] The role of rhinitis and the unified airway points to the fact that patients with rhinitis are more prone to manifest with dysphonia and laryngitis.^[11]

A study by Bhattacharyya indicated that infectious laryngitis is the most common diagnosis in adults with voice problems in the United States. Analyzing cases from the 2012 National Health Interview Survey, Bhattacharyya estimated that 17.9 million adults reported voice problems in the 12 months preceding the survey, with an estimated 685,000 cases having been diagnosed with infectious laryngitis and an estimated 308,000 having been diagnosed with GERD.^[12]

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Laboratory Studies

See the list below:

• No laboratory studies are necessary. If the patient has an exudate in the oropharynx or overlying the vocal folds, a culture may be taken. As Vaughan indicates, do not institute antibiotic coverage until the results of the Gram stain and cultures with sensitivity have been determined.^[6]

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Imaging Studies

See the list below:

• Direct fiberoptic or indirect laryngoscopy may be performed to provide a view of the larynx. This examination reveals redness and small dilated vasculature on the inflamed vocal folds.
• Analysis of vocal fold movement reveals asymmetry and aperiodicity with reduced mucosal waves and incomplete vibratory closure. The propagation of the mucosal wave is also reduced. Ng describes a finding by Colton and Casper that the mucosal wave appears to have 2 distinct velocities of travel.^[5] The wave travels at 1 speed on the surface of the vocal fold; but, at a discrete point, it changes its speed of travel. Indeed, this change may be because of the edema and intrinsic inflammation of the vocal fold, which affects the inherent motion of the vocal fold in an irregular manner.

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Medical Care

Vaughan states that patients know that laryngitis treatment requires only time and the common-sense avoidance of vocal excess and other irritants. The following measures can help to lessen the intensity of the laryngitis while waiting for the condition to resolve:

• Inhaling humidified air promotes moisture of the upper airway, helping to clear secretions and exudate.
• Complete voice rest is suggested, although this recommendation is nearly impossible to follow. If the patient must speak, soft sighing phonation is best. Avoidance of whispering is best, as whispering promotes hyperfunctioning of the larynx.
• Prevailing data do not support the use of antihistamines and corticosteroids. If a patient uses these medications, he or she may have the false impression that the laryngitis is resolving and may continue to use his or her voice, leading to further insult. The drying effect of these medicines may also be deleterious.

A patient who smokes must cease smoking in order to promote timely resolution of the acute laryngitis. If the patient's laryngitis is from an infectious etiology, continued smoking delays prompt resolution of the disease process.

A study by Müller et al indicated that a mouth and throat spray containing the osmolyte ectoine is effective against acute pharyngitis and/or laryngitis, demonstrating good to very good tolerability and reducing cervical lymph node swelling to a significantly greater degree than saline lozenges. The prospective, controlled, nonrandomized trial included 95 patients.^[14]

The most common etiology for acute laryngitis is an infectious source, usually a viral upper respiratory tract infection. In 1985, Schalen observed that, at the time of the acute laryngitic episode, many patients were carriers of bacterial infectious agents, the most common of which were Branhamella catarrhalis and Haemophilus influenzae.^[15] These patients experienced more severe dysphonia than patients with negative culture results.

Despite the high isolation rate of organisms from the nasopharynx, a double-blind, placebo-controlled study of patients with acute laryngitis revealed that administration of penicillin V was not advantageous in the treatment of acute laryngitis.^[15] The study found that penicillin V administration did not decrease bacterial counts or alleviate symptoms. Schalen concluded that antibiotic treatment for otherwise healthy patients with acute laryngitis is currently unsupported; however, for high-risk patients and patients with severe symptoms, antibiotics may be considered. Others advocate the use of narrow-spectrum antibiotics only in the presence of an identifiable Gram stain and culture.^[6]

A study by Reveiz and Cardona, from the Cochrane Database of Systematic Reviews, indicated that when objective outcomes are evaluated, antibiotic therapy does not seem to be effective for acute laryngitis, although there was some subjective indication that erythromycin can improve voice disturbance and cough. One study in the report also found a higher cure rate associated with fusafungine on the fifth day of therapy when compared with no treatment but did not find significant differences in the cure rate at later points in time. The investigators cautioned that the randomized, controlled trials used in their report had a moderate to high risk of bias and low quality of evidence.^[16]

A retrospective study by Silverman et al found that primary care physician practices in Ontario, Canada, provided antibiotic prescriptions to 46% of elderly patients (aged 66 years or above) with nonbacterial acute upper respiratory tract infections. Those most likely to write such prescriptions included midcareer to late career physicians, physicians who received their training outside of Canada or the United States, and physicians who saw 25 or more patients per day.^[17]

The treatment for gastroesophageal reflux disease (GERD)–related laryngitic conditions includes dietary and lifestyle modifications, as well as antireflux medications. Antacid medications that suppress acid production, such as H2-receptor and proton pump blocking agents, are highly effective against gastroesophageal reflux. Of the various classes of medicines available to treat GERD, the proton pump inhibitors are the most effective.^[1] Patients on prolonged antireflux therapy or with a history of long-standing GERD should be evaluated by a gastroenterologist to ensure that serious sequelae of GERD, such as Barrett esophagitis, have not manifested or do not develop.

Note that optimal timing of proton pump inhibitor intake increases its efficacy. For patients who require twice-a-day dosing, suggested dosing times that are 15-30 minutes before breakfast and dinner.^[18] Katz cautions that treatment durations may be longer for patients with reflux laryngitis than for patients with other extraesophageal manifestations of GERD (eg, asthma, cough, noncardiac chest pain).

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Diet

Dietary restrictions are recommended for patients with GERD. These include avoidance of caffeine, fatty foods, chocolate, peppermint, and late meals (ie, < 3 h before retiring).^[18] The patient should maintain hydration and fluid intake at a stress level to support requirements during the illness. The patient should drink at least 6-8 glasses (8 oz each) of water per day.

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Activity

Although not always possible, patients who use their voices professionally should attempt complete vocal rest. If the patient must communicate, soft sighing use of the voice causes the least vocal trauma. Patients suspected of having GERD should avoid lying down after meals and should elevate the heads of their beds.

A physician is often consulted to decide if a professional voice user should cancel or perform an engagement. A contraindication to performance is the presence of vocal fold hemorrhage or exudative laryngitis.^[6] If the patient has mild laryngitis, the physician's decision whether to allow the patient to perform becomes difficult. Vaughan's guiding principle is to do no harm because tomorrow is important, also. If the professional performer wants the show to proceed, he or she should adapt the show and vocal efforts during the performance to minimize vocal abuse.

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Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

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Omeprazole (Prilosec)

• Dosing, Interactions, etc.

Clinical Context:  Specifically suppress gastric acid secretion by potent inhibition of the H+/K+ ATPase enzyme system at secretory surface of gastric parietal cell. This blocks the final step in gastric acid production. Effect is dose related and inhibits both basal and meal stimulated acid secretion.

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Esomeprazole magnesium (Nexium)

• Dosing, Interactions, etc.

Clinical Context:  S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H⁺/K⁺ ATP pump at secretory surface of gastric parietal cells.

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Lansoprazole (Prevacid)

• Dosing, Interactions, etc.

Clinical Context:  Suppresses gastric acid secretion by specifically inhibiting H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells.

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Class Summary

These agents inhibit gastric acid secretion by inhibition of the H+/K+/ATP-ase enzyme system in the gastric parietal cells. These agents are used in cases of severe esophagitis.

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Further Outpatient Care

If the patient's laryngitis symptoms have not resolved after approximately 3 weeks, an otolaryngologist should be consulted to evaluate the patient for chronic laryngitis. A patient who has hoarseness and is not following a usual course of acute laryngitis or has risk factors for upper aerodigestive tract carcinoma should be promptly seen by an otolaryngologist.

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Inpatient & Outpatient Medications

In addition to conservative treatment of an upper respiratory tract infection and humidification of the airway with vocal rest, antipyretics and decongestants may be administered for the patient's comfort. Mucolytics such as guaifenesin may be used to aid in clearing secretions.

An excellent systematic review attempted to answer the question of whether antibiotics were recommended in cases of acute laryngitis. The authors cite 2 studies by the same research group. In one study, patients received either penicillin V (800 mg for 5 d) or placebo. The 2 groups showed no significant difference in symptoms or blinded voice evaluation findings. The research group published a second study in which erythromycin was administered. Those who received erythromycin showed a small voice benefit after one week and slightly better cough symptoms after 2 weeks. The overall conclusion from the Cochrane Database Systematic Review was that antibiotics are not indicated for most cases of acute laryngitis.^{[16, 19]}

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Prognosis

Acute laryngitis is usually self-limited. If the patient adheres to a treatment plan as outlined above, the prognosis for a rapid recovery to a premorbid level of phonation is excellent.

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Patient Education

For excellent patient education resources, visit eMedicineHealth's Ear, Nose & Throat Center. Also, see eMedicineHealth's patient education article Laryngitis.

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