Laryngitis

Laryngitis is an inflammation of the larynx most commonly due to infection or trauma that can be either acute or chronic. In this condition, the 2 folds of mucous membranes that make up the vocal cords become inflamed and irritated. The inflammation results in a distortion of the voice produced, resulting in a hoarse sound that may lead to an inability to produce any sound (aphonia) in severe cases. In the presence of an infectious cause, patients often also present with rhinorrhea, cough, and mild sore throat.

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Etiology

Laryngitis may be secondary to infection, allergies, trauma, benign or malignant lesions, neurologic dysfunction, functional issues, or systemic causes (see table).

Causes of acute laryngitisCauses of chronic laryngitis
Viral (most common):
  • Rhinovirus
  • Influenza virus
  • Parainfluenza virus
  • Adenovirus
  • Coronavirus
  • Respiratory syncytial virus
  • Compromised immune systems may suffer from herpes, HIV, or coxsackievirus infections
Bacterial:
  • Group A streptococcus
  • Streptococcus pneumoniae
  • Corynebacterium diphtheriae
  • Moraxella catarrhalis
  • Haemophilus influenzae
  • Bordetella pertussis
  • Bacillus anthracis
  • Mycobacterium tuberculosis
Fungal:
  • Histoplasma
  • Blastomyces
  • Candida (immunocompromised patients)
  • Cryptococcus
  • Coccidioides
Trauma: excessive yelling, recent intubation, screaming, singing
  • Allergies
  • Nerve damage
  • Acid reflux
  • Autoimmune disorders
  • Anatomic defects (e.g., polyps, nodules, sores, cancer on the larynx)
  • Irritants (e.g., inhaled toxins, chemical fumes, tobacco smoke, chronic alcohol use, postnasal drip)
  • Muscle tension dysphonia
  • Neurological dysfunction (e.g., unilateral recurrent laryngeal nerve injury post-operatively)
  • Neurological disease (e.g., Parkinson’s, myasthenia gravis)
  • Trauma
  • Stroke

Clinical Presentation

History

  • Triggering factors: concurrent upper respiratory infection, vocal overuse/abuse, exposure to allergens or toxins
  • Smoking, alcohol use, new medications
  • Recent or past surgery involving the head and/or neck
  • Recent or past trauma involving the head and/or neck

Signs and Symptoms (variable)

  • Hoarseness
  • Breathiness
  • Dry or sore throat
  • Coughing
  • Frequent throat clearing
  • Increased saliva production
  • Dysphagia
  • Globus pharyngeus (feeling of a lump in the throat)
  • Cold or flu-like symptoms
  • Swollen lymph nodes in the neck, chest, or face
  • Fever
  • Myalgia
  • Shortness of breath
  • Vocal fatigue
  • Aphonia (inability to voice a sound)

Diagnosis

  • Laryngitis due to trauma: a history of trauma to the head and/or neck
  • Acute viral laryngitis: diagnosed by the low vocal pitch and hoarseness
  • Fungal laryngitis: confirmation made by biopsy and culturing of abnormal lesions
  • Laryngoscopy or stroboscopy for direct and complete visualization of true vocal folds, false vocal folds, epiglottis, pyriform sinus; and vallecula for:
    • Erythema (reddening)
    • Edema (swelling)
    • Dilated blood vessels (acute)
    • Thick, dry laryngeal tissue (chronic)
    • Stiff vocal folds
    • Viscous secretions in the vicinity of the vocal folds

Management

Acute laryngitisChronic laryngitis
Viral
  • Vocal rest, therapy, and oral hygiene
  • Pain medication
  • Mucolytics
  • Home remedies (salt water, honey)
  • Hydration
  • Humidification
Reflux
  • Wearing loose clothing
  • Smaller but more frequent meals
  • Avoid caffeine, alcohol, spicy foods
  • Over-the-counter medications for neutralizing acids (antacids)
  • Antireflux medication
Bacterial
  • Humidification
  • Antibiotics
  • Corticosteroids
  • Nebulized adrenaline
Inflammatory
  • Remove offending agent if present
  • Topical nasal steroids
  • Immunotherapy
  • Antihistamines
Fungal
  • Oral antifungal medication
  • Topical nystatin (as a suspension or pastille)
Autoimmune
  • Cyclophosphamide
  • Prednisolone
Trauma
  • Vocal rest, therapy, and hygiene
Granulomatous
  • Systemic corticosteroids

Prognosis

Acute

  • Persistent but self-limited, typically resolving within 3 weeks
  • Recovery is enhanced when patient follows the treatment regimen.
  • In viral laryngitis, symptoms can persist for an extended period, even when upper respiratory tract inflammation has been resolved.

Chronic

  • Laryngitis that persists for more than 3 weeks
  • Prognosis is dependent on the etiology of laryngitis.
  • In the absence of upper respiratory infection symptomatology, patients with hoarseness persisting longer than 2 weeks should be referred for a complete otolaryngologist examination, especially in the presence of:
    • Associated head and neck cancer risk factors (e.g., tobacco and alcohol use)
    • Red flag symptomatology of a possible malignancy (e.g., hemoptysis, unilateral pain, dysphagia, unexplained weight loss, shortness of breath)

Differential Diagnosis

The following conditions are in included in the differential diagnoses of laryngitis:

  • Any condition that presents with dysphagia: patients experience difficulty swallowing certain foods or liquids, while others can’t swallow at all. Dysphagia may present due to allergies or “colds,” dehydration, gastroesophageal reflux disease, certain medications, or tumors in the mouth, throat, or esophagus.
  • Gastroesophageal reflux disease: the upward movement of gastric acid into the esophagus, which results in heartburn or chest pain. Acid reflux may spill over into the larynx, and acidic irritation to larynx may result in voice hoarseness. 
  • Tonsillitis: an inflammation of the pharyngeal tonsils that is most commonly present in combination with an inflammation of the pharynx. Tonsillitis is very common among children and young adults and is primarily caused by viruses and group A streptococci.
  • Laryngeal carcinoma: a malignant tumor of the larynx that affects older men most commonly. Risk factors include smoking and excessive alcohol consumption.
  • Allergic rhinitis: an inflammation of the nasal mucosa classified into allergic, non-allergic, and infectious. Allergic rhinitis is due to a type 1 hypersensitivity reaction. All 3 types present with nasal congestion, rhinorrhea, and sneezing.

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