What is the treatment for fungal laryngeal infections?

Treatment of Fungal Laryngeal Infections

The treatment of fungal laryngeal infections primarily consists of oral fluconazole 200-400 mg daily for 14-21 days, with intravenous amphotericin B reserved for severe cases or fluconazole-refractory infections. 1

Diagnosis and Assessment

• Early clinical detection and documentation through otolaryngologist-directed fiberoptic laryngoscopy or indirect laryngoscopy is crucial to demonstrate localization of lesions, assess airway patency, obtain cultures, and enable rapid initiation of antifungal therapy 1
• The most common presenting symptom is dysphonia (hoarseness), present in approximately 69% of patients with laryngeal candidiasis 2
• Laryngeal candidiasis commonly affects the striking zone (anterior 1/3rd to posterior 2/3rd) of vocal folds in approximately 89% of cases 3

Treatment Options

First-Line Therapy

• Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 14-21 days is the recommended first-line treatment for fungal laryngeal infections 1
• Most patients respond to a single course of oral antifungal medication, with 96% success rate reported in clinical studies 2
• Complete resolution typically occurs after 3 weeks of oral fluconazole in approximately 65.5% of patients, while 27.3% may need extended treatment for up to 6 weeks 3

Alternative Therapies

• Intravenous amphotericin B at 0.7-1.0 mg/kg/day is recommended for severe infections or when oral therapy cannot be tolerated 1
• Intravenous fluconazole may be appropriate for patients who cannot take oral medications but require systemic antifungal therapy 1
• For fluconazole-refractory cases, itraconazole solution, posaconazole suspension, or voriconazole may be effective alternatives 1

Special Considerations

• Risk factors for fungal laryngeal infections include:

  • Use of inhaled corticosteroids (89% of patients in one study) 2
  • Systemic steroid use 4
  • Immunocompromised status 1
  • Prior antibiotic use 4
  • Diabetes mellitus 4

• For patients using inhaled steroids, consider temporary discontinuation or reduction of dose if possible, and advise proper mouth rinsing after inhaler use 2, 4

• Impending airway obstruction should be managed by endotracheal intubation while initiating antifungal therapy 1

Follow-up and Monitoring

• Clinical improvement should be assessed within 7-10 days of starting therapy 5
• Treatment should continue for at least 14 days and at least 7 days after resolution of all symptoms 5
• If no improvement is seen within 7-10 days, consider:
  • Resistance to the antifungal agent
  • Need for surgical debridement
  • Alternative diagnosis 1

Common Pitfalls

• Fungal laryngitis is often misdiagnosed, with an average delay in diagnosis of up to 6 months after symptom onset 4
• Lesions may mimic malignancy or premalignant conditions, sometimes leading to unnecessary surgical procedures 6, 4
• Empiric steroid therapy without antifungal coverage can exacerbate fungal infections and potentially lead to dissemination 7
• Failure to identify and address underlying risk factors (especially inhaled steroids) may lead to treatment failure or recurrence 2, 4

Treatment Algorithm

1. Confirm diagnosis through laryngoscopy and culture
2. Initiate oral fluconazole 200-400 mg daily for 14-21 days
3. Address risk factors (modify steroid use if possible)
4. Assess response after 7-10 days
5. If improving: Complete full course of treatment
6. If not improving: Consider alternative antifungals (IV amphotericin B, itraconazole, posaconazole) or surgical intervention for biopsy/debridement