Treatment of Laryngitis
For acute viral laryngitis, focus on symptomatic relief with voice rest, hydration, and analgesics—avoid antibiotics and systemic corticosteroids as they provide no benefit and carry significant risks. 1, 2
First-Line Management
Symptomatic treatment is the cornerstone of laryngitis management:
- Voice rest is essential to reduce vocal fold irritation and promote healing 1
- Adequate hydration maintains mucosal moisture and reduces irritation 1, 2
- Analgesics or antipyretics (acetaminophen or NSAIDs) for pain or fever relief 1, 2
- Avoid both loud speaking and whispering, as both strain the vocal cords 1
Most cases are self-limited, with improvement occurring within 7-10 days even without specific treatment 1, 3. The most common viral pathogens include parainfluenza viruses, rhinovirus, influenza, and adenovirus 1, 2, 4.
What NOT to Prescribe
Antibiotics Should Be Avoided
Antibiotics have no role in routine viral laryngitis treatment:
- Show no objective benefit in treating acute laryngitis 2
- Contribute to bacterial antibiotic resistance 1, 2
- Increase healthcare costs unnecessarily 1
- May cause side effects including laryngeal candidiasis 1, 2
Exceptions where antibiotics may be appropriate: immunocompromised patients, confirmed bacterial infection, or bacterial laryngotracheitis with mucosal crusting and increased work of breathing 2
Systemic Corticosteroids Should Be Avoided
Corticosteroids should not be routinely prescribed for laryngitis due to lack of efficacy evidence and well-documented risks:
- Cardiovascular disease and hypertension 1, 3
- Osteoporosis and avascular necrosis 1, 3
- Cataracts 1, 3
- Impaired wound healing and increased infection risk 1, 3
- Mood disorders 1, 3
- Weight gain and diabetogenesis 3
Specific circumstances where prednisone may be considered:
- Professional voice users with confirmed allergic laryngitis who are acutely dependent on their voice 3
- Severe airway obstruction after appropriate evaluation 3
- Certain autoimmune disorders involving the larynx (systemic lupus erythematosus, sarcoidosis, granulomatosis with polyangiitis) 3
- Pediatric croup with associated symptoms 1, 3, 4
Critical caveat: Corticosteroids should not be empirically prescribed before laryngoscopy visualization of the larynx, as empiric use may delay appropriate diagnosis and treatment 3
Reflux-Associated Laryngitis
Anti-reflux treatment requires a nuanced approach based on laryngoscopy findings:
When to Consider Anti-Reflux Therapy
Anti-reflux medications are an option only when laryngoscopy demonstrates signs of laryngitis (erythema, edema, redundant tissue, and/or surface irregularities of the inter-arytenoid mucosa, arytenoid mucosa, posterior laryngeal mucosa, and/or vocal folds) 5, 1
When NOT to Use Anti-Reflux Therapy
Do not use anti-reflux medications empirically for hoarseness without:
- Symptoms of GERD (heartburn and regurgitation) 5
- Laryngeal findings consistent with laryngitis on laryngoscopy 5
The evidence for empiric PPI therapy is weak—a Cochrane systematic review found no high-quality trials supporting this approach, and a randomized trial of 145 subjects with chronic laryngeal symptoms showed no benefit in symptom scores with esomeprazole 40 mg twice daily versus placebo 5.
PPI Side Effects to Consider
If prescribing PPIs for documented reflux laryngitis, counsel patients about potential adverse effects:
- Decreased calcium absorption and increased hip fracture risk in older adults 5, 1
- Vitamin B12 deficiency in a dose-dependent manner 5, 1
- Iron deficiency anemia 5, 1
- Increased risk of pancreatitis 5
When to Seek Additional Evaluation
Red flags requiring further workup:
- Symptoms persisting beyond 2-3 weeks 1, 2
- Progressive worsening of symptoms 1, 2
- Signs of airway compromise 1, 2
- Suspicion of bacterial superinfection 1, 2
Patient Education Points
Explain to patients:
- The viral nature of most laryngitis cases and expected 7-10 day time course 1, 2, 3
- Voice conservation techniques and adequate hydration recommendations 1, 2
- Why antibiotics and steroids are not appropriate for typical viral laryngitis 1, 2
Special Pediatric Considerations
For pediatric croup with laryngitis symptoms: