Treatment of Laryngitis
For acute viral laryngitis, focus on symptomatic relief with voice rest, adequate hydration, and analgesics while avoiding antibiotics and systemic corticosteroids, which provide no benefit and carry potential harm. 1, 2
First-Line Management for Acute Laryngitis
The cornerstone of treatment is conservative symptomatic care:
- Voice rest is essential to reduce vocal fold irritation and promote healing 1, 2
- 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 acute laryngitis is viral in etiology (parainfluenza viruses, rhinovirus, influenza, adenovirus) and self-limited, with improvement within 7-10 days even with placebo treatment 1, 2
Medications to Explicitly Avoid
Antibiotics
- Do not routinely prescribe antibiotics for viral laryngitis 1, 2
- Antibiotics show no objective benefit in treating acute laryngitis 2
- They contribute to bacterial resistance, increase healthcare costs, cause side effects, and may lead to laryngeal candidiasis 1, 2
- Exception: Consider antibiotics only for immunocompromised patients, confirmed bacterial infection, or bacterial laryngotracheitis with mucosal crusting and increased work of breathing 2
Systemic Corticosteroids
- Do not routinely prescribe systemic corticosteroids for viral laryngitis in adults due to lack of efficacy evidence 1, 2
- Potential adverse effects include cardiovascular disease, hypertension, osteoporosis, cataracts, impaired wound healing, infection risk, and mood disorders 1
- Exception: Pediatric croup with associated hoarseness may benefit from systemic steroids 1
Chronic Laryngitis Management
For patients with chronic laryngitis (symptoms >3 weeks), the approach differs:
Anti-Reflux Treatment
- Consider anti-reflux medication only if laryngoscopy shows signs of chronic laryngitis (erythema, edema, redundant tissue, or surface irregularities of the interarytenoid mucosa, arytenoid mucosa, posterior laryngeal mucosa, and/or vocal folds) 3
- Do not prescribe anti-reflux medications empirically for hoarseness without signs or symptoms of GERD 3
- This recommendation is based on randomized trials showing no benefit of PPIs for hoarseness without documented reflux findings 3
- When PPIs are indicated, be aware of potential side effects: decreased calcium absorption, increased hip fracture risk, vitamin B12 deficiency, and iron deficiency anemia 1
Clinical Evidence Nuance
The evidence on anti-reflux therapy is mixed. While older observational studies suggested benefit (96% symptom response with progressive antireflux treatment) 4, a more rigorous randomized trial of 145 subjects with chronic laryngeal symptoms and laryngoscopic evidence of laryngitis showed no benefit of esomeprazole 40 mg twice daily versus placebo 3. This highlights the importance of not using PPIs empirically without documented reflux laryngitis on examination.
When to Escalate Care
Additional evaluation is required for:
- 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: