What is the treatment for laryngitis?

Treatment of Laryngitis

Most cases of laryngitis are viral and self-limited, requiring only symptomatic care with voice rest, hydration, and analgesics—antibiotics and systemic corticosteroids should not be routinely used due to lack of proven benefit and potential for harm. 1

Initial Management Approach

For patients with new-onset hoarseness, initial observation is reasonable as viral laryngitis typically resolves within 1-3 weeks. 2 However, if hoarseness persists beyond 4 weeks or if there is serious underlying concern, laryngoscopy should be performed to visualize the larynx and establish a diagnosis. 2

First-Line Symptomatic Treatment

• Voice rest is essential to reduce vocal fold irritation and promote healing 1
• Adequate hydration helps maintain mucosal moisture and reduce irritation 1
• Analgesics or antipyretics (acetaminophen or NSAIDs) can be used for pain or fever relief 1
• Avoid both loud speaking and whispering, as both strain the vocal cords 1

Medications to Avoid in Routine Cases

Antibiotics Are Not Indicated

Antibiotics should not be prescribed for typical viral laryngitis. 1 The evidence is clear:

• Antibiotics show no effectiveness in treating acute laryngitis 1
• They contribute to bacterial antibiotic resistance 1
• They increase healthcare costs unnecessarily 1
• They may cause side effects, including laryngeal candidiasis 1

Systemic Corticosteroids Are Not Recommended

Corticosteroids should not be empirically prescribed for hoarseness or laryngitis before visualization of the larynx. 3 The American Academy of Otolaryngology-Head and Neck Surgery found a "preponderance of harm over benefit" based on: 3

• No clinical trials demonstrating efficacy for corticosteroids in treating dysphonia or laryngitis in adults 3
• Well-documented adverse effects even with short-term use, including:
  • Cardiovascular disease, hypertension, and cerebrovascular disease 3
  • Osteoporosis, myopathy, and avascular necrosis 3
  • Cataracts 3
  • Impaired wound healing and increased infection risk 3
  • Mood disorders 3
  • Diabetogenesis and weight gain 3

Anti-Reflux Therapy: When to Consider

Do Not Use Empirically

Anti-reflux medications should not be used empirically for hoarseness without symptoms of GERD or laryngoscopic evidence of laryngitis. 2 A randomized trial of 145 subjects with chronic laryngeal symptoms showed no benefit in symptom scores between esomeprazole 40 mg twice daily versus placebo after 16 weeks. 2

When Laryngoscopy Shows Reflux Laryngitis

Anti-reflux treatment may be considered as an option when laryngoscopy demonstrates signs of laryngitis (erythema, edema, redundant tissue, and/or surface irregularities of the interarytenoid mucosa, arytenoid mucosa, posterior laryngeal mucosa, and/or vocal folds). 2

For patients with both extraesophageal symptoms (laryngitis) AND concomitant esophageal GERD symptoms, once- or twice-daily PPIs are recommended. 2 However, be aware of PPI side effects:

• Decreased calcium absorption and increased hip fracture risk 1
• Vitamin B12 deficiency 1
• Iron deficiency anemia 1
• Increased risk of pancreatitis 2

Special Circumstances Where Steroids May Be Appropriate

Professional Voice Users

In professional voice users with confirmed allergic laryngitis who are acutely dependent on their voice, prednisone may be considered after: 3

• Laryngoscopy confirms the diagnosis 3
• Shared decision-making discusses limited evidence and documented risks 3
• Using the lowest effective dose for the shortest duration 3

Pediatric Croup

In pediatric patients with croup and associated hoarseness, systemic steroids have shown better outcomes. 1 Dosage should be high—more than 0.3 mg/kg dexamethasone for 48 hours, followed by oral corticosteroids. 4

Severe Airway Obstruction

Prednisone may be considered in cases of severe airway obstruction after appropriate evaluation determines the cause. 3 Epinephrine nebulization may be used for post-extubation stridor caused by laryngeal edema in pediatric patients, with effects occurring within 30 minutes but lasting only about 2 hours. 1

When to Escalate Care

Refer for laryngoscopy if:

• Hoarseness persists beyond 4 weeks 2
• Progressive worsening of symptoms 1
• Signs of airway compromise 1
• Suspicion of bacterial superinfection 1
• Patient is a professional voice user with significant voice-related quality of life impairment 2

Common Pitfalls to Avoid

Do not delay laryngoscopy beyond 4 weeks in persistent hoarseness. Studies show that most patients wait 88.7 to 119.2 days before seeking treatment, and 64% of primary care providers prefer to treat rather than refer patients with chronic dysphonia. 2 This delay can worsen outcomes, particularly if malignancy is present.

Do not assume all laryngeal findings indicate reflux. The presence of abnormal findings such as the interarytenoid bar has been noted in normal individuals, and inter-rater reliability for findings of edema and erythema is poor to moderate. 2