What is the treatment for acute laryngitis?

Treatment of Acute Laryngitis

Acute laryngitis should be managed with supportive care alone—antibiotics should not be prescribed, and corticosteroids should not be used empirically without laryngoscopy. 1, 2

Core Management Strategy

Do Not Use Antibiotics

• Antibiotics are strongly contraindicated for routine treatment of acute laryngitis, as systematic reviews and randomized trials demonstrate no objective benefit and a preponderance of harm over benefit. 1, 3
• Acute laryngitis is caused by viral pathogens (parainfluenza, rhinovirus, influenza, adenovirus) and is self-limited, with symptomatic improvement occurring within 7-10 days regardless of treatment. 1, 2
• A Cochrane review found that antibiotics do not improve objective voice scores at any time point. 3, 4
• While erythromycin showed modest subjective improvement in voice disturbance at one week (RR 0.64, NNTB 3.76), these subjective benefits do not outweigh the risks of adverse effects, costs, and contribution to antibiotic resistance. 4
• Penicillin V showed no benefit whatsoever in treating acute laryngitis in a double-blind trial of 100 adults. 5

Do Not Use Corticosteroids Empirically

• Corticosteroids should not be prescribed empirically for laryngitis before visualization of the larynx via laryngoscopy. 1, 2
• The evidence for benefit is extremely limited (no clinical trials demonstrating efficacy), while the risks are well-documented even with short-term use. 2
• Documented risks include hypertension, cardiovascular disease, osteoporosis, avascular necrosis, pancreatitis, diabetogenesis, impaired wound healing, infections, mood disorders, and sleep disturbances. 1, 2

Supportive Care Approach

• Provide symptomatic relief with analgesics: ibuprofen or acetaminophen are first-line options for pain management. 6
• Counsel patients that acute laryngitis is self-limited with resolution expected within 7-10 days. 1, 2
• Voice rest and hydration are reasonable supportive measures, though not formally studied. 2

Special Circumstances Requiring Different Management

When Laryngoscopy Is Indicated

• Perform laryngoscopy if hoarseness persists beyond 2-4 weeks without a known benign cause. 2
• No patient should wait longer than 3 months for laryngeal examination if symptoms persist. 2
• Laryngoscopy may reveal reversible structural changes including new masses, erythema, and edema that resolve with conservative management. 7

Professional Voice Users

• In professional voice users with confirmed allergic laryngitis who are acutely dependent on their voice, corticosteroids may be considered only after laryngoscopy confirms the diagnosis. 1, 2
• This requires shared decision-making discussing the limited evidence for benefit and well-documented risks. 1, 2
• Even in this select population, the recommendation is based only on limited case reports, not controlled trials. 2

Bacterial Laryngitis (Rare)

• Antibiotics may be appropriate in immunosuppressed patients with documented bacterial infections (e.g., laryngeal tuberculosis in transplant patients, atypical mycobacterial infection). 1
• Bacterial laryngotracheitis secondary to S. aureus presenting with severe symptoms (cough, stridor, increased work of breathing, mucosal crusting) requires antibiotics. 1
• These cases require definitive diagnosis before treatment initiation. 1

Severe Airway Obstruction

• Corticosteroids may be considered in cases of severe airway obstruction, but only after appropriate evaluation determines the cause. 1
• This is distinct from routine acute laryngitis and represents a medical emergency. 1

Critical Pitfalls to Avoid

Antibiotic Misuse Consequences

• Antibiotic overuse contributes to bacterial resistance, with regions of higher resistance experiencing 33% higher treatment costs for infectious diseases. 1
• Antibiotics can cause adverse effects including rash, abdominal pain, diarrhea, vomiting, and drug interactions. 1
• Antibiotics can increase the risk of or exacerbate laryngeal candidiasis. 1
• Medications account for one-fifth to one-third of total direct costs in laryngeal disorder management, with 30% attributable to unnecessary antibiotics. 1

Steroid Misuse Consequences

• Empiric steroid use without laryngoscopy may delay appropriate diagnosis and treatment of underlying serious conditions. 2
• Even single-dose steroid therapy can result in sleep disturbances, mood disorders, gastrointestinal disturbances, metabolic effects, and infection risk. 2
• The per-event costs of steroid-related complications are substantial (e.g., $18,357.90 for fracture, $26,471.80 for non-fatal MI). 2