What is the differential diagnosis and treatment approach for recurrent laryngitis?

Differential Diagnosis for Recurrent Laryngitis

The most common causes of recurrent laryngitis are laryngopharyngeal reflux (LPR), vocal abuse/misuse, chronic rhinosinusitis with postnasal drainage, allergic rhinitis, and chronic irritant exposure (smoking, environmental pollutants). 1

Primary Differential Diagnoses

Laryngopharyngeal Reflux (LPR)

• LPR accounts for up to 15% of all otolaryngology visits and is the leading cause of chronic/recurrent laryngitis in adults. 2, 3
• Key symptoms include hoarseness, throat clearing, globus sensation, chronic cough, and sore throat—often without typical heartburn or regurgitation. 2, 3, 4
• Laryngoscopic findings include posterior laryngeal erythema, edema, vocal cord edema, and occasionally granulomas. 5, 6
• The larynx requires less acid exposure than the esophagus to sustain injury, so intermittent small-volume reflux can cause significant laryngeal damage. 2

Vocal Abuse/Misuse and Functional Voice Disorders

• Excessive voice use, improper vocal technique, shouting, or chronic throat clearing can cause recurrent laryngeal inflammation. 1
• Voice therapy is strongly recommended for patients with hoarseness that reduces voice-related quality of life. 1
• Professional voice users (teachers, singers, performers) are at particularly high risk. 1

Chronic Rhinosinusitis with Postnasal Drainage

• Recurrent acute rhinosinusitis (≥4 episodes/year with complete symptom resolution between episodes) or chronic rhinosinusitis can cause laryngeal irritation from postnasal drainage. 7, 1
• Associated symptoms include purulent nasal discharge, nasal obstruction, facial pressure, and decreased smell. 1, 7
• Underlying allergic rhinitis is present in a significant proportion of patients with recurrent sinusitis. 1, 7

Allergic Rhinitis and Non-Allergic Rhinitis

• Both conditions can cause postnasal drainage leading to chronic laryngeal irritation. 1
• Allergic rhinitis requires evaluation for IgE sensitization to inhalant allergens. 1, 7
• Non-allergic rhinitis variants (vasomotor rhinitis, NARES) can also contribute to recurrent laryngitis. 1

Chronic Irritant Exposure

• Cigarette smoke is a major modifiable risk factor and smoking cessation is mandatory. 1, 7
• Environmental pollutants, occupational exposures, and allergens can cause chronic laryngeal inflammation. 1

Secondary/Less Common Causes to Consider

Recurrent Respiratory Infections

• Viral upper respiratory infections can cause acute laryngitis that becomes recurrent in susceptible individuals. 1
• Antibiotics should NOT be routinely prescribed for hoarseness, as most cases are viral or non-infectious. 1

Immunodeficiency

• Consider in patients with recurrent laryngitis plus recurrent sinusitis, otitis media, bronchitis, or pneumonia. 1, 7
• Evaluation includes quantitative immunoglobulins (IgG, IgA, IgM) and functional antibody responses to tetanus and pneumococcal vaccines. 1, 7

Ciliary Dysfunction Syndromes

• Primary ciliary dyskinesia or secondary ciliary dysfunction can contribute to recurrent upper respiratory inflammation including laryngitis. 1
• Associated with recurrent sinusitis and chronic rhinitis. 1

Structural Abnormalities

• Laryngeal structural issues, velopharyngeal insufficiency, or anatomic variants may predispose to recurrent inflammation. 1
• CT imaging of sinuses may reveal anatomic obstruction contributing to chronic drainage and laryngeal irritation. 1, 7

Diagnostic Approach

Initial Evaluation

• Laryngoscopy (direct or indirect) should be performed or the patient referred to a specialist who can visualize the larynx, particularly if hoarseness persists beyond 2-4 weeks. 1
• Document specific laryngeal findings: erythema, edema, vocal cord appearance, presence of granulomas or masses. 5, 6
• Assess for red flags: prior neck surgery/radiation, recent intubation, progressive symptoms, dysphagia, hemoptysis, or weight loss. 1

Testing for Underlying Causes

• Allergy testing is indicated when allergic rhinitis is suspected as a contributing factor. 1, 7
• CT scan of paranasal sinuses if chronic or recurrent sinusitis is suspected. 1, 7
• Immunologic assessment if immunodeficiency suspected (recurrent infections in multiple sites). 1, 7
• pH monitoring is rarely needed initially, as empiric PPI therapy is the standard diagnostic/therapeutic approach for suspected LPR. 2, 3, 4

Treatment Approach Based on Etiology

For Suspected LPR (Most Common)

• Empiric trial of twice-daily proton pump inhibitor (PPI) therapy for 2-4 months is the recommended first-line approach. 2, 3, 4
• Dietary modifications: avoid late-night eating, acidic foods, caffeine, alcohol, and fatty foods. 1
• Elevate head of bed, avoid tight clothing around abdomen. 1
• Objective improvement can be documented with repeat laryngoscopy and, if hoarse, acoustic voice analysis. 5
• Studies show 50-80% improvement in laryngeal signs and 68-79% resolution of symptoms with PPI therapy. 5, 6

For Vocal Dysfunction

• Voice therapy is strongly recommended and should be advocated for patients with voice-related quality of life impairment. 1
• Referral to speech-language pathologist for voice assessment and therapy. 1
• Vocal hygiene education: adequate hydration, voice rest during illness, avoid throat clearing and shouting. 1

For Chronic/Recurrent Rhinosinusitis

• Daily intranasal corticosteroids are the most important preventive intervention. 7
• Daily high-volume saline nasal irrigation (150ml) combined with intranasal corticosteroids is more effective than either alone. 7
• For acute exacerbations: high-dose amoxicillin-clavulanate for 10-14 days. 7
• Treat underlying allergic rhinitis with environmental control, pharmacotherapy, and consider immunotherapy. 1, 7

For Irritant Exposure

• Mandatory smoking cessation. 1, 7
• Identify and eliminate occupational or environmental irritants. 1
• Good hand hygiene to minimize viral exposures. 7

Specialist Referral Indications

• Hoarseness persisting >4 weeks warrants laryngoscopy by otolaryngologist. 1
• Failure to respond to appropriate medical therapy after 2-4 months. 7, 2, 3
• Suspected structural abnormalities on imaging. 7
• Need for allergy evaluation or immunologic assessment. 1, 7
• Professional voice users requiring specialized voice therapy. 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics routinely for hoarseness—most cases are non-bacterial. 1
• Do not assume all recurrent laryngitis is infectious; LPR and vocal misuse are far more common. 2, 3
• Do not use short courses (<2 months) of standard-dose PPIs for suspected LPR—twice-daily dosing for 2-4 months is required. 2, 3, 4
• Do not overlook smoking as a modifiable risk factor. 1, 7
• Do not delay laryngoscopy in patients with persistent hoarseness, as malignancy must be excluded. 1