What is the recommended steroid treatment for laryngitis?

Steroid Treatment for Laryngitis

Corticosteroids should NOT be routinely prescribed for laryngitis or hoarseness before visualization of the larynx by laryngoscopy, as there is no evidence of benefit and substantial documented harm even with short-term use. 1, 2

Primary Recommendation

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine corticosteroid use for dysphonia or laryngitis prior to laryngeal examination. 1 This is a Grade B recommendation based on:

• Zero clinical trials demonstrating efficacy for corticosteroids in treating laryngitis or dysphonia in adults 1, 2
• Documented adverse events occurring even with short-term steroid courses 1
• Self-limited nature of acute laryngitis, with improvement in 7-10 days regardless of treatment 2

The guideline explicitly states there is a "preponderance of harm over benefit for steroid use" in this context. 1

Why Steroids Should Be Avoided

Documented Risks (Even Short-Term Use)

Corticosteroids carry significant risks that occur even with brief courses:

• Metabolic complications: Insulin resistance, weight gain, lipodystrophy, metabolic syndrome, increased cardiovascular risk 1, 2
• Musculoskeletal effects: Hip/femur fractures (21-30% incidence), vertebral fractures, osteoporosis, myopathy, avascular necrosis 1, 2
• Neuropsychiatric: Sleep disturbances (>30% incidence), mood disorders, insomnia 1
• Gastrointestinal: Peptic ulcers, pancreatitis, GI disturbances 1, 2
• Other: Adrenal suppression (>30% incidence), hypertension (>30% incidence), cataracts, impaired wound healing, increased infection risk 1, 2

The per-event costs are substantial: $26,471.80 for non-fatal myocardial infarction and $18,357.90 for fracture. 1, 2

Lack of Evidence for Benefit

A systematic search of MEDLINE, CINAHL, EMBASE, and the Cochrane Library revealed no studies supporting corticosteroids as empiric therapy for hoarseness or laryngitis except in the special circumstances outlined below. 1

Specific Exceptions Where Steroids May Be Considered

1. Professional Voice Users with Confirmed Allergic Laryngitis

Steroids may be appropriate only when ALL of the following criteria are met: 2

• Laryngoscopy performed to confirm allergic laryngitis diagnosis 2
• Acute voice dependency (e.g., scheduled performance) 2
• Shared decision-making discussing limited evidence and documented risks 2

This exception is based on limited case reports, not controlled trials. 2

2. Pediatric Croup (Acute Laryngotracheobronchitis)

This is the only ENT infection where steroids have demonstrated benefit: 3, 4, 5

• Single dose of dexamethasone 0.6 mg/kg (oral or intramuscular) for moderate to severe croup 4, 5
• High-dose systemic corticosteroids (>0.3 mg/kg dexamethasone for 48 hours) for severe glotto-subglottic laryngitis in hospital settings 3
• Nebulized budesonide 2000 mcg via jet nebulizer is also effective 4

Important caveat: Steroid use should be limited to 24 hours, and antibiotics should be reserved only for signs of bacterial infection to avoid complications like candida laryngotracheitis. 6

3. Severe Airway Obstruction

After appropriate evaluation and determination of cause, steroids may be considered for severe airway compromise. 2

4. Specific Autoimmune Disorders

Steroids may be used for laryngeal involvement in systemic lupus erythematosus, sarcoidosis, or granulomatosis with polyangiitis. 2

Critical Pitfalls to Avoid

Empiric Prescribing Without Laryngoscopy

Prescribing steroids without visualizing the larynx leads to: 1, 2

• Missed or inaccurate diagnoses 1
• Delayed appropriate treatment 2
• Unnecessary exposure to serious adverse effects 1

Inhaled Corticosteroids

Inhaled corticosteroids (particularly fluticasone preparations like Advair and Flovent) can themselves cause laryngitis and dysphonia through direct laryngeal effects, not just candidiasis. 7 Strobovideolaryngoscopy reveals abnormalities in mucosal wave symmetry (76%), phase closure (74%), and glottic closure (63%) in patients using inhaled steroids. 7

Confusion with Other ENT Infections

There is no evidence supporting steroids for non-allergic rhinitis, sinusitis, pharyngitis, tonsillitis, or otitis media. 5 The only ENT infection where steroids have proven benefit is pediatric croup. 5

Recommended Management Algorithm for Adult Laryngitis

1. Do NOT prescribe steroids empirically 1, 2
2. Counsel patient that acute laryngitis is self-limited (7-10 day resolution) 2
3. Perform laryngoscopy if: 2
   • Hoarseness persists >2-4 weeks without known benign cause
   • Concern for underlying serious condition
   • Patient is a professional voice user requiring urgent diagnosis
4. After laryngoscopy, treat based on specific diagnosis identified 1, 2
5. Consider voice therapy if hoarseness reduces quality of life and persists beyond acute phase (Level 1a evidence for effectiveness) 2

Special Consideration: Bacterial Epiglottitis

For supraglottic laryngitis (epiglottitis), which is bacterial (often H. influenzae type B), treatment requires: 3

• Antibiotics in combination with corticosteroids 3
• This is a medical emergency requiring hospital management 3
• Can occur in adults with severity equal to children 3

This represents a distinct entity from typical viral laryngitis and requires immediate specialist involvement.