What is the best treatment for a healthy 50-year-old female with laryngitis, nasal congestion, and productive cough, who has tested negative for influenza (flu) and COVID-19?

Treatment of Acute Viral Upper Respiratory Infection with Laryngitis

For this healthy 50-year-old woman with laryngitis, nasal congestion, and productive cough who has tested negative for influenza and COVID-19, the best treatment is symptomatic management with non-pharmacological measures as first-line therapy, including adequate hydration, honey for cough suppression, and controlled breathing techniques, with consideration of dextromethorphan for persistent distressing cough.

First-Line Non-Pharmacological Management

Cough Management

• Start with simple measures such as honey (if not contraindicated) to suppress cough 1
• Avoid lying flat on the back as this makes coughing ineffective 1
• Ensure adequate hydration (no more than 2 liters per day) to help thin mucus secretions 1

Nasal Congestion Management

• Consider nasal irrigation with isotonic or hypertonic saline, which provides moisture to respiratory epithelia, gels mucus, promotes ciliary beating, and improves mucociliary clearance 2
• Saline nasal irrigation has been shown to reduce symptoms of seasonal coronaviruses and other common cold viruses 2

Breathing Techniques for Associated Breathlessness

• Implement pursed-lip breathing (inhale through nose, exhale slowly through pursed lips) to relieve perception of breathlessness 1, 3
• Position sitting upright to increase peak ventilation and reduce airway obstruction 3
• Encourage forward-leaning posture with arms bracing a chair to improve ventilatory capacity 1, 3

Pharmacological Options for Persistent Symptoms

For Distressing Cough

• If cough remains distressing despite honey and hydration, consider dextromethorphan as a cough suppressant 4
• Dextromethorphan is available as an extended-release oral suspension providing 12-hour cough relief 4
• Alternative option: short-term use of codeine linctus or codeine phosphate tablets for distressing cough 1

For Fever (if present)

• Use paracetamol for fever and other symptoms rather than NSAIDs 1

Monitoring and Red Flags

Watch for Clinical Deterioration

• Monitor closely for development of shortness of breath or worsening symptoms, which may indicate progression to pneumonia or secondary bacterial infection 1
• Be aware that breathlessness can cause anxiety, which can further worsen breathlessness, creating a vicious cycle 3

Consider Secondary Bacterial Infection

• If symptoms persist beyond 7-10 days or worsen after initial improvement, consider secondary bacterial infection requiring antibiotic therapy 5
• Laboratory markers such as elevated C-reactive protein (CRP) and procalcitonin (PCT) can help distinguish bacterial superinfection 5

Important Clinical Pitfalls to Avoid

• Avoid nebulized therapies in favor of metered-dose inhaler alternatives if bronchodilators are needed, as nebulizers generate aerosols 6
• Do not assume all upper respiratory symptoms are benign; maintain vigilance for progressive dyspnea that could indicate alternative diagnoses 7
• Recognize that similar symptoms can occur with multiple viral pathogens, and co-infections are possible 8

Treatment Duration and Follow-up

• Most viral upper respiratory infections are self-limited and resolve within 7-10 days with symptomatic management 9
• Advise the patient to return or seek further evaluation if symptoms worsen, fever persists beyond 3-5 days, or new symptoms develop (particularly shortness of breath or chest pain) 1