What is the management for a patient with aphonia (loss of voice) due to tonsillitis?

Management of Aphonia Due to Tonsillitis

For aphonia (loss of voice) caused by tonsillitis, antibiotics should NOT be routinely prescribed, as the American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation against antibiotic use for dysphonia. 1 The voice loss is typically viral in origin (70-95% of tonsillitis cases are viral), and management should focus on supportive care with expectant observation, as symptoms resolve spontaneously within 7-10 days in most patients. 2, 3

Initial Assessment and Red Flags

• Assess the patient's history for factors requiring urgent laryngeal evaluation: recent head/neck/chest surgery, recent intubation, concomitant neck mass, respiratory distress or stridor, tobacco abuse history, or professional voice user status. 1, 2
• Determine if bacterial infection (Group A Streptococcus) is present using clinical criteria or rapid testing, as only 5-15% of adult tonsillitis cases are bacterial. 3
• Voice quality assessment should identify whether the dysphonia is breathy (suggesting vocal fold paralysis) or strained (suggesting other pathology). 1

Primary Management Strategy

Supportive care is the cornerstone of treatment:

• Voice rest and adequate hydration are recommended supportive measures, though formal evidence for their efficacy is limited. 2
• Patient education about the self-limited nature of viral aphonia is essential—most cases resolve within 7-10 days without intervention. 2
• Analgesia with paracetamol and NSAIDs has good evidence of action for symptom relief. 4
• Corticosteroids may provide moderate benefit with a single dose initially followed by reassessment, though the American Academy of Otolaryngology-Head and Neck Surgery recommends against routine use prior to laryngoscopy. 1, 4

When Antibiotics Are Appropriate

Antibiotics should only be prescribed in specific circumstances:

• If Group A Streptococcus is confirmed by testing, penicillin V (500 mg twice daily for 10 days) is the first-line antibiotic. 3, 4, 5
• For penicillin-allergic patients, alternative regimens exist but should be guided by allergy history. 1
• Immunosuppressed patients with confirmed bacterial infection may require antibiotics, but diagnosis must be established prior to initiating therapy. 2

Critical Timing for Laryngoscopy

Perform laryngoscopy or refer when:

• Dysphonia persists beyond 4 weeks without improvement, regardless of the initial presumed cause. 1, 2
• A serious underlying cause is suspected at any time, irrespective of duration. 1
• Delayed laryngoscopy beyond 4 weeks can miss serious conditions like laryngeal cancer, leading to higher disease stages and worse prognosis. 2

Voice Therapy Considerations

• If symptoms persist after laryngoscopy confirms benign findings, voice therapy should be advocated with techniques including gentle phonation exercises, postural manipulations, and circumlaryngeal massage. 1, 2
• Laryngoscopy must be performed before prescribing voice therapy, with results documented and communicated to the speech-language pathologist. 1
• Moderate-to-good evidence supports direct symptomatic and behavioral voice therapies, either alone or combined with education and vocal hygiene. 1

Common Pitfalls to Avoid

• Do not assume all aphonia with tonsillitis is viral—functional (psychogenic) aphonia can present similarly and requires different management with voice therapy and sometimes psychological support. 1, 2
• Do not prescribe antibiotics empirically without confirming bacterial infection—this contributes to antibiotic resistance and provides no benefit for viral causes. 1, 2
• Do not obtain CT or MRI prior to visualization of the larynx for patients with a primary voice complaint. 1
• Do not prescribe antireflux medications based on symptoms alone without laryngeal visualization. 1
• Professional voice users may require more urgent evaluation due to occupational impact, even if symptoms are recent. 1, 2