What is the recommended treatment approach for a patient presenting with laryngitis?

Treatment of Laryngitis

For acute laryngitis, provide symptomatic relief with voice rest, adequate hydration, and analgesics while avoiding antibiotics and systemic corticosteroids, which lack proven benefit and carry potential harm. 1

Initial Management Approach

First-Line Conservative Treatment

• Voice rest is essential to reduce vocal fold irritation and promote healing 1, 2
• Maintain adequate hydration to preserve mucosal moisture and reduce irritation 1, 2
• Use analgesics or antipyretics (acetaminophen or NSAIDs) for pain or fever relief 1, 2
• Avoid both loud speaking and whispering, as both strain the vocal cords 1, 2

Expected Clinical Course

• Viral laryngitis typically resolves within 1-3 weeks even with placebo treatment 1
• Most cases are caused by viral pathogens including parainfluenza viruses, rhinovirus, influenza, and adenovirus 1, 3
• Symptoms improving within 7-10 days support the viral etiology 1

Medications to AVOID

Antibiotics - Do Not Prescribe Routinely

• Antibiotics show no effectiveness in treating acute viral laryngitis 1, 3
• They contribute to bacterial antibiotic resistance and increase healthcare costs unnecessarily 1, 3
• May cause side effects including laryngeal candidiasis 1, 3
• The presence of colored mucus does NOT differentiate viral from bacterial infection 2, 3

Systemic Corticosteroids - Do Not Prescribe Routinely

• Lack supporting evidence for efficacy in viral laryngitis 1, 3
• Carry significant potential adverse effects including cardiovascular disease, hypertension, osteoporosis, cataracts, impaired wound healing, infection risk, and mood disorders 1
• Should not be routinely prescribed despite common practice 1, 3

When to Perform Laryngoscopy

Timing for Visualization

• Perform laryngoscopy if symptoms persist beyond 4 weeks or if serious underlying concern exists at any time 4
• The 2018 updated guideline shortened the observation window from 3 months to 4 weeks based on evidence showing delays in diagnosis lead to worse outcomes 4
• Immediate laryngoscopy is warranted for professional voice users (singers, teachers) whose livelihood depends on their voice 4

Red Flags Requiring Prompt Evaluation

• Symptoms persisting beyond 2-3 weeks 1, 3
• Progressive worsening of symptoms 1, 3
• Signs of airway compromise or decreased air entry 2
• Suspicion of bacterial superinfection 1, 3
• High fever (≥39°C/102.2°F) for at least 3 consecutive days plus thick colored mucus 3

Special Clinical Scenarios

Reflux-Associated Laryngitis

• Consider anti-reflux treatment if laryngoscopy shows signs of reflux laryngitis 1
• Be aware of PPI side effects including decreased calcium absorption, increased hip fracture risk, vitamin B12 deficiency, and iron deficiency anemia 1
• Proton pump inhibitors were used in 79% of chronic laryngitis cases in one primary care cohort 5

Pediatric Considerations

• For croup with associated hoarseness, systemic steroids have shown better outcomes 1
• Epinephrine nebulization may be used for post-extubation stridor, with effects occurring within 30 minutes but lasting only about 2 hours 1

Chronic Laryngitis (>3 weeks)

• Laryngoscopy is mandatory to rule out malignancy or vocal fold paralysis 4, 6
• Chronic cases may be related to vocal overuse, occupational exposures, or gastroesophageal reflux 6, 7
• The yearly incidence is 3.47 per 1,000 people, with up to 21% developing chronic laryngitis in their lifetime 5

Common Pitfalls to Avoid

• Do not prescribe sequential antibiotics for viral postinfectious cough, as this promotes antibiotic resistance without clinical benefit 2
• Do not use colored mucus as an indicator for bacterial infection—this misconception leads to inappropriate antibiotic prescribing 2, 3
• Do not delay laryngoscopy beyond 4 weeks in persistent cases, as delays in diagnosis of laryngeal cancer lead to higher disease stages and worse prognosis 4
• Do not overlook professional voice users who require more expedient evaluation regardless of symptom duration 4

Patient Education Points

• Explain the viral nature of most laryngitis cases and the expected 1-3 week time course 1, 3
• Recommend voice conservation techniques and adequate hydration 1, 3
• Advise against the use of antibiotics and steroids for typical viral laryngitis 1, 3
• Emphasize that improvement should occur within 2-3 weeks, and persistence warrants further evaluation 1, 3