What is the treatment for a patient with laryngitis, considering their age, medical history, and severity of symptoms?

Treatment of Laryngitis

Laryngitis should be managed with symptomatic care including voice rest, hydration, and analgesics—antibiotics and systemic corticosteroids should NOT be routinely prescribed as they provide no benefit for typical viral laryngitis and cause unnecessary harm. 1, 2

First-Line Management

The cornerstone of laryngitis treatment is supportive care, as most cases are viral and self-limited, resolving within 7-10 days:

• Voice rest is essential to reduce vocal fold irritation and promote healing 1, 2
• Adequate hydration maintains mucosal moisture and reduces irritation 1, 2
• 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

What NOT to Prescribe

Antibiotics: No Benefit, Only Harm

Antibiotics should not be prescribed for acute laryngitis. 1, 3 The evidence is clear:

• Penicillin V showed no significant differences in objective voice scores or symptom resolution compared to placebo at 1 week, 2 weeks, or 2-6 months follow-up 3, 4
• Erythromycin showed only minimal subjective benefit (slight improvement in voice disturbance at 1 week) but no objective improvement 3
• Antibiotics contribute to bacterial resistance, increase healthcare costs, and cause side effects including laryngeal candidiasis 1
• Even when bacterial pathogens (Branhamella catarrhalis, Hemophilus influenzae) are cultured, antibiotic treatment does not improve outcomes 4

Systemic Corticosteroids: Avoid in Typical Cases

Systemic corticosteroids should not be routinely prescribed for laryngitis due to lack of efficacy evidence and significant potential adverse effects including cardiovascular disease, hypertension, osteoporosis, cataracts, impaired wound healing, infection risk, and mood disorders. 1

The exception is pediatric croup with respiratory distress, where steroids have proven benefit. 1, 5

Special Considerations

Reflux-Associated Laryngitis

• Consider anti-reflux treatment (PPIs) if laryngoscopy demonstrates signs of reflux laryngitis 1
• Be aware of PPI side effects: decreased calcium absorption, increased hip fracture risk, vitamin B12 deficiency, and iron deficiency anemia 1
• Note that in one study, 79% of chronic laryngitis patients were initially treated with PPIs, though this was observational data 6

Pediatric Laryngitis with Respiratory Distress

• Nebulized epinephrine is effective for emergency treatment of acute laryngitis with significant respiratory distress, with effects occurring within 30 minutes but lasting only about 2 hours 1, 5, 7
• Oral or parenteral corticosteroids (such as dexamethasone) are effective for reducing subglottic edema in moderate to severe cases 5, 7
• Maintain adequate hydration and supported sitting position to expand lungs and improve respiratory symptoms 5
• Avoid aspirin in children due to Reye syndrome risk 5

When to Escalate Care

Immediate evaluation is required for:

• Life-threatening airway obstruction, particularly epiglottitis or severe laryngeal edema with decreased air entry 2
• Symptoms persisting beyond 2-3 weeks 1
• Progressive worsening of symptoms 1
• Signs of airway compromise 1
• Suspicion of bacterial superinfection 1

Laryngoscopy Indications

Laryngoscopy should be performed if hoarseness persists beyond 3 months, or at any time if a serious underlying disorder is suspected. 8 This is critical because:

• Most community-acquired hoarseness is viral and resolves within 1-3 weeks 8
• Delays in diagnosis of laryngeal cancer beyond 3 months lead to higher disease stages and worse prognosis 8
• Professionals with high vocal demands (singers, performers) may benefit from immediate evaluation 8

Common Pitfalls to Avoid

• Do not prescribe sequential antibiotics for viral postinfectious cough, as this promotes antibiotic resistance without clinical benefit 2
• Colored mucus does not differentiate viral from bacterial infection—this misconception leads to inappropriate antibiotic prescribing 2
• Decreased air entry requires careful assessment to exclude serious airway compromise before attributing symptoms to simple laryngitis 2
• Do not confuse acute laryngitis (which requires only supportive care) with acute bacterial rhinosinusitis or streptococcal pharyngitis (which may warrant antibiotics under specific criteria) 8