What is the recommended treatment for a patient with laryngitis, considering potential causes such as viral or bacterial origin, acid reflux, and voice misuse?

Treatment of Laryngitis

Antibiotics should NOT be routinely prescribed for laryngitis, as acute laryngitis is typically viral and self-limited, resolving within 7-10 days without treatment. 1, 2

Acute Viral Laryngitis (Most Common)

Primary Management - Symptomatic Relief Only

• Analgesics or antipyretics for pain or fever 2
• Adequate hydration to maintain vocal fold moisture 2
• Voice rest to reduce vocal fold irritation 2, 3
• Symptoms typically improve within 7-10 days regardless of treatment 1

What NOT to Do

• Do NOT prescribe antibiotics routinely - they show no objective benefit in acute laryngitis and contribute to antibiotic resistance, unnecessary costs, side effects (rash, diarrhea, vomiting), and risk of laryngeal candidiasis 1, 2, 4
• Do NOT prescribe systemic corticosteroids routinely prior to laryngoscopy - lack of evidence for efficacy and potential for significant adverse effects 1, 2
• Do NOT prescribe antireflux medications (PPIs) based on symptoms alone without laryngoscopy - no benefit demonstrated for isolated dysphonia 1

When to Escalate Care

Perform or Refer for Laryngoscopy If:

• Dysphonia persists beyond 4 weeks 1
• Recent head, neck, or chest surgery 1
• Recent endotracheal intubation 1
• Concomitant neck mass 1
• Respiratory distress or stridor 1
• History of tobacco abuse 1
• Professional voice user 1
• Any suspicion of serious underlying cause 1

Chronic Laryngitis (>3 weeks duration)

Diagnostic Approach

• Laryngoscopy is mandatory before initiating any treatment to establish diagnosis and rule out malignancy 1, 3
• Document findings and communicate results to speech-language pathologist if voice therapy indicated 1

Treatment Based on Etiology

Voice Therapy:

• Strongly advocate for voice therapy when dysphonia is from a cause amenable to therapy (vocal overuse, nodules, functional disorders) 1
• Must perform laryngoscopy BEFORE prescribing therapy 1

Reflux-Related (Only After Laryngoscopy):

• Consider antireflux treatment only if laryngoscopy shows specific findings: erythema, edema, or surface irregularities of interarytenoid mucosa, arytenoid mucosa, posterior laryngeal mucosa, or vocal folds 1
• PPIs may improve laryngeal lesions in select cases with documented laryngoscopic findings 1
• Be aware: PPIs carry risks including decreased calcium/vitamin B12/iron absorption, increased hip fracture risk in elderly, and potential pancreatitis 1

Exceptions Where Antibiotics May Be Appropriate

Antibiotics should only be considered in these specific circumstances:

• Immunocompromised patients (e.g., laryngeal tuberculosis in transplant/HIV patients) 1
• Confirmed bacterial infection (diagnosis established prior to therapy) 1
• Bacterial laryngotracheitis with mucosal crusting, stridor, increased work of breathing, and systemic symptoms 1
• Pertussis outbreaks with confirmed diagnosis 1

Critical Pitfalls to Avoid

• Colored mucus does NOT differentiate viral from bacterial infection - this is a common misconception 2
• Do not obtain CT or MRI before visualizing the larynx 1
• Do not use decongestants for acute or chronic laryngitis 3
• Avoid polypharmacy in elderly patients, as multiple medications increase fall risk 5

Patient Education

Explain to patients:

• The viral nature of acute laryngitis 2
• Expected resolution within 7-10 days 1
• Voice conservation techniques 2
• Importance of adequate hydration 2
• When to return if symptoms persist beyond 2-3 weeks or worsen 2