What is the best treatment approach for a patient with laryngitis?

Treatment Approach for Laryngitis

For acute viral laryngitis, focus on symptomatic relief with voice rest, hydration, and analgesics while avoiding antibiotics and systemic corticosteroids, which lack proven benefit and may cause harm. 1

Initial Management Strategy

First-Line Symptomatic 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 spontaneously 3
• Most cases are caused by parainfluenza viruses, rhinovirus, influenza, and adenovirus 1, 4
• Improvement occurs within 7-10 days even with placebo treatment 1

Critical Medications to AVOID

Antibiotics - Do NOT Use Routinely

• Antibiotics show no effectiveness in treating acute viral laryngitis 1, 4
• They contribute to bacterial antibiotic resistance and increase healthcare costs unnecessarily 1
• May cause side effects including laryngeal candidiasis 1
• Important caveat: Colored mucus does NOT differentiate viral from bacterial infection 2, 4

Systemic Corticosteroids - Do NOT Use Routinely

• Lack supporting evidence for efficacy in viral laryngitis 1, 4
• Potential for significant adverse effects including cardiovascular disease, hypertension, osteoporosis, cataracts, impaired wound healing, infection risk, and mood disorders 1
• Exception: Pediatric croup with associated symptoms may benefit from systemic steroids 1

When to Escalate Care

Timing for Laryngoscopy

• Perform laryngoscopy if hoarseness persists beyond 4 weeks or if serious underlying concern exists 3
• The 2018 guideline update shortened the observation window from 3 months to 4 weeks based on consensus that earlier evaluation prevents diagnostic delays 3
• Immediate laryngoscopy is warranted for professional voice users whose livelihood depends on their voice 3

Red Flags Requiring Additional Evaluation

• Symptoms persisting beyond 2-3 weeks 1, 4
• Progressive worsening of symptoms 1, 4
• Signs of airway compromise 1, 4
• Suspicion of bacterial superinfection 1, 4
• Decreased air entry requiring assessment to exclude serious airway compromise 2

Special Clinical Scenarios

Reflux-Associated Laryngitis

• Consider anti-reflux treatment if laryngoscopy shows signs of reflux laryngitis 1
• Use once- or twice-daily PPIs for patients with suspected extraesophageal GERD syndrome (laryngitis) only when concomitant esophageal GERD syndrome is present 3
• Be aware of PPI side effects: decreased calcium absorption, increased hip fracture risk, vitamin B12 deficiency, and iron deficiency anemia 1
• Evidence is weak for treating laryngitis with PPIs in the absence of esophageal GERD symptoms 3

Pediatric Considerations

• Parainfluenza viruses are the most common causative agents 5
• For croup with laryngeal edema: oral glucocorticoids are effective 5
• Epinephrine nebulization may be used for post-extubation stridor, with effects occurring within 30 minutes but lasting only about 2 hours 1
• In children under one year, consider structural and functional anomalies that may mimic laryngitis 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 interpret colored mucus as bacterial infection - this misconception leads to inappropriate antibiotic prescribing 2, 4
• Do not delay laryngoscopy beyond 4 weeks in persistent hoarseness, as delays in diagnosis of laryngeal cancer lead to higher stages and worse prognosis 3
• Do not overlook professional voice users who require more expedient evaluation regardless of symptom duration 3

Patient Education Points

• Explain the viral nature of most laryngitis cases and expected 1-3 week time course 1, 4
• Recommend voice conservation techniques and adequate hydration 1, 4
• Advise against the use of antibiotics and steroids for typical viral laryngitis 1, 4
• Counsel on when to return: symptoms beyond 2-3 weeks, worsening symptoms, or breathing difficulty 1, 4