What is the recommended treatment for a patient with laryngitis?

Treatment for Laryngitis

For viral laryngitis, focus on symptomatic relief with voice rest, hydration, and analgesics while avoiding antibiotics and systemic corticosteroids, which provide no benefit and carry potential harm. 1, 2

Initial Management Approach

Symptomatic Treatment (First-Line)

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

Expected Clinical Course

• Viral laryngitis typically resolves spontaneously within 1-3 weeks 3
• Most cases improve within 7-10 days even without specific treatment 2
• Common viral pathogens include parainfluenza viruses, rhinovirus, influenza, and adenovirus 1, 2

Medications to AVOID

Antibiotics - Do NOT Use Routinely

• Antibiotics show no objective benefit in treating acute viral laryngitis 1, 4
• A Cochrane review found antibiotics ineffective for objective voice outcomes 4
• Antibiotic misuse contributes to bacterial resistance, unnecessary costs, potential side effects, and risk of laryngeal candidiasis 1, 2
• The only modest subjective benefit found was erythromycin reducing voice disturbance at one week, but this does not outweigh the harms 4

Systemic Corticosteroids - Do NOT Use Routinely

• Avoid systemic corticosteroids for viral laryngitis in adults due to lack of efficacy evidence and significant potential adverse effects 1, 2
• Potential harms include cardiovascular disease, hypertension, osteoporosis, cataracts, impaired wound healing, infection risk, and mood disorders 2

When to Escalate Care

Timing for Laryngoscopy

• Perform laryngoscopy if hoarseness persists beyond 4 weeks 3
• Proceed immediately if serious underlying concern exists (potential malignancy or significant impact on professional voice users) 3
• The 4-week threshold balances timely diagnosis against over-utilization, as viral laryngitis typically resolves within 1-3 weeks 3

Red Flags Requiring Additional Evaluation

• Symptoms persisting beyond 2-3 weeks 1, 2
• Progressive worsening of symptoms 1, 2
• Signs of airway compromise 1, 2
• Suspicion of bacterial superinfection 1, 2

Special Clinical Scenarios

When Antibiotics MAY Be Appropriate

• Immunocompromised patients 1
• Confirmed bacterial infection (not just colored mucus, which does NOT differentiate viral from bacterial) 1
• Bacterial laryngotracheitis with mucosal crusting and increased work of breathing 1
• True bacterial infection: high fever ≥39°C (102.2°F) for at least 3 consecutive days plus thick colored mucus 1

Reflux-Associated Laryngitis

• Consider anti-reflux treatment if laryngoscopy demonstrates signs of reflux laryngitis 2
• Be aware of PPI side effects: decreased calcium absorption, increased hip fracture risk, vitamin B12 deficiency, and iron deficiency anemia 2
• Note that reflux laryngitis remains controversial with limited high-quality evidence 3

Pediatric Considerations

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

Patient Education Points

• Explain the viral nature of the condition and expected 1-3 week time course 1, 2
• Emphasize that colored mucus does NOT indicate bacterial infection requiring antibiotics 1
• Recommend voice conservation techniques and adequate hydration 1, 2
• Advise against requesting antibiotics or steroids for typical viral laryngitis 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics based solely on colored mucus - this is not a reliable indicator of bacterial infection 1
• Do not delay laryngoscopy beyond 4 weeks for persistent hoarseness, as this may delay diagnosis of malignancy or other serious conditions 3
• Do not use systemic corticosteroids routinely in adults with viral laryngitis, despite their use in pediatric croup 1, 2
• Recognize that acute laryngitis can cause reversible structural changes including new masses that resolve with conservative management 5