What are the treatment options for a patient with laryngitis, considering potential underlying causes such as acid reflux and possible bacterial infection?

Treatment of Laryngitis

Laryngitis should be managed with supportive care only—voice rest, hydration, and analgesics—while avoiding antibiotics and systemic corticosteroids, as these provide no benefit and cause harm. 1, 2

Acute Viral Laryngitis (Most Common Presentation)

First-Line Management

• Voice rest is essential to reduce vocal fold irritation and promote healing 3, 2
• Adequate hydration maintains mucosal moisture and reduces irritation 3, 2
• Analgesics or antipyretics (acetaminophen or NSAIDs) for pain or fever relief 3, 2
• Avoid both loud speaking and whispering, as both strain the vocal cords 3, 2

Natural Course

• Acute laryngitis is self-limited, with improvement occurring within 7-10 days even with placebo treatment 1, 2
• Viral pathogens include parainfluenza, rhinovirus, influenza, and adenovirus 1, 4

What NOT to Prescribe

Antibiotics: Strong Recommendation Against

Antibiotics should not be routinely prescribed for laryngitis. 1, 2 The evidence is definitive:

• No objective benefit in treating acute laryngitis demonstrated in systematic reviews 1, 5
• Cochrane review of 206 patients found no significant differences in objective voice scores between antibiotic and placebo groups 5
• One trial showed erythromycin reduced subjective voice disturbance at one week (RR 0.7,95% CI 0.51-0.96), but this is not clinically relevant 5
• Harms include: bacterial antibiotic resistance, unnecessary healthcare costs, side effects, and risk of laryngeal candidiasis 2, 4

Exception: Antibiotics may be appropriate only for confirmed bacterial infection (not suspected), immunocompromised patients, or bacterial laryngotracheitis with mucosal crusting and increased work of breathing 4

Systemic Corticosteroids: Avoid Routine Use

Steroids should not be routinely prescribed for laryngitis in adults. 1, 2

• No supporting evidence for efficacy in typical viral laryngitis 2, 4
• Significant adverse effects include cardiovascular disease, hypertension, osteoporosis, cataracts, impaired wound healing, infection risk, and mood disorders 2
• Consider only in specific cases (e.g., pediatric croup with hoarseness), but routine empiric use is unwarranted 1

Addressing Underlying Causes

Reflux-Associated Laryngitis

When laryngoscopy shows signs of reflux laryngitis:

• Anti-reflux treatment with proton pump inhibitors (PPIs) can be considered 2, 6
• Nocturnal antireflux precautions and acid-suppressing medications have shown efficacy in prospective studies 6
• Be aware of PPI side effects: decreased calcium absorption, increased hip fracture risk, vitamin B12 deficiency, and iron deficiency anemia 2
• Most patients with chronic laryngitis (79%) are treated with PPIs in clinical practice 7

Postinfectious Cough Component

If productive cough persists, suggesting postinfectious bronchial inflammation:

• Inhaled ipratropium bromide as initial treatment 3
• First-generation antihistamine/decongestant combination for upper airway cough syndrome symptoms 3
• Avoid sequential antibiotics, as this promotes resistance without clinical benefit 3

When to Escalate Care

Immediate Evaluation Required

• Decreased air entry or signs of airway obstruction—rule out epiglottitis or severe laryngeal edema before standard management 3
• Clinical signs of airway compromise require careful assessment 3

Laryngoscopy Indications

Perform laryngoscopy if: 1

• Symptoms persist beyond 3 months (mandatory safety net)
• Any time a serious underlying disorder is suspected (malignancy, vocal fold paralysis)
• Professional voice users (singers, teachers) who cannot wait for resolution
• Post-surgical or post-intubation hoarseness

Delays in diagnosis beyond 3 months lead to higher cancer stages and worse prognosis 1

Additional Evaluation Needed

• Symptoms persisting beyond 2-3 weeks 2, 4
• Progressive worsening of symptoms 2, 4
• Signs of airway compromise 2, 4
• Suspicion of bacterial superinfection 2, 4

Critical Pitfalls to Avoid

• Colored mucus does NOT differentiate viral from bacterial infection—this misconception leads to inappropriate antibiotic prescribing 3, 4
• Do not use decongestants for acute or chronic laryngitis 8
• Avoid sequential antibiotics for viral postinfectious cough 3
• Do not delay laryngoscopy in high-risk patients or those with persistent symptoms beyond 3 months 1

Patient Education

Explain to patients: 2, 4

• The viral nature of most laryngitis cases
• Expected time course of 7-10 days for improvement
• Voice conservation techniques and adequate hydration
• Why antibiotics and steroids are not indicated for typical viral laryngitis