What are the differential diagnoses and management options for a patient with laryngitis?

Differential Diagnosis of Laryngitis

Primary Etiologic Categories

Viral infections are the most common cause of acute laryngitis, typically resolving within 1-3 weeks, while chronic laryngitis (symptoms >3-4 weeks) represents a distinct entity requiring laryngoscopy to exclude serious pathology. 1, 2

Viral Causes (Most Common)

• Parainfluenza virus, rhinovirus, influenza, and adenovirus are the primary viral agents causing acute laryngitis 3
• Respiratory syncytial virus, coxsackievirus, ECHO viruses, and herpes simplex virus also cause acute pharyngitis/laryngitis 1
• Epstein-Barr virus causes pharyngitis with generalized lymphadenopathy and splenomegaly 1
• Varicella zoster can cause laryngeal infection, though rare 4
• Measles, cytomegalovirus, rubella, and influenza may present with pharyngitis/laryngitis 1

Bacterial Causes (Less Common)

• Group A β-hemolytic streptococcus is the most common bacterial cause of pharyngitis but rarely causes isolated laryngitis 1
• Haemophilus influenzae type B causes epiglottitis (supraglottic laryngitis), a bacterial emergency 5
• Groups C and G β-hemolytic streptococci can cause pharyngitis 1
• Corynebacterium diphtheriae (diphtheria) - rare but serious 1
• Neisseria gonorrhoeae in sexually active individuals 1
• Arcanobacterium haemolyticum (associated with scarlet fever-like rash) 1
• Mixed anaerobic infections (Vincent's angina) 1

Non-Infectious Causes

• Gastroesophageal reflux disease (GERD) is a major cause of chronic laryngitis, with 79% of patients receiving proton pump inhibitors as initial therapy 6, 7
• Voice overuse/misuse (particularly in professional voice users) 1
• Allergic laryngitis (though does not necessarily progress to chronic laryngitis) 5
• Laryngeal malignancy (must be excluded in persistent cases) 1
• Vocal fold paralysis 1
• Intubation trauma 1
• Postviral vagal neuropathy presenting as chronic cough 4
• Idiopathic ulcerative laryngitis (possibly viral-induced) 4

Critical Diagnostic Algorithm

Initial Assessment (Week 0-3)

For acute laryngitis with typical viral presentation, initiate conservative management with voice rest, adequate hydration, and analgesics while avoiding antibiotics and systemic corticosteroids. 2, 3

• Voice rest reduces vocal fold irritation and promotes healing 2
• Adequate hydration maintains mucosal moisture 2
• Analgesics (acetaminophen or NSAIDs) for pain relief 2
• Do NOT prescribe antibiotics - they show no objective benefit for viral laryngitis and contribute to antibiotic resistance 3, 8
• Do NOT prescribe systemic corticosteroids routinely - lack of efficacy evidence and significant adverse effects (cardiovascular disease, osteoporosis) 2, 3

The 3-4 Week Decision Point

Laryngoscopy is mandatory at 4 weeks for persistent hoarseness to visualize the larynx and vocal folds, as this represents the optimal balance between allowing spontaneous resolution and preventing diagnostic delay for serious conditions like laryngeal cancer. 1, 2

• Viral laryngitis typically resolves within 1-3 weeks 1, 2
• Delays in diagnosis of laryngeal cancer beyond 3 months lead to higher disease stages and worse prognosis 1
• The 3-month window is a safety net to prevent missed diagnoses 1

Indications for EARLIER Laryngoscopy (Before 3-4 Weeks)

Perform immediate or early laryngoscopy for: 1

• Professional voice users (singers, performers) with significant work impairment 1, 2
• Hoarseness with dysphagia, odynophagia, otalgia, or airway compromise 1
• Hoarseness with neurologic symptoms 1
• Unexplained weight loss 1
• Worsening hoarseness 1
• Immunocompromised patients 1
• Suspected foreign body aspiration 1
• Post-surgical hoarseness (intubation or neck surgery) 1
• Neonatal hoarseness 1

Management After Laryngoscopy

If Inflammatory Findings Present

Anti-reflux therapy should only be prescribed if laryngoscopy demonstrates inflammatory findings (erythema, edema), not empirically for hoarseness alone. 2

• Do not use heartburn measurement tools to assess laryngeal symptoms - these are not validated for dysphonia, cough, or throat symptoms 2

If Bacterial Epiglottitis Suspected

Epiglottitis (supraglottic laryngitis) is a bacterial emergency requiring immediate hospitalization, high-dose systemic and inhaled glucocorticoids (>0.3 mg/kg dexamethasone for 48 hours), and antibiotics. 5

• Can occur in adults with severity equal to children 5
• Primarily caused by H. influenzae type B but other bacteria possible 5

If Streptococcal Pharyngitis Confirmed

For confirmed Group A streptococcal pharyngitis (not isolated laryngitis), treat with appropriate antibiotics per IDSA guidelines, but recognize this is distinct from viral laryngitis. 1

Common Pitfalls to Avoid

1. Prescribing antibiotics for viral laryngitis - No objective benefit, increases resistance, causes unnecessary costs and side effects including laryngeal candidiasis 3, 8

2. Assuming colored mucus indicates bacterial infection - Colored mucus does NOT differentiate viral from bacterial infection 3

3. Empiric PPI therapy without laryngoscopy - Anti-reflux therapy should only follow laryngoscopic confirmation of inflammatory findings 2

4. Delaying laryngoscopy beyond 3-4 weeks in persistent cases - Risk of missing laryngeal malignancy or other serious pathology 1, 2

5. Confusing streptococcal carriers with acute infection - Up to 20% of school-aged children are asymptomatic carriers who may develop intercurrent viral infections 1, 9

Patient Education Essentials

Educate patients that most post-viral laryngitis resolves in 1-3 weeks, antibiotics provide no benefit, and laryngoscopy will be necessary if symptoms persist beyond 3-4 weeks to identify the underlying cause. 2, 3

• Emphasize voice conservation techniques and adequate hydration 2, 3
• Explain the viral nature of most cases 3
• Set expectations for 1-3 week resolution time 2