What is the appropriate treatment approach for a patient diagnosed with laryngitis, considering potential underlying medical conditions such as asthma or chronic obstructive pulmonary disease (COPD)?

Treatment of Laryngitis

For acute laryngitis, vocal rest is the primary treatment; antibiotics and decongestants should not be used. 1 For chronic laryngitis lasting more than 3 weeks, laryngoscopy is mandatory to visualize the vocal cords and rule out malignancy before initiating treatment. 2

Acute Laryngitis Management

Primary Treatment Approach

• Vocal rest is the cornerstone of treatment for acute laryngitis, which is most commonly viral in origin. 1
• Do not prescribe antibiotics unless there is clear evidence of bacterial infection (such as acute epiglottitis with systemic symptoms and respiratory distress). 1
• Avoid decongestants as they provide no benefit and may worsen vocal cord dryness. 1

When to Suspect Bacterial Infection

• Bacterial laryngitis (epiglottitis) presents with systemic symptoms and respiratory distress, not just dysphonia alone. 1, 3
• Emergency administration of systemic and inhaled glucocorticoids is indicated for severe glotto-subglottic laryngitis, with dexamethasone dosing exceeding 0.3 mg/kg for 48 hours. 3

Chronic Laryngitis Management (Symptoms >3 Weeks)

Mandatory Diagnostic Step

• All patients with hoarseness lasting more than 3 months must undergo laryngoscopy to exclude serious underlying conditions including laryngeal cancer. 2
• Laryngoscopy should be performed immediately if there is concern for malignancy or other serious conditions, not delayed to the 3-month mark. 2

Treatment Based on Underlying Cause

For Reflux-Related Chronic Laryngitis:

• Do not use empiric proton pump inhibitors (PPIs) for dysphonia alone without documented GERD. 2
• PPIs are only recommended when patients have concomitant esophageal GERD symptoms (heartburn, regurgitation) or documented esophagitis. 2
• If GERD is documented, use twice-daily PPI therapy for 3-4 months. 2
• The evidence for PPIs in isolated laryngitis without esophageal symptoms is poor, with most placebo-controlled trials showing no benefit. 2

For Vocal Overuse/Occupational Laryngitis:

• Vocal rest remains the primary treatment for nodules, polyps, or chronic irritation from vocal strain. 1
• Voice therapy should be offered for patients with chronic dysphonia related to vocal cord lesions or muscle tension dysphonia. 2

Special Considerations for Patients with Asthma or COPD

Asthma Patients with Laryngitis

• Beta-blockers are only relatively contraindicated in asthma, not absolutely contraindicated. 2
• Cardioselective beta-blockers (bisoprolol, metoprolol succinate, nebivolol) are preferred if needed for cardiac indications. 2
• Start with low doses and monitor closely for wheezing or prolonged expiration. 2
• Do not use albuterol nebulizers for cough unless there is documented bronchospasm. 4

COPD Patients with Laryngitis

• Beta-blockers are not contraindicated in COPD and cardioselective agents should be used if indicated. 2
• For acute COPD exacerbations with wheezing, use short-acting beta-agonists (salbutamol 2.5-5 mg nebulized) plus ipratropium bromide 500 µg if response is inadequate. 5, 6
• Drive nebulizers with compressed air, not oxygen, if CO₂ retention is present to avoid worsening hypercapnia. 5, 6
• Add oral corticosteroids if the patient has severe symptoms (cannot complete sentences, RR >25/min, HR >110/min). 5
• If sputum becomes purulent, add empirical antibiotics for 7-14 days. 5

Critical Pitfall to Avoid

• First-dose supervision is essential in elderly patients when using beta-agonists, as they may precipitate angina. 5, 4
• Ipratropium can worsen glaucoma—use a mouthpiece rather than face mask to minimize ocular exposure. 5

Treatment Algorithm Summary

For Acute Laryngitis (<3 weeks):

1. Prescribe vocal rest
2. Avoid antibiotics and decongestants
3. Reserve antibiotics only for bacterial epiglottitis with systemic symptoms

For Chronic Laryngitis (>3 weeks):

1. Perform laryngoscopy to exclude malignancy
2. Identify underlying cause (reflux, vocal overuse, occupational exposure)
3. Treat reflux only if documented GERD symptoms present
4. Refer for voice therapy if vocal cord lesions or overuse identified

For Patients with Asthma/COPD:

1. Treat laryngitis as above
2. Use bronchodilators only if documented bronchospasm present
3. Avoid empiric albuterol for cough without wheezing
4. Monitor carefully for cardiac effects in elderly patients