What is the appropriate management for a patient diagnosed with laryngitis?

Management of Laryngitis

For acute laryngitis, initiate conservative management with voice rest, adequate hydration, and analgesics (acetaminophen or NSAIDs), while avoiding antibiotics and systemic corticosteroids, and proceed to laryngoscopy only if symptoms persist beyond 3-4 weeks. 1, 2

Initial Conservative Treatment (First-Line Approach)

The cornerstone of laryngitis management is symptomatic relief, as most cases are viral and self-limited, resolving within 7-10 days even with placebo treatment. 2, 3

Essential conservative measures include:

• Voice rest to reduce vocal fold irritation and promote healing—this is the single most important intervention. 1, 2, 4
• Adequate hydration to maintain mucosal moisture and reduce irritation. 1, 2, 4
• Analgesics or antipyretics (acetaminophen or NSAIDs) for pain or fever relief. 1, 2, 4
• Avoid both loud speaking and whispering, as both strain the vocal cords. 2, 4

Medications to Explicitly Avoid

Do not prescribe antibiotics for typical viral laryngitis. Antibiotics show no effectiveness in treating acute laryngitis when assessing objective outcomes, contribute to antibiotic resistance, increase healthcare costs unnecessarily, and may cause side effects including laryngeal candidiasis. 2, 5 A Cochrane review of 351 participants found no significant differences in objective voice scores between antibiotic and placebo groups. 5

Do not routinely prescribe systemic corticosteroids. They lack supporting evidence for efficacy in laryngitis and carry significant adverse effects including cardiovascular disease, hypertension, osteoporosis, cataracts, impaired wound healing, infection risk, and mood disorders. 1, 2

Critical 4-Week Decision Point

Perform laryngoscopy at 4 weeks if symptoms persist. 1 This timing represents the optimal balance between allowing spontaneous resolution (viral laryngitis typically resolves within 1-3 weeks) and preventing diagnostic delay for serious conditions such as malignancy. 1, 3 Chronic laryngitis is defined as symptoms lasting more than 3 weeks and requires visualization of the vocal cords to rule out malignant lesions, nodules, or polyps. 3

Indications for Earlier Laryngoscopy

Consider earlier laryngoscopy for:

• Professional voice users (singers, teachers) with significant work impairment, as they may require prompt treatment to prevent long-term vocal fold damage. 1
• Progressive worsening of symptoms or signs of airway compromise. 2
• Suspicion of bacterial superinfection (though rare). 2

Special Clinical Scenarios

For reflux-associated laryngitis: Only prescribe anti-reflux therapy if laryngoscopy demonstrates inflammatory findings such as erythema or edema—do not prescribe empirically for hoarseness without laryngoscopic evidence. 1, 2 Be aware of PPI side effects including decreased calcium absorption, increased hip fracture risk, vitamin B12 deficiency, and iron deficiency anemia. 2

For postinfectious cough component: If productive cough persists after acute laryngitis, consider inhaled ipratropium bromide or a first-generation antihistamine/decongestant combination for upper airway cough syndrome symptoms. 4

For pediatric croup with laryngitis: Systemic steroids have shown better outcomes in children with croup-associated hoarseness, which differs from adult laryngitis management. 2, 6

Rare Exception: True Bacterial Laryngitis

In the uncommon scenario of culture-proven bacterial laryngitis (MSSA, MRSA, Pseudomonas aeruginosa), multiple courses of prolonged antibiotics may be necessary, particularly for staphylococcal infections. 7 However, this requires biopsy for culture and should not be assumed without microbiological confirmation. 7

Critical Pitfalls to Avoid

• Do not use colored mucus as an indication for antibiotics—it does not differentiate viral from bacterial infection. 4
• Do not use heartburn measurement tools to assess laryngeal symptoms, as these are not validated for dysphonia, cough, or throat symptoms. 1
• Do not prescribe sequential antibiotics for viral postinfectious cough, as this promotes antibiotic resistance without clinical benefit. 4
• Assess for life-threatening airway obstruction (epiglottitis, severe laryngeal edema) before proceeding with standard management if decreased air entry is present. 4

Patient Education

Educate patients on the viral nature of most laryngitis cases, the expected 1-3 week resolution time, and the importance of voice conservation techniques. 1, 2 Explain that antibiotics provide no benefit for viral laryngitis and that laryngoscopy will be necessary if symptoms persist beyond 3-4 weeks to identify the underlying cause. 1