What is the treatment for a patient with laryngitis?

Treatment of Laryngitis

Most laryngitis is viral and self-limited, requiring only supportive care with voice rest, hydration, and analgesics—antibiotics should not be prescribed as they provide no benefit and contribute to antibiotic resistance. 1, 2

Acute Laryngitis: First-Line Management

Conservative Measures (Primary Treatment)

• Voice rest is essential to reduce vocal fold irritation and promote healing 3, 4, 2
• Adequate hydration maintains mucosal moisture and reduces laryngeal irritation 3, 4, 2
• Analgesics or antipyretics (acetaminophen or NSAIDs) for pain or fever relief 3, 4, 2
• Avoid both loud speaking and whispering, as both strain the vocal cords 4, 2

Expected Clinical Course

• Acute viral laryngitis typically resolves within 7-10 days without specific treatment 1, 2
• Symptoms may persist for 1-3 weeks in some cases 1, 3

Medications to AVOID

Antibiotics: Do Not Prescribe

• Antibiotics are ineffective for viral laryngitis based on Cochrane systematic reviews showing no objective benefit 1, 5, 6
• Antibiotics contribute to bacterial resistance, increase healthcare costs, cause side effects (rash, diarrhea, vomiting), and may precipitate laryngeal candidiasis 1, 2
• The only exceptions are immunosuppressed patients or confirmed bacterial infections (e.g., pertussis, bacterial laryngotracheitis, laryngeal tuberculosis) 1

Systemic Corticosteroids: Avoid Routine Use

• No evidence supports routine corticosteroid use for uncomplicated laryngitis 2
• Significant adverse effects include cardiovascular disease, hypertension, osteoporosis, cataracts, impaired wound healing, infection risk, and mood disorders 2
• Exception: Pediatric croup with stridor may benefit from systemic steroids 2

When to Perform Laryngoscopy

Mandatory Laryngoscopy Timing

• Perform laryngoscopy if hoarseness persists beyond 3 months to exclude serious pathology including malignancy or vocal fold paralysis 1
• Consider laryngoscopy at 4 weeks for optimal balance between allowing spontaneous resolution and preventing diagnostic delay 3

Indications for Earlier Laryngoscopy

• Professional voice users (singers, performers, teachers) with significant work impairment require prompt evaluation 1, 3
• Suspicion of serious underlying disorder at any time, including concern for malignancy, vocal fold immobility, or intubation trauma 1
• Post-surgical or post-intubation hoarseness warrants immediate bedside laryngoscopy 1
• Signs of airway compromise require urgent evaluation to exclude epiglottitis or severe laryngeal edema 4

Diagnostic Importance

• Delays in laryngeal cancer diagnosis beyond 3 months lead to higher disease stage and worse prognosis 1
• Laryngoscopy is the primary tool for assessing laryngeal structure and function 1

Anti-Reflux Therapy: Selective Use Only

When NOT to Prescribe PPIs

• Do not prescribe PPIs empirically for hoarseness without laryngoscopic evidence of laryngitis or GERD symptoms 1, 3
• Randomized trials show no benefit of esomeprazole 40 mg twice daily versus placebo for chronic laryngeal symptoms without confirmed reflux findings 1

When to Consider Anti-Reflux Treatment

• Only prescribe PPIs if laryngoscopy demonstrates inflammatory findings: erythema, edema, redundant tissue, or surface irregularities of the vocal folds, arytenoid mucosa, or posterior commissure 1, 3
• Laryngoscopic findings predictive of PPI response include interarytenoid mucosal abnormalities and true vocal fold changes 1

PPI Adverse Effects to Consider

• Decreased calcium absorption with increased hip fracture risk in older adults 1, 3
• Vitamin B12 deficiency in dose-dependent manner 1, 3
• Iron deficiency anemia 1, 3
• Increased pancreatitis risk 1

Voice Therapy Considerations

When to Refer for Voice Therapy

• Perform diagnostic laryngoscopy before prescribing voice therapy and communicate findings to the speech-language pathologist 1
• Advocate for voice therapy when dysphonia has an etiology that may improve with behavioral intervention (e.g., primary muscle tension dysphonia) 1

Critical Pitfalls to Avoid

• Do not use colored mucus as indication for antibiotics—it does not differentiate viral from bacterial infection 4
• Do not prescribe sequential antibiotics for postinfectious cough, as this promotes resistance without benefit 4
• Do not use heartburn measurement tools to assess laryngeal symptoms, as these are not validated for dysphonia or throat symptoms 3
• Do not delay laryngoscopy beyond 3 months for persistent hoarseness, as this risks missing malignancy 1, 3

Patient Education

• Explain the viral nature of most laryngitis and expected 1-3 week resolution 3, 2
• Emphasize that antibiotics provide no benefit for viral laryngitis 3, 2
• Recommend voice conservation techniques and adequate hydration 3, 2
• Inform patients that laryngoscopy will be necessary if symptoms persist beyond 3-4 weeks to identify underlying causes 3