Are systemic corticosteroids recommended for uncomplicated acute laryngitis, and in which situations (e.g., severe vocal‑cord edema, airway obstruction, professional voice users) should they be considered?

Steroids for Laryngitis

Systemic corticosteroids should NOT be routinely prescribed for uncomplicated acute laryngitis, as the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against empiric corticosteroid use before laryngeal visualization, citing a "preponderance of harm over benefit" with no clinical trials demonstrating efficacy. 1

When Steroids Are NOT Indicated

• Uncomplicated acute laryngitis in adults should be managed with supportive care only, as the condition is self-limited with improvement in 7-10 days regardless of treatment 1
• Do not prescribe steroids empirically without laryngoscopy, as this may delay appropriate diagnosis and treatment of other serious conditions 1
• The recommendation against routine steroid use is Grade B evidence, based on the absence of clinical trial data showing benefit, well-documented adverse events even with short-term use, and the naturally self-resolving course of viral laryngitis 1

Specific Exceptions Where Steroids May Be Considered

Laryngoscopy must be performed FIRST before considering steroids in any of these situations: 1

Professional Voice Users with Confirmed Allergic Laryngitis

• Steroids may be appropriate only when a professional voice user (singer, actor, teacher) has confirmed allergic laryngitis on laryngoscopy and is acutely dependent on their voice 1
• Prednisolone 50 mg per day for 3 days can provide rapid relief within 12 hours through anti-inflammatory effects 1
• This exception requires shared decision-making discussing the limited evidence (based only on case reports) against well-documented risks 1
• Biological evidence shows steroids reduce proinflammatory cytokines (IL-1β, IL-6) by 50% and increase anti-inflammatory IL-10 by 6.3-fold in acute phonotrauma 2

Severe Airway Obstruction

• In cases of severe airway obstruction with dyspnea, steroids may be considered after laryngoscopy determines the cause 1
• For bacterial epiglottitis (supraglottic laryngitis), high-dose systemic corticosteroids (>0.3 mg/kg dexamethasone) combined with antibiotics are indicated 3
• For viral subglottic laryngitis in children (croup), a single dose of dexamethasone 0.6 mg/kg or nebulized budesonide 2000 mcg is first-line therapy 4, 5

Autoimmune Laryngeal Involvement

• Steroids are appropriate for systemic lupus erythematosus, sarcoidosis, or granulomatosis with polyangiitis affecting the larynx 1

Critical Safety Considerations

Even short-term steroid use carries significant risks that must be weighed against minimal benefits: 1

• Cardiovascular: Hypertension, cardiovascular disease, cerebrovascular disease 1
• Metabolic: Lipodystrophy, diabetes, weight gain 1
• Musculoskeletal: Osteoporosis, myopathy, avascular necrosis (including rare femoral head necrosis) 1, 4
• Infectious: Increased infection risk, severe chickenpox complications 1, 4
• Other: Sleep disturbances, mood disorders, gastrointestinal disturbances, cataracts, impaired wound healing 1

Clinical Decision Algorithm

1. Initial presentation of hoarseness/laryngitis:

   • Provide supportive care (voice rest, hydration) 1
   • Counsel patient about 7-10 day self-limited course 1
   • Do NOT prescribe antibiotics (viral etiology) or empiric steroids 1

2. If patient is a professional voice user with urgent voice need:

   • Perform laryngoscopy to visualize vocal folds and confirm diagnosis 1
   • If allergic laryngitis confirmed, discuss risks/benefits of prednisolone 50 mg daily for 3 days 1
   • Use lowest effective dose for shortest duration 1

3. If hoarseness persists beyond 2-4 weeks:

   • Perform laryngoscopy to rule out vocal cord pathology, malignancy, or reflux 1
   • No patient should wait longer than 3 months for laryngeal examination 1

4. If severe dyspnea/airway obstruction present:

   • Perform urgent laryngoscopy to determine etiology 1
   • For bacterial epiglottitis: high-dose dexamethasone plus antibiotics 3
   • For viral croup: single-dose dexamethasone 0.6 mg/kg 4, 5

Common Pitfalls to Avoid

• Never prescribe steroids without laryngoscopy first - you may miss malignancy, vocal cord paralysis, or other serious pathology requiring different management 1
• Do not assume all hoarseness is "just laryngitis" - the differential includes serious conditions that steroids could mask 1
• Avoid the temptation to prescribe steroids for patient satisfaction - the documented harms outweigh the unproven benefits in routine cases 1
• Do not use inhaled budesonide for acute laryngitis in adults - evidence only supports its use in pediatric croup, not adult laryngitis 1