How should acute laryngitis be managed, including symptomatic therapy, NSAIDs, steroids, antibiotics, and red‑flag signs requiring urgent care?

Management of Acute Laryngitis

Do Not Prescribe Antibiotics for Acute Laryngitis

Antibiotics should not be routinely prescribed for acute laryngitis in adults, as they do not improve objective voice outcomes and the condition is predominantly viral and self-limited. 1, 2

• Acute laryngitis is caused by viral pathogens (parainfluenza, rhinovirus, influenza, adenovirus) and resolves spontaneously within 7-10 days in most patients regardless of treatment 1
• A Cochrane systematic review found no significant differences in objective voice scores between antibiotic and placebo groups at one week, two weeks, or two to six months 2
• The modest subjective benefits (erythromycin reduced voice disturbance at one week) do not outweigh the costs, adverse effects, and contribution to antibiotic resistance 2
• Antibiotics may be appropriate only in select immunosuppressed patients or when secondary bacterial infection is documented (e.g., bacterial laryngotracheitis with Staphylococcus aureus) 1

First-Line Symptomatic Management

Provide symptomatic relief with analgesics and voice rest while the viral infection resolves naturally. 1, 3

• NSAIDs (ibuprofen) or acetaminophen reduce pain and fever associated with laryngitis 1, 3
• Voice rest allows inflamed vocal cords to heal without further mechanical trauma 1
• Adequate hydration helps maintain mucosal moisture and facilitates clearance of secretions 1
• Humidified air may provide symptomatic relief, though evidence is limited 1

Do Not Use Corticosteroids Empirically

Steroids should not be used empirically for acute laryngitis due to significant risk profile and limited evidence of benefit. 1

• Corticosteroids carry dose-dependent risks including oral candidiasis, pharyngitis, and potential for laryngeal candidiasis when combined with antibiotics 1, 4
• If steroids are considered (e.g., for professional voice users with urgent performance needs), a shared decision must be made after discussing risks and limited evidence 1
• One case report documented candida laryngotracheitis as a complication of combined steroid and antibiotic use in a child with croup 4

Red-Flag Signs Requiring Urgent Evaluation

Immediately evaluate for airway compromise or bacterial supraglottitis if any of the following are present: 5, 6, 7

• Dyspnea or stridor (inspiratory stridor suggests glottic/supraglottic obstruction; biphasic stridor suggests subglottic involvement) 5, 6
• Drooling, inability to swallow, or "tripod" positioning (suggests epiglottitis) 6, 7
• High fever (>39°C) with toxic appearance (bacterial epiglottitis until proven otherwise) 6
• Rapid progression of symptoms over hours rather than days 7
• Muffled or "hot potato" voice (suggests supraglottic swelling) 7

Management of Suspected Epiglottitis (Supraglottic Laryngitis)

• Do not examine the throat or lay the patient flat—this can precipitate complete airway obstruction 7
• Secure the airway immediately (intubation or tracheotomy) before any diagnostic procedures 7
• Administer IV antibiotics (ampicillin or third-generation cephalosporin) to cover Haemophilus influenzae type B 6
• High-dose systemic corticosteroids (dexamethasone >0.3 mg/kg for 48 hours) may be used after airway is secured, though evidence is limited 5

Expected Clinical Course and When to Reassess

Most patients experience symptomatic improvement within 7-10 days without intervention. 1, 2

• Reassess if symptoms persist beyond 10-14 days or worsen at any time 1
• Consider alternative diagnoses (chronic laryngitis, laryngopharyngeal reflux, vocal cord lesions) if dysphonia persists beyond two weeks 1
• Refer to otolaryngology for laryngoscopy if hoarseness persists >3-4 weeks to exclude malignancy or structural lesions 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on dysphonia alone—this is almost always viral 1, 2
• Do not use aspirin in children due to risk of Reye syndrome 1
• Do not combine steroids and antibiotics empirically—this increases risk of fungal superinfection 4
• Do not delay airway intervention in patients with signs of upper airway obstruction—complications from intubation/tracheotomy are a risk, but airway obstruction is a certainty 7