How should laryngitis be managed?

Treatment of Laryngitis

For acute laryngitis, provide symptomatic relief with voice rest, adequate hydration, and analgesics while avoiding antibiotics and systemic corticosteroids, which lack proven benefit and carry potential harm. 1

Immediate Assessment

Before initiating standard treatment, rule out life-threatening airway obstruction, particularly epiglottitis or severe laryngeal edema, especially in patients with decreased air entry or respiratory distress. 2 This is critical because bacterial epiglottitis requires immediate antibiotics and corticosteroids, unlike viral laryngitis. 3

First-Line Conservative Management

Core Interventions

• Voice rest is essential to reduce vocal fold irritation and promote healing—avoid both loud speaking and whispering, as both strain the vocal cords. 1, 4
• Adequate hydration maintains mucosal moisture and reduces irritation. 1, 4
• Analgesics or antipyretics (acetaminophen or NSAIDs) for pain or fever relief. 1, 4

Most acute viral laryngitis is self-limited and improves within 7-10 days even with placebo treatment, as it's commonly caused by parainfluenza viruses, rhinovirus, influenza, and adenovirus. 1

What NOT to Prescribe

Avoid Antibiotics

Antibiotics should not be routinely prescribed for viral laryngitis because they show no effectiveness in treating acute laryngitis, contribute to bacterial antibiotic resistance, increase healthcare costs unnecessarily, and may cause side effects including laryngeal candidiasis. 1, 4 The only exception is bacterial epiglottitis, which presents with systemic symptoms and respiratory distress. 3

Avoid Systemic Corticosteroids

Systemic corticosteroids should not be routinely prescribed due to lack of supporting evidence for efficacy and potential for significant adverse effects, including cardiovascular disease, hypertension, osteoporosis, cataracts, impaired wound healing, infection risk, and mood disorders. 1, 4 The exception is pediatric croup with associated hoarseness, where systemic steroids have shown better outcomes. 1

Timeline-Based Management Algorithm

Symptoms Persisting Beyond 2-3 Weeks

Additional evaluation is required for symptoms persisting beyond 2-3 weeks, progressive worsening of symptoms, signs of airway compromise, or suspicion of bacterial superinfection. 1

Critical 4-Week Decision Point

Laryngoscopy should be performed at 4 weeks to visualize the larynx and vocal folds, as viral laryngitis typically resolves within 1-3 weeks, and this timing represents the optimal balance between allowing spontaneous resolution and preventing diagnostic delay for serious conditions like malignancy. 4 This is particularly important because chronic laryngitis (symptoms >3 weeks) is a distinct nosological entity from acute laryngitis and requires visualization to rule out malignant lesions. 3, 5

Earlier Laryngoscopy Indications

Professional voice users (singers, teachers) with significant work impairment may require earlier laryngoscopy to prevent long-term damage. 4

Special Considerations

Reflux-Associated Laryngitis

Anti-reflux therapy should only be considered if laryngoscopy demonstrates inflammatory findings (erythema or edema), and should not be prescribed empirically for hoarseness without laryngoscopic evidence of laryngitis or GERD symptoms. 4 If prescribed, be aware of potential PPI side effects including decreased calcium absorption, increased hip fracture risk, vitamin B12 deficiency, and iron deficiency anemia. 1

Postinfectious Cough Component

If productive cough persists, consider postinfectious bronchial inflammation rather than bacterial infection—inhaled ipratropium bromide or first-generation antihistamine/decongestant combinations can be used for these symptoms. 2

Chronic Bacterial Laryngitis (Rare)

In the unusual case of true chronic bacterial laryngitis confirmed by culture, MRSA may be the responsible pathogen in up to 30% of cases, requiring prolonged antibiotic therapy with agents like sulfamethoxazole-trimethoprim rather than amoxicillin-clavulanate. 6 However, this diagnosis requires tissue culture confirmation and should not be assumed.

Common Pitfalls to Avoid

• Colored mucus does not differentiate viral from bacterial infection—this misconception leads to inappropriate antibiotic prescribing. 2
• Do not use heartburn measurement tools to assess laryngeal symptoms, as these are not validated for dysphonia, cough, or throat symptoms. 4
• Avoid sequential antibiotics for viral postinfectious cough, as this promotes antibiotic resistance without clinical benefit. 2

Patient Education

Explain the viral nature of most laryngitis cases and expected 1-3 week resolution time, recommend voice conservation techniques and adequate hydration, and advise against the use of antibiotics and steroids for typical viral laryngitis. 1, 4 Inform patients that laryngoscopy will be necessary if symptoms persist beyond 3-4 weeks to identify the underlying cause. 4