Management of Acute Laryngitis
Acute laryngitis in adults should be managed with symptomatic treatment only—antibiotics are not indicated and provide no objective benefit. 1, 2
Diagnosis and Natural History
Acute laryngitis is predominantly viral (caused by parainfluenza, rhinovirus, influenza, and adenovirus) and is self-limited, with most patients experiencing symptomatic improvement within 7–10 days irrespective of treatment. 1
The hallmark symptom is hoarseness (dysphonia), often accompanied by sore throat, globus sensation, and altered voice quality. 1
Dyspnea is the leading sign of acute laryngitis in children and correlates with disease severity, whereas dysphonia predominates in adults. 3
Acute laryngitis does not progress to chronic laryngitis—these are distinct nosological entities. 3
First-Line Symptomatic Management
Analgesics and Supportive Care
Acetaminophen or NSAIDs (ibuprofen) should be prescribed for pain relief and fever control in all patients with acute laryngitis. 4, 5
Saline nasal irrigation (2–3 times daily) provides symptomatic relief by facilitating clearance of nasal secretions and reducing congestion. 6, 5
Adequate hydration, warm facial packs, and sleeping with the head elevated are recommended supportive measures. 6
Viscous lidocaine and throat lozenges may provide temporary relief, though supporting data are limited. 4
Antibiotic Therapy: Not Indicated
Evidence Against Routine Antibiotic Use
Antibiotics do not objectively improve voice scores or reduce symptom duration in acute laryngitis. A Cochrane review of randomized controlled trials found no significant differences in objective voice scores between penicillin V or erythromycin and placebo at 1 week, 2 weeks, or 2–6 months. 2
Erythromycin showed a modest subjective benefit at 1 week (fewer voice complaints) and 2 weeks (less cough), but these outcomes are not clinically relevant and do not justify routine antibiotic use. 2, 7
Antibiotics expose patients to unnecessary adverse effects (rash, abdominal pain, diarrhea, vomiting) and contribute to antimicrobial resistance without providing meaningful benefit. 1
Moraxella catarrhalis and Haemophilus influenzae are isolated from the nasopharynx in 50–55% and 8–15% of cases, respectively, but their presence does not indicate bacterial infection requiring antibiotics. 7
When Antibiotics May Be Considered (Rare Exceptions)
Immunocompromised patients (e.g., HIV, renal transplant recipients, chronic corticosteroid use) with suspected bacterial laryngitis (e.g., laryngeal tuberculosis, atypical mycobacterial infection) may warrant antibiotics after appropriate diagnostic workup. 1
Bacterial laryngotracheitis (secondary to Staphylococcus aureus) presenting with severe upper respiratory symptoms (cough, stridor, increased work of breathing, mucosal crusting) requires antibiotics, but this is a distinct entity from uncomplicated acute laryngitis. 1
Professional voice users (singers, teachers, actors) who are professionally dependent on voice function may benefit from a shared decision with their clinician about erythromycin use, after discussing the limited evidence and risks. 1, 7
Corticosteroids: Not Recommended for Routine Use
Systemic or inhaled corticosteroids should not be used empirically for acute laryngitis due to significant risk profiles (candidiasis, pharyngitis, dose-dependent adverse events) and lack of supporting evidence. 1
Corticosteroids may be considered in specific cases (e.g., allergic laryngitis in performers, acute laryngitis with marked mucosal edema), but only after a shared decision between patient and clinician regarding risks and limited benefits. 1
Emergency administration of high-dose systemic and inhaled glucocorticoids (>0.3 mg/kg dexamethasone for 48 hours) is reserved for glotto-subglottic laryngitis (croup) in the hospital setting, which is a distinct entity from uncomplicated acute laryngitis. 3
Intranasal Corticosteroids: Limited Role
Intranasal corticosteroids (e.g., mometasone, fluticasone, budesonide) may provide modest symptom improvement in viral upper respiratory infections, but the effect is small and typically requires about 15 days to become apparent. 5
Intranasal corticosteroids are not indicated for acute laryngitis specifically, but may be used as adjunctive therapy for associated rhinosinusitis symptoms. 6, 5
Adjunctive Therapies
Zinc lozenges (≥75 mg/day of zinc acetate or gluconate) started within 24 hours of symptom onset may reduce the duration of upper respiratory symptoms, but weigh benefits against adverse effects (nausea, bad taste). 5
Oral decongestants (e.g., pseudoephedrine) may relieve nasal congestion but should be avoided in patients with hypertension, anxiety, cardiac arrhythmia, angina, cerebrovascular disease, bladder-neck obstruction, or glaucoma. 5
Topical nasal decongestants (e.g., oxymetazoline) may be used for severe congestion only for 3–5 days to prevent rebound congestion (rhinitis medicamentosa). 5
When to Reassess or Escalate Care
Reassess patients with symptoms persisting ≥10 days without improvement, high fever ≥39°C with purulent nasal discharge or facial pain for ≥3–4 consecutive days, or worsening symptoms after initial improvement ("double sickening"). 6, 5
Consider antibiotics only if clear evidence of secondary bacterial infection develops, such as acute bacterial rhinosinusitis meeting specific criteria (persistent symptoms ≥10 days, severe symptoms ≥3–4 days, or "double sickening"). 6, 5
Prolonged ulcerative laryngitis (hoarseness lasting up to 1 year despite aggressive medical therapy) is a rare entity that may require otolaryngology referral for further evaluation. 8
Common Pitfalls to Avoid
Do not prescribe antibiotics based on hoarseness alone—acute laryngitis is viral and self-limited. 1, 2
Do not prescribe antibiotics to prevent complications—antibiotics do not prevent bacterial sinusitis, asthma exacerbation, or otitis media in viral upper respiratory infections. 4, 5
Do not use systemic corticosteroids routinely—they provide no benefit in uncomplicated acute laryngitis and carry significant risks. 1
Do not extend topical decongestant use beyond 5 days—this leads to rebound congestion requiring prolonged therapy. 5
Patient Education
Symptoms typically peak within 3 days and resolve within 10–14 days without specific treatment. 5
Hand hygiene is the most effective method to reduce transmission of viral upper respiratory infections. 5
The illness resolves without antibiotics, even when bacterial pathogens are present in the nasopharynx. 5, 7
Purulent (colored) nasal discharge reflects neutrophil activity rather than bacterial infection and should not trigger antibiotic therapy. 6, 5