What is the most likely diagnosis and recommended management for a 17‑year‑old with acute hoarseness, odynophonia, a negative streptococcal test, and persistent symptoms for one week?

Acute Laryngitis (Viral) with Vocal Cord Inflammation

This 17-year-old has acute viral laryngitis, not bacterial pharyngitis, and should receive only symptomatic treatment with voice rest and analgesics—antibiotics are not indicated.

Diagnostic Reasoning

The clinical presentation strongly indicates viral laryngitis rather than streptococcal pharyngitis:

• Loss of voice (hoarseness) and pain with talking (odynophonia) are hallmark features of laryngeal inflammation, not typical pharyngitis. 1
• The presence of hoarseness is a key clinical feature that points toward viral etiology and effectively rules out Group A Streptococcus (GAS) as the cause. 2, 1
• Viral laryngitis is the most common cause of acute hoarseness (42.1% of all cases), caused by direct inflammation of the vocal cords from viruses such as rhinovirus, adenovirus, parainfluenza, and respiratory syncytial virus. 3, 4
• The negative streptococcal test confirms the absence of bacterial infection and, combined with the vocal symptoms, definitively establishes a viral diagnosis. 2, 1

Why This Is Not Streptococcal Pharyngitis

• Patients with overt viral features like hoarseness should not be tested for GAS pharyngitis because these signs strongly indicate viral etiology. 2, 1
• GAS pharyngitis presents with sudden-onset sore throat, fever, tonsillar exudates, and tender anterior cervical lymphadenopathy—not with hoarseness or voice loss. 2, 1
• Even in adolescents aged 5–15 years (the peak age for streptococcal infection), the presence of hoarseness makes GAS pharyngitis extremely unlikely. 2, 1

Recommended Management

Primary Treatment: Voice Rest

• The best treatment for acute and chronic vocal cord overuse or inflammation is complete vocal rest—patients should avoid speaking, whispering, and throat clearing. 3
• Voice therapy is highly effective for functional and organic vocal disturbances, with level 1a evidence supporting its use. 4

Symptomatic Relief

• Ibuprofen (400–600 mg every 6–8 hours) or acetaminophen (650–1000 mg every 6 hours) are the only evidence-based pharmacologic therapies for pain relief. 1, 5
• Throat lozenges may provide additional comfort as an adjunctive measure. 1

What NOT to Do

• Antibiotics should be strongly discouraged—they provide no benefit for viral laryngitis and expose the patient to unnecessary adverse effects such as diarrhea, yeast infections, and allergic reactions. 1, 3, 4
• Decongestants are not recommended for acute laryngitis. 3
• Empirical treatment with corticosteroids is not recommended for uncomplicated viral laryngitis. 1, 4

Expected Clinical Course

• Acute viral laryngitis typically resolves within 3–7 days without intervention. 1, 5
• Symptoms persisting beyond 3 weeks warrant laryngoscopy to rule out chronic laryngitis, vocal cord nodules, polyps, or malignancy. 3, 4

When to Reassess

• If symptoms worsen significantly or persist beyond 3–4 days, consider suppurative complications or alternative diagnoses. 1
• Red flag symptoms requiring urgent evaluation include dysphagia, unilateral symptoms, weight loss, or respiratory distress—these may indicate epiglottitis, abscess, or malignancy. 5, 6

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on the duration of symptoms alone—one week of viral laryngitis is entirely consistent with the natural course of the illness. 1, 3
• Do not confuse hoarseness with typical pharyngitis—the presence of voice changes fundamentally alters the differential diagnosis away from bacterial infection. 2, 1
• Avoid testing or treating asymptomatic household contacts, as this serves no clinical purpose. 1