What is the recommended management for an adult with acute laryngitis, including supportive care, indications for antibiotics or steroids, and criteria for referral?

Management of Acute Laryngitis in Adults

For an adult with acute laryngitis, do not prescribe antibiotics or systemic corticosteroids routinely; instead, provide supportive care with voice rest, hydration, and analgesics, and refer to otolaryngology only if symptoms persist beyond 2–3 weeks or if severe airway compromise develops. 1

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Diagnosis and Natural History

• Acute laryngitis is predominantly viral (caused by parainfluenza, rhinovirus, influenza, and adenovirus), is self-limited, and resolves within 7–10 days in most patients irrespective of treatment. 1
• The hallmark symptom is hoarseness (dysphonia), often accompanied by sore throat, cough, globus sensation, and altered voice quality. 1
• Dyspnea is rare in adults but may occur in severe cases; it is more common in children and signals disease severity. 2
• Acute laryngitis does not progress to chronic laryngitis; these are distinct entities. 2

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Supportive Care (First-Line Management)

• Voice rest is the cornerstone of management: advise patients to minimize speaking and avoid whispering (which strains vocal cords). 1, 3
• Adequate hydration helps maintain mucosal moisture and facilitates mucus clearance. 1
• Analgesics (acetaminophen or ibuprofen) provide symptomatic relief for throat pain and discomfort. 1
• Humidified air or steam inhalation may offer subjective comfort, though evidence for efficacy is limited. 4
• Cough suppressants (e.g., dextromethorphan) can be considered if cough is severe and disrupts sleep, but are not routinely necessary. 1

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Antibiotics: Not Indicated

• Antibiotics do not improve objective outcomes (voice quality, laryngeal inflammation) in acute laryngitis. 1, 5
• A Cochrane review found that antibiotics (penicillin V, erythromycin) showed no significant benefit in objective voice scores at 1 week, 2 weeks, or 2–6 months. 5
• Erythromycin showed a modest subjective benefit (reduced voice disturbance at 1 week, reduced cough at 2 weeks), but this does not outweigh the risks of adverse effects (rash, diarrhea, vomiting) and antibiotic resistance. 5
• Routine empiric antibiotic use is unwarranted because acute laryngitis is viral, not bacterial. 1
• Antibiotics may be appropriate in select immunocompromised patients (e.g., laryngeal tuberculosis in HIV/transplant patients, atypical mycobacterial infection in inhaled steroid users) or in bacterial laryngotracheitis with severe symptoms (cough, stridor, increased work of breathing, mucosal crusting). 1

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Corticosteroids: Not Routinely Recommended

• Systemic corticosteroids should not be used empirically for acute laryngitis in adults due to significant risks (hyperglycemia, hypertension, mood disturbances, adrenal suppression, fractures) and lack of supporting evidence. 1
• Steroids may be considered in specific cases (e.g., professional voice users with urgent performance needs, allergic laryngitis), but only after shared decision-making and discussion of risks versus limited benefits. 1
• Inhaled corticosteroids (e.g., budesonide) are used in pediatric croup but have no established role in adult acute laryngitis. 4
• Steroid use can increase the risk of laryngeal candidiasis and pharyngitis in a dose-dependent manner. 1

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Laryngoscopy: When to Perform

• Diagnostic laryngoscopy is not required for typical acute laryngitis with a clear viral prodrome and expected resolution within 7–10 days. 1
• Perform laryngoscopy if:
  • Hoarseness persists >2–3 weeks despite conservative management. 1
  • Symptoms worsen or fail to improve. 1
  • There is concern for structural lesions (vocal fold nodules, polyps, masses, ulceration). 6, 3
  • The patient is a professional voice user requiring precise diagnosis. 1
• Laryngoscopy may reveal reversible structural changes (erythema, edema, new masses) that resolve with conservative management. 3

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Criteria for Referral to Otolaryngology

• Refer to ENT if:
  • Hoarseness persists >2–3 weeks without improvement. 1
  • Severe or worsening dyspnea, stridor, or airway compromise develops. 2
  • Suspected complications (e.g., epiglottitis, bacterial laryngotracheitis, laryngeal abscess). 2
  • Recurrent episodes of acute laryngitis (≥3 per year) suggest underlying pathology (e.g., chronic laryngopharyngeal reflux, vocal cord dysfunction, allergic laryngitis). 1, 2
  • Professional voice users require expedited evaluation and management. 1

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Special Considerations

Prolonged Ulcerative Laryngitis

• A subset of patients (often young, nonsmokers, nondrinkers) may develop prolonged hoarseness, laryngeal inflammation, and vocal fold ulceration lasting up to 1 year despite aggressive medical therapy. 6
• This entity is rare but should be considered in patients with persistent symptoms; laryngoscopy is essential for diagnosis. 6

Bacterial Laryngotracheitis

• Suspect bacterial infection (e.g., Staphylococcus aureus) if the patient presents with severe upper respiratory symptoms (cough, stridor, increased work of breathing, mucosal crusting). 1
• Diagnosis should be established (via laryngoscopy or culture) before initiating antibiotics. 1

Epiglottitis (Supraglottic Laryngitis)

• Epiglottitis is a medical emergency caused by bacterial infection (most commonly Haemophilus influenzae type B, though other pathogens are possible). 2
• It can occur in adults and is as severe as in children. 2
• Presents with severe sore throat, dysphagia, drooling, muffled voice, and respiratory distress. 2
• Do not examine the throat if epiglottitis is suspected; secure the airway first and administer systemic antibiotics (e.g., ceftriaxone) plus high-dose corticosteroids (e.g., dexamethasone >0.3 mg/kg for 48 hours). 2

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Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically for typical acute laryngitis; this contributes to resistance and exposes patients to unnecessary adverse effects. 1, 5
• Do not use systemic corticosteroids routinely; risks outweigh benefits in most cases. 1
• Do not delay laryngoscopy if hoarseness persists >2–3 weeks; structural lesions or other pathology may be present. 1
• Do not overlook red-flag symptoms (severe dyspnea, stridor, drooling, inability to swallow) that suggest epiglottitis or airway compromise. 2

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Patient Education

• Reassure patients that acute laryngitis is self-limited and typically resolves within 7–10 days. 1, 5
• Advise voice rest (minimize speaking, avoid shouting/whispering) and hydration. 1, 3
• Explain that antibiotics are not effective for viral laryngitis and may cause harm. 1, 5
• Instruct patients to return if hoarseness persists >2–3 weeks or if new symptoms (dyspnea, stridor, severe pain) develop. 1, 2