Treatment of acute infectious laryngitis will vary depending on the severity of the illness.
Particular care must be taken with patients with any degree of airway compromise.
Certain types of infection require urgent and specialised care, such as epiglottitis and diphtheria.
Treatment for viral laryngitis relies on a thorough understanding of the natural course of the disease. There is a paucity of data on this.
Most physicians therefore approach viral laryngitis as a usually self-limiting illness, requiring supportive treatment alone. [Ref_1]
Antibiotics
The challenge for the physician is to decide when antibiotics may be required for possible bacterial infection.
A Cochrane review update in 2015 addressed the question of antibiotics for acute laryngitis in adults.
The review found three randomised controlled trials: one trial compared penicillin V with placebo, the second compared erythromycin with placebo, and the third compared fusafungine with or without clarithromycin to no treatment.
It found that the erythromycin group had significantly better voice results at 1 week only, and significantly better cough at 2 weeks only.
Additionally, patients treated with inhaled fusafungine had a higher rate of clinical cure by day 5, but no difference at day 8 or after.
Fusafungine is not commonly used in clinical practice, and is not available in some countries including the US.
All other voice and outcome measures did not demonstrate significant improvement for either treatment group.
The Cochrane review concluded that there appears to be no clinically significant benefit to the use of antibiotics to treat acute laryngitis; however, no definitive recommendations could be made.
The use of antibiotics could lead to increased rates of resistant organisms as well as undue adverse risks and costs.
Corticosteroids
Evidence in the literature for corticosteroid use for acute laryngitis is incomplete.
One study compared inhaled corticosteroid versus oral corticosteroid. There was a significant improvement in oedema in the inhaled corticosteroid cohort compared with the oral corticosteroid cohort.
In another study, oral corticosteroid therapy was shown to reduce pro-inflammatory markers and increase anti-inflammatory markers in a human phonotrauma model.[Ref_3]
The authors of the study concluded that this provides a biological basis supporting the use of corticosteroids in acute vocal fold inflammation associated with phonotrauma.
Patients with potential airway compromise
If there is respiratory distress, the patient should be assessed in a controlled environment with the facility to perform safe intubation.
Emergency tracheotomy may be required if, through swelling, a normal intubation is not possible.
Children presenting with symptoms and signs of epiglottitis (e.g., high fever, sore throat, toxic appearance, drooling, tripod positioning, difficulty breathing, and irritability) should be examined in a controlled setting, such as the operating room, where intubation is performed if there is any doubt about the airway.
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| A child in tripod positioning |
If the patient is an adult, flexible laryngoscopy may be performed. Any manipulation of the supraglottic area should be avoided.
If necessary, intubation can be performed during flexible laryngoscopy with direct visualisation.
Acute respiratory distress is unlikely in the setting of uncomplicated acute laryngitis unless there is an underlying risk factor, such as a condition that limits the airway.
In acute laryngitis, conditions such as subglottic stenosis or bilateral vocal fold paralysis greatly increase the risk of respiratory failure.
Even slight inflammation and oedema of the endolaryngeal structures can cause airway compromise and can be detrimental for the patient. Therefore, upper respiratory infections (URIs) and acute laryngitis should be treated with diligence.
Corticosteroids are administered to alleviate oedema in all patients with potential airway compromise, and early antibiotic treatment should be considered. The airway should be monitored closely to assess the need for tracheotomy.
Patients with diphtheria may appear on the verge of airway compromise.
The patient needs to be hospitalised and observed closely.
Serial fibre-optic indirect laryngoscopies are performed.
The airway should be secured in case of developing obstructions from progression of the exudates.
Acute infectious laryngitis (non-diphtherial)
Most cases of acute infectious laryngitis are viral, and the treatment is supportive with analgesics and cough suppressants as required.
Vocal hygiene is the most important component of the treatment regimen.
It includes, but is not limited to:
- voice rest
- Increased hydration
- Humidification
- Limited caffeine intake.
Voice rest for viral laryngitis, in particular, cannot be overemphasised. The duration of voice rest suggested may differ depending on each physician's usual practice, but is usually between 3 and 14 days. [Ref_4]
Singers should not sing or do vocal exercises during this period.
Voice rest is important because heavy voice use in an already injured larynx can lead to the formation of further pathology, such as scarring or haemorrhage of the vocal folds and muscle tension dysphonia.
Caffeine should be avoided because it has diuretic effects and will cause further volume depletion. Decongestants are not recommended. There is no evidence supporting the use of corticosteroids for these patients.
Despite a lack of conclusive trials, mucolytics have been used widely to decrease the viscosity of the secretions.
Mucolytics may restore the watery quality of the mucus in the glottis that is essential for lubrication of the true vocal folds. Thick mucus also triggers throat clearing, which in turn increases vocal fold oedema and injury, leading to vocal fold pathologies.
Antibiotics are indicated only when a bacterial infection is suspected, and are started empirically. Most acute laryngitis cases are viral.
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Acute laryngitis due to diphtheria, following successful airway management
Medical management is started as soon as the diagnosis is suspected, with antibiotics and antitoxin.
Antibiotics are essential for eradicating the organism and eliminating its spread, but they are not a substitute for antitoxin treatment.
Antibiotics are also important for eradicating colonisation in contacts and for post-exposure prophylaxis.
Administration of diphtheria antitoxin is a crucial step in the treatment of diphtheria. It neutralises only extracellular toxin and therefore must be administered as early as possible, generally before the disease is microbiologically confirmed.
Antitoxin is an equine serum, so patients must be tested for hypersensitivity before administration. Even if hypersensitivity is shown, antitoxin will still need to be administered, but only after desensitisation.
As clinical infection does not always induce immunity, a course of diphtheria toxoid should be administered at the end of the first week of the illness and completed during convalescence.
Meanwhile, palatal and pharyngeal paralysis may necessitate nasogastric tube feeding.
Patients should be isolated until two cultures from the nasopharyngeal and throat (or skin lesions if cutaneous diphtheria) taken at least 24 hours apart and more than 24 hours after completing antibiotics are negative for toxigenic C. diphtheriae, C. ulcerans or C. pseudotuberculosis. Analgesics, mucolytics, and cough medications may be used as supportive care following urgent therapy.
Laryngitis due to tuberculosis or fungal infection
Detailed discussions of tuberculous laryngitis or fungal laryngitis are beyond the scope of this topic. Patients with suspected tuberculosis require referral to an infectious disease or pulmonary specialist for antituberculosis therapy and care.
Vocal hygiene, analgesics, mucolytics, and cough medications may be used as supportive care.
Patients with fungal laryngitis are managed by otolaryngology specialists.
Where hoarseness has developed in patients on inhaled corticosteroids, it would be appropriate for the primary care physician to advise the patient to rinse their mouth with water before and after inhalation.
The dose of corticosteroid should be reduced if at all possible to the lowest dose required. Referral to an otolaryngology specialist may still be required.
Chronic laryngitis due to tuberculosis or fungal infection
Chronic tuberculous laryngitis is treated with an antituberculosis regimen and care provided by an infectious disease specialist.
Chronic laryngitis may also be due to fungal infection. Patients with fungal laryngitis are managed by otolaryngology specialists.
The detailed treatment of fungal laryngitis is beyond the scope of this topic.
Non-infectious laryngitis
The mainstay of treatment for laryngitis due to chronic phonotrauma is speech therapy by an experienced voice therapist.
For these patients with vocal strain, vocal hygiene is essential. This includes, but is not limited to, voice rest, increased hydration, humidification, and limited caffeine intake.
Voice rest is important because heavy voice use in an already injured larynx can lead to the formation of further pathology, such as scarring or haemorrhage of the vocal folds and muscle tension dysphonia.
The duration of voice rest suggested may differ depending on each physician's usual practice, but is usually between 3 and 14 days. Singers should not sing or do vocal exercises during this period.
Professional voice users
In professional voice users such as singers, multiple factors can be addressed including vocal hygiene, reflux, and social habits.
Treatment options that can be considered include therapy with a singing voice specialist, oral or nasal corticosteroids for rhinitis or other inflammation, as well as antibiotics for cases of bacterial sinusitis that inflame the larynx.
Hoarseness is not always due to laryngitis, and therefore careful examination using videostroboscopy to evaluate the vocal folds and rule out a more serious vocal fold injury (haemorrhage or vocal mucosal tear) is essential.
If there is a serious vocal injury, voice rest and avoidance of heavy voice use should be recommended.
Where acute viral laryngitis is present, the patient should be evaluated by an otolaryngologist. If there is no serious vocal injury, intramuscular corticosteroids, aggressive hydration, and essential voice use may salvage a performance in this setting.
The patient must be counselled about an increased risk of haemorrhage, more permanent damage, or reduced vocal abilities with an inflamed larynx if there is continued vocal use.
Treatment algorithm
INITIAL
With potential airway compromise:
without suspected diphtheria
1st line:
secure airway + supportive care
Plus:
corticosteroid + empiric antibiotics
With suspected diphtheria
Plus:
Isolation + antibiotics + diphtheria antitoxin.
ACUTE
viral
1st line
supportive care + vocal hygiene
Consider –
mucolytic and/or cough suppressant
Suspected bacterial: non-diphtheria and non-tuberculous
1st line –
antibiotics
Plus –
supportive care + vocal hygiene
Consider –
mucolytic and/or cough suppressant
Confirmed diphtheria
1st line –
continued isolation + antibiotics + diphtheria toxoid
Consider –
analgesia
Consider –
mucolytic and/or cough suppressant
Tuberculosis
1st line –
isolation and antituberculosis therapy
Plus –
supportive care + vocal hygiene
Consider –
mucolytic and/or cough suppressant
Fungal
1st line –
refer to otolaryngology specialist
vocal strain
1st line –
vocal hygiene.
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