Laryngitis

OVERVIEW: What every practitioner needs to know

Are you sure your patient has laryngitis? What should you expect to find?

Key symptoms of the disease include:

Hoarseness
Aphonia
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Itchy Throat
Odynophagia
Dyspnea
Fever

In summary, the inflamed larynx does not phonate, swallow, or breathe well.

Key physical findings of the disease include:

Inspiratory Stridor
Laryngeal edema, as is illustrated in Figure 1

How did the patient develop laryngitis? What was the primary source from which the infection spread?

The infectious agents are transmitted by air droplets during exhalation, sneezing, or coughing.

Which individuals are of greater risk of developing laryngitis?

Anyone of any age or gender is at risk of having viral or bacterial laryngitis.

In the case of fungal laryngitis, there are risk factors, such as chemoradiation, steroid use, immunosupressive medications, and immunodeficiencies. Populations at risk of fungal laryngitis include those with history of head and neck cancer, bone marrow transplantation, leukemia, lymphoma, HIV, sarcoidosis, and cirrhosis.

Beware: there are other diseases that can mimic laryngitis:

Gastroesophageal reflux disease (the most common non-infectious cause)
Allergies and irritants, including alcohol and tobacco
Vocal Abuse
Neoplasias, laryngeal papillomatosis, or squamous cell carcinoma
Nerve injury (vagus or recurrent laryngeal nerve)

What laboratory studies should you order and what should you expect to find?

Results consistent with the diagnosis

Peripheral WBC with differential should be ordered.

The diagnosis of laryngitis is fundamentally clinical.

Results that confirm the diagnosis

Any patient with hoarseness lasting longer than 2 weeks in the absence of an apparent benign cause requires a thorough evaluation of the larynx by direct or indirect laryngoscopy.

Laryngoscopy provides the ability to obtain tissue for histopathology and culture.
Fungal and bacterial cultures are only necessary when no other common causes are obvious, as in the case of chronic infections and malignancies.

Other procedures to collect samples to confirm the diagnosis include:

Nasopharyngeal swab
Nasopharyngeal aspirate
Nasopharyngeal wash

What imaging studies will be helpful in making or excluding the diagnosis of laryngitis?

Although not indispensable, an X-ray could be helpful in the differential diagnosis.

Anteroposterior neck film with steeple sign (see Figure 2): Croup

What consult service or services would be helpful for making the diagnosis and assisting with treatment?

Otorhinolaryngology (ENT) for the evaluation of the larynx by direct or indirect laryngoscopy in cases in which there is suspicion of malignancy or an unusual etiology.

If you decide the patient has laryngitis what therapies should you initiate immediately?

Key principles of therapy

Since most of the cases of infectious laryngitis are due to a viral infection (up to 90%), the treatment is generally symptomatic with:

Voice rest
Analgesic therapy: NSAIDs or parecetamol
Humidification
If laryngitis associated with upper respiratory symptoms, nasal decongestants, such as pseudoephedrine or antihistamines

1. Anti-infective agents

If I am not sure what pathogen is causing the infection what anti-infective should I order?

According to a Cochrane review of 2007, use of antibiotics does not have a significant effect in treating acute laryngitis.

2. Other key therapeutic modalities.

In cases of respiratory distress, as in laryngotracheitis, the use of oxygen is necessary.

Particularly in this condition, there are better outcomes with the use of dexamethasone within the first 24 hours.

What complications could arise as a consequence of laryngitis?

What should you tell the family about the patient's prognosis?

Laryngitis is usually a mild and self-limited syndrome.

How do you contract laryngitis and how frequent is this disease?

The incidence of acute laryngitis reported in the literature varies and is highly dependent on the study method used, reflecting its familiarity and it association with the ubiquitous “upper respiratory infections.”

In a study from Greece with 800 patients, it was found that, during the coldest month of the year, there was an almost two-fold increase in the frequency of laryngitis.

The mode of spread is by entering in contact with air droplets from an infected individual.

What pathogens are responsible for this disease?

Endopharyngeal purulent secretions is more commonly seen than in viral laryngitis.

Mycoplasma pneumoniae

Chlamydophila pneumoniae

Group A B-hemolytic Streptoccocus

Haemophilus influenzae type B

Corynebacterium diphtheriae (encountered infrequently)

Treponema pallidum

Tuberculous

Mycobacterium tuberculosis ( the most common granulomatous disease of the larynx)

Mycobacterium leprae

Formation of endolaryngeal and perilaryngeal white plaques, granulation tissue, and ulcerations

Candida albicans

Blastomyces dermatitidis

Histoplasma capsulatum

Coccidiodes immitis and posadasii

Paracoccidiodes brasiliensis

Cryptoccocus neoformans

Rhinovirus

Influenza

Parainfluenza

Adenovirus

Coronavirus

Leishmania

How do these pathogens cause laryngitis?

Laryngitis refers to the inflammation of the tissues of the larynx. Virus and bacteria mainly produce an acute inflammation, in contrast, to mycobacterial and fungal infections that produce chronic inflammation and a granulomatous response.

What other additional laboratory findings may be ordered?

None needed

How can laryngitis be prevented?

There are no preventative measures for the most common cause of laryngitis-that due to viruses.

WHAT'S THE EVIDENCE for specific management and treatment recommendations?

Bourayou, R, Maghraoui-Slim, V, Koné-Paut, I, Cohen, J, Powderly, WG, Opal, SM. “Laryngitis, epiglottitis and pharyngitis”. Cohen & Powderly: infectious diseases. 2010. pp. 262-9. (This is a very interesting chapter of upper respiratory tract infection management, including epiglottitis and pharyngitis, whose symptoms overlap with the ones from laryngitis.)

Danielides, V, Nousia, CS, Patrikakos, G. “Effect of meteorological parameters on acute laryngitis in adults”. Acta Otolaryngol. vol. 122. 2002. pp. 655-60. (Support the evidence that most of the cases of acute laryngitis are caused by viruses, being viral infections more common in the coldest months of the year.)

Dworkin, JP. “Laryngitis: types, causes, and treatments”. Otolaryngol Clin North Am. vol. 41. 2008. pp. 419-36. (Great complements for Tulunay's article, by presenting pictures and describing the symptoms and the macroscopic characteristics of inflammation produced by the most common causes of laryngitis.)

Loehrl, TA, Smith, TL. “Inflammatory and granulomatous lesions of the larynx and pharynx”. Am J Med. vol. 111. 2001. pp. 113S-7S. (Chronic laryngitis with granulomatous lesions can be the presentation of GERD and many systemic diseases, which are well described in this article.)

Merati, AL, Flint, PW, Haughey, BH, Lund, VJ, Niparko, JK, Richardson, MA, Robbins, KT, Thomas, R. “Acute and chronic laryngitis”. Cummings otolaryngology: head and neck surgery. 2010. pp. 883-9. (This is a wonderful succinct chapter about acute and chronic causes of laryngitis.)

Schwartz, SR, Cohen, SM, Dailey, SH. “Clinical practice guideline: hoarseness (dysphonia)”. Otolaryngol Head Neck Surg. vol. 141. 2009. pp. S1-31. (Evidence-based recommendations for the approach of patient who presents with hoarseness.)

Tulunay, O. “Laryngitis: diagnosis and management”. Otolaryngol Clin North Am. vol. 41. 2008. pp. 437-51. (An extensive list and description of the many infectious and non-infectious causes of laryngitis, as well as their management.)

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