eMedicine - Acute Laryngitis : Article by Rahul K Shah, MD

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Acute Laryngitis
Last Updated: September 27, 2006

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Synonyms and related keywords: acute laryngitis, laryngitis, inflammation of the larynx, chronic laryngitis, rheumatoid arthritis, relapsing polychondritis, Wegener granulomatosis, sarcoidosis, vocal misuse, noxious agents, upper respiratory infections, URI, laryngeal inflammation, vocal abuse, dysphonia, hoarse voice, breathy voice, vocal fold, hoarseness, aphonia, gastroesophageal reflux disease, GERD, vocal trauma, psychogenic dysphonia, phonation

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AUTHOR INFORMATION

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Author: Rahul K Shah, MD, Assistant Professor of Otolaryngology, Division of Otolaryngology, Children's National Medical Center Coauthor(s): Stanley Shapshay, MD, Chief, Professor, Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center Rahul K Shah, MD, is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery Editor(s): John M Truelson, MD, FACS, Chairman, Division of Head and Neck Surgery, Associate Professor, Department of Otorhinolaryngology, University of Texas Southwestern Medical Center at Dallas; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Erik Kass, MD, Chief, Department of Clinical Otolaryngology, Associates in Otolaryngology of Northern VA; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; and Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Disclosure

Chronic Laryngitis, Infectious or Allergic Reflux Laryngitis Spasmodic Dysphonia

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INTRODUCTION

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Laryngitis Symptoms Laryngitis Treatment

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Background: Laryngitis is one of the most common conditions identified in the larynx. Laryngitis, an inflammation of the larynx, manifests in both acute and chronic forms. Acute laryngitis has an abrupt onset and is usually self-limited. If a patient has symptoms of laryngitis for more than 3 weeks, the condition is classified as chronic laryngitis. The etiology of acute laryngitis includes vocal misuse, exposure to noxious agents, or infectious agents leading to upper respiratory tract infections. The infectious agents are most often viral but sometimes bacterial. Rarely, laryngeal inflammation results from an autoimmune condition such as rheumatoid arthritis, relapsing polychondritis, Wegener granulomatosis, or sarcoidosis. A case report showed a 2-year-old intubated patient who was given activated charcoal for poisoning, resulting in obstructive laryngitis. This unusual case demonstrates the myriad potential etiologies of acute laryngitis. Chronic laryngitis, as the name implies, involves a longer duration of symptoms; it also takes longer to develop. Chronic laryngitis may be caused by environmental factors such as inhalation of cigarette smoke or polluted air (eg, gaseous chemicals), irritation from asthma inhalers, vocal misuse (eg, prolonged vocal use at abnormal loudness or pitch), or gastrointestinal esophageal reflux. Vocal misuse results in an increased adducting force of the vocal folds with subsequent increased contact and friction between the contacting folds. The area of contact between the folds becomes swollen. Vocal therapy has the greatest benefit in the patient with chronic laryngitis. Although acute laryngitis is usually not a result of vocal abuse, vocal abuse is often a result of acute laryngitis. The underlying infection or inflammation results in a hoarse voice. Typically, the patient exacerbates the dysphonia by misuse of the voice in an attempt to maintain premorbid phonating ability. Pathophysiology: Acute laryngitis is an inflammation of the vocal fold mucosa and larynx that lasts less than 3 weeks. When the etiology of acute laryngitis is infectious, white blood cells remove microorganisms during the healing process. The vocal folds then become more edematous, and vibration is adversely affected. The phonation threshold pressure may increase to a degree that generating adequate phonation pressures in a normal fashion becomes difficult, thus eliciting hoarseness. Frank aphonia results when a patient cannot overcome the phonation threshold pressure required to set the vocal folds in motion. The membranous covering of the vocal folds is usually red and swollen. The lowered pitch in laryngitic patients is a result of this irregular thickening along the entire length of the vocal fold. Some authors believe that the vocal fold stiffens rather than thickens. Conservative treatment measures, as outlined below, are usually enough to overcome the laryngeal inflammation and to restore the vocal folds to their normal vibratory activity. Frequency: In the US: The exact prevalence of acute laryngitis is not reported because many patients often use conservative measures to treat their inflammation rather than seek medical consultation. Symptoms of an upper respiratory tract infection often accompany the disease; thus, patients are accustomed to managing their own treatment. Nevertheless, laryngitis is one of the most common laryngeal pathologies. Mortality/Morbidity: Because acute laryngitis is usually self-limited and treated with conservative measures, significant morbidity and mortality are not encountered. Patients who develop acute laryngitis from an infectious etiology rather than vocal trauma may ultimately injure their vocal folds. The deficient voice

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production in patients with acute laryngitis may result in application of a greater adduction force or tension to compensate for the incomplete glottic closure during an acute laryngitic episode. This tension further strains the vocal folds and decreases voice production, ultimately delaying return of normal phonation. In 1997, Ng conducted a study of the aerodynamic and acoustic characteristics of acute laryngitis. His study demonstrated that across the 5 vowels, the fundamental frequency values were lower in patients with acute laryngitis than in patients with a normal voice. The authors concluded that acute laryngitis changes the vocal fold mass, resulting in a reduction of the fundamental frequency; other authors (Vaughan, 1982) have anecdotally corroborated this finding. Patients with acute laryngitis have an increased open quotient value. This indicates that the patient's vocal folds are open longer, and less time is spent in the closed position, which contributes to the hoarseness and breathiness of the voice. Age: Studies have demonstrated that, usually, acute laryngitis affects individuals aged 18-40 years. Children, a category not included in the above study, are clinically observed with acute laryngitis when aged 3 years and older.

CLINICAL

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History: In addition to symptoms of an upper respiratory tract infection (ie, fever, cough, rhinitis), the patient also experiences dysphonia or a hoarse voice. A hoarse voice is defined as one that has the components of breathiness and tension (Ng, 1997). These symptoms are consistent with laryngitis and are not specific for acute or chronic laryngitis. Patients with laryngitis may also experience odynophonia, dysphagia, odynophagia, dyspnea, rhinorrhea, postnasal discharge, sore throat, congestion, fatigue, and malaise (Postma, 1998). The patient's vocal symptoms usually last 7-10 days. If symptoms persist longer than 3 weeks, a workup for chronic laryngitis should be performed. Physical: As Postma indicates, the diagnosis of acute laryngitis may be made solely based on the history and symptoms; thus, visual examination of the larynx is not always imperative. Certainly, if seen by an otolaryngologist, the patient would have a thorough examination of the head and neck, involving visual inspection of the larynx. Delay in referral to an otolaryngologist for 3 weeks may be acceptable for a primary care physician. However, an otolaryngologist who does not perform laryngoscopy in a patient with hoarseness may miss other pathologies, such as cancer, vocal nodules, or papillomas. Delaying examination of the larynx is unacceptable for an otolaryngologist. Other than findings of a common upper respiratory tract infection, the patient may appear healthy. Indirect examination of the airway with a mirror or direct examination with a flexible nasolaryngoscope reveals erythema and edema of the vocal folds, secretions, and irregularities of the surface contour of the vocal folds. Note the presence of normal vocal fold mobility and the absence of airway obstruction. Causes: Any of the following etiologies may cause acute laryngitis:

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Infection (usually viral upper respiratory tract infection [Postma, 1998]) Rhinoviruses Parainfluenza viruses Respiratory syncytial virus Adenoviruses Influenza viruses Measles virus Mumps virus Bordetella pertussis Varicella-zoster virus Gastroesophageal reflux disease Environmental insults (pollution) Vocal trauma Use of asthma inhalers DIFFERENTIALS
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Chronic Laryngitis, Infectious or Allergic Reflux Laryngitis Spasmodic Dysphonia Other Problems to be Considered: Much of the epidemiology of acute laryngitis is also observed in patients with psychogenic dysphonia. In psychogenic dysphonia, however, the voice analysis reveals monotonous and bizarre aberrations and a normal cough (Schalen, 1988). Systemic illnesses with viral etiologies (eg, measles, mumps, chickenpox) may result in acute laryngitis (Postma, 1998). A recent report notes herpes simplex virus as another viral etiology (Thompson, 2006).

WORKUP

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Lab Studies: No laboratory studies are necessary. If the patient has an exudate in the oropharynx or overlying the vocal folds, a culture may be taken. As Vaughan indicates, do not institute antibiotic coverage until the results of the Gram stain and cultures with sensitivity have been determined.

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Imaging Studies: Direct fiberoptic or indirect laryngoscopy may be performed to provide a view of the larynx. This examination reveals redness and small dilated vasculature on the inflamed vocal folds. Analysis of vocal fold movement reveals asymmetry and aperiodicity with reduced mucosal waves and incomplete vibratory closure. The propagation of the mucosal wave is also reduced. Ng describes a finding by Colton and Casper that the mucosal wave appears to have 2 distinct velocities of travel. The wave travels at 1 speed on the surface of the vocal fold; but, at a discrete point, it changes its speed of travel. Indeed, this change may be because of the edema and intrinsic inflammation of the vocal fold, which affects the inherent motion of the vocal fold in an irregular manner. TREATMENT
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Medical Care: Vaughan states that patients know that treatment requires only time and the commonsense avoidance of vocal excess and other irritants. The following measures can help lessen the intensity of the laryngitis while waiting for the condition to resolve: Inhaling humidified air promotes moisture of the upper airway, helping to clear secretions and exudate. Complete voice rest is suggested, although this recommendation is nearly impossible to follow. If the patient must speak, soft sighing phonation is best. Avoidance of whispering is best, as whispering promotes hyperfunctioning of the larynx. Prevailing data do not support the use of antihistamines and corticosteroids. If a patient uses these medications, he or she may have the false impression that the laryngitis is resolving and may continue to use his or her voice, leading to further insult. The drying effect of these medicines may also be deleterious. A patient who smokes must cease smoking in order to promote timely resolution of the acute laryngitis. If the patient's laryngitis is from an infectious etiology, continued smoking delays prompt resolution of the disease process. The most common etiology for acute laryngitis is an infectious source, usually a viral upper respiratory tract infection. In 1985, Schalen observed that, at the time of the acute laryngitic episode, many patients were carriers of bacterial infectious agents, the most common of which were Branhamella catarrhalis and Haemophilus influenzae. These patients experienced more severe dysphonia than patients with negative culture results. Despite the high isolation rate of organisms from the nasopharynx, a double-blind, placebo-controlled study of patients with acute laryngitis revealed that administration of penicillin V was not advantageous in the treatment of acute laryngitis (Schalen, 1985). The study found that penicillin V administration did not decrease bacterial counts or alleviate symptoms. Schalen concluded that antibiotic treatment for otherwise healthy patients with acute laryngitis is currently unsupported; however, for high-risk patients and patients with severe symptoms, antibiotics may be considered. Others advocate the use of narrow-spectrum antibiotics only in the presence of an identifiable Gram stain and culture (Vaughan, 1982). The treatment for gastroesophageal reflux disease (GERD)related laryngitic conditions includes dietary and lifestyle modifications as well as antireflux medications. Antacid medications that suppress acid production, such as H2-receptor and proton pump blocking agents, are highly effective against gastroesophageal reflux. Of the various classes of medicines available to treat GERD, the proton pump inhibitors are the most effective (Modlin, 2004). Patients on prolonged antireflux therapy

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or with a history of long-standing GERD should be evaluated by a gastroenterologist to ensure that serious sequelae of GERD, such as Barrett esophagitis, have not manifested or do not develop. Note that optimal timing of taking the proton pump inhibitor increases its efficacy. For patients who require twice-a-day dosing, suggested dosing times are 15-30 minutes before breakfast and dinner (Katz, 2001). Katz cautions that treatment durations may be longer for patients with reflux laryngitis than for patients with other extraesophageal manifestations of GERD (eg, asthma, cough, noncardiac chest pain). Diet: Dietary restrictions are recommended for patients with GERD. These include avoidance of caffeine, fatty foods, chocolate, peppermint, and late meals (ie, <3 h before retiring [Katz, 2001]). The patient should maintain hydration and fluid intake at a stress level to support requirements during the illness. The patient should drink at least 6-8 glasses (8 oz each) of water per day. Activity: Although not always possible, patients who use their voices professionally should attempt complete vocal rest. If the patient must communicate, soft sighing use of the voice causes the least vocal trauma. Patients suspected of having GERD should avoid lying down after meals and should elevate the heads of their beds. A physician is often consulted to decide if a professional voice user should cancel or perform an engagement. A contraindication to performance is the presence of vocal fold hemorrhage or exudative laryngitis (Vaughan, 1982). If the patient has mild laryngitis, the physician's decision whether to allow the patient to perform becomes difficult. Vaughan's guiding principle is to do no harm because tomorrow is important, also. If the professional performer wants the show to proceed, he or she should adapt the show and vocal efforts during the performance to minimize vocal abuse.

MEDICATION

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The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Proton pump inhibitors -- These agents inhibit gastric acid secretion by inhibition
of the H+/K+/ATP-ase enzyme system in the gastric parietal cells. These agents are used in cases of severe esophagitis. Omeprazole (Prilosec) -- Specifically suppress gastric acid secretion by potent inhibition of the H+/ K+ ATPase enzyme system at secretory surface of gastric parietal cell. This blocks the final step in gastric acid production. Effect is dose related and

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inhibits both basal and meal stimulated acid secretion. Adult Dose Pediatric Dose 20 mg PO bid; patient may benefit from higher dose Not established May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin C - Safety for use during pregnancy has not been established. Bioavailability may increase in the elderly Esomeprazole magnesium (Nexium) -- S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H+/K+ ATP pump at secretory surface of gastric parietal cells. 20-40 mg PO qd for 4-8 wk Not established Amoxicilin or clarithromycin may increase plasma levels of esomeprazole when used concurrently; may reduce absorption of dapsone; may increase levels of diazepam and GI absorption of digoxin; may decrease absorption of iron, ketoconazole and itraconazole C - Safety for use during pregnancy has not been established. Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy Lansoprazole (Prevacid) -- Suppresses gastric acid secretion by specifically inhibiting H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells. Treatment: 30 mg PO qd for 4-8 wk Maintenance: 15 mg PO qd Not established May decrease effects of ketoconazole and itraconazole; may increase theophylline clearance B - Usually safe but benefits must outweigh the risks. Consider adjusting dose in liver impairment
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Contraindications Documented hypersensitivity Interactions Pregnancy Precautions

Drug Name

Adult Dose Pediatric Dose

Contraindications Documented hypersensitivity

Interactions

Pregnancy Precautions

Drug Name

Adult Dose Pediatric Dose

Contraindications Documented hypersensitivity Interactions Pregnancy Precautions FOLLOW-UP

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Further Outpatient Care: If the patient's symptoms have not resolved after approximately 3 weeks, an otolaryngologist should be consulted to evaluate the patient for chronic laryngitis. A patient who has hoarseness

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and is not following a usual course of acute laryngitis or has risk factors for upper aerodigestive tract carcinoma should be promptly seen by an otolaryngologist. In/Out Patient Meds: In addition to conservative treatment of an upper respiratory tract infection and humidification of the airway with vocal rest, antipyretics and decongestants may be administered for the patient's comfort. Mucolytics such as guaifenesin may be used to aid in clearing secretions. An excellent systematic review attempted to answer the question of whether antibiotics were recommended in cases of acute laryngitis. The authors cite 2 studies by the same research group. In one study, patients received either penicillin V (800 mg for 5 d) or placebo. The 2 groups showed no significant difference in symptoms or blinded voice evaluation findings. The research group published a second study in which erythromycin was administered. Those who received erythromycin showed a small voice benefit after one week and slightly better cough symptoms after 2 weeks. The overall conclusion from the Cochrane Database Systematic Review was that antibiotics are not indicated for most cases of acute laryngitis. Prognosis: Acute laryngitis is usually self-limited. If the patient adheres to a treatment plan as outlined above, the prognosis for a rapid recovery to a premorbid level of phonation is excellent. Patient Education: For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education article Laryngitis. MISCELLANEOUS
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Medical/Legal Pitfalls: The physician must be acutely aware when treating patients who use their voices professionally. The pressure to allow a show to continue may be significant, but the physician should be aware that stressing the voice in a patient with acute laryngitis may further exacerbate the course of the condition. Special Concerns: The professional voice user should be aware of the implications of acute laryngitis (see Activity) . PICTURES
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Caption: Picture 1. This view depicts the larynx of a 62-year-old woman with an intermittent history of exudative acute laryngitis that was treated conservatively. Courtesy of Ann Kearney, Palo Alto, Calif.

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Picture Type: Photo Caption: Picture 2. This view depicts the larynx of a 53-year-old woman, a sixthgrade science teacher, whose chief symptom was a hoarse and breathy voice. Note the alternating areas of erythema and normal mucosa on the vocal folds. Also note irregularities in the contour of the vocal folds. Courtesy of Ann Kearney, Palo Alto, Calif. View Full Size Image

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Picture Type: Photo BIBLIOGRAPHY

Section 11 of 11
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Donoso A, Linares M, Len J: Activated charcoal laryngitis in an intubated patient. Pediatr Emerg Care 2003 Dec; 19(6): 420-1[Medline]. Katz PO: Gastroesophageal reflux disease--state of the art. Rev Gastroenterol Disord 2001; 1 (3): 128-38[Medline]. Modlin IM, Moss SF, Kidd M, et al: Gastroesophageal reflux disease: then and now. J Clin Gastroenterol 2004 May-Jun; 38(5): 390-402[Medline]. Ng ML, Gilbert HR, Lerman JW: Some aerodynamic and acoustic characteristics of acute laryngitis. J Voice 1997 Sep; 11(3): 356-63[Medline]. Postma GN, Koufman JA: Laryngitis. In: Bailey BJ, ed. Head and Neck Surgery-Otolaryngology. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998: 731-739. Reveiz L, Cardona AF, Ospina EG: Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev 2005; CD004783[Medline]. Schalen L: Acute laryngitis in adults: diagnosis, etiology, treatment. Acta Otolaryngol Suppl 1988; 449: 31[Medline]. Schalen L, Christensen P, Eliasson I, et al: Inefficacy of penicillin V in acute laryngitis in adults. Evaluation from results of double-blind study. Ann Otol Rhinol Laryngol 1985 Jan-Feb; 94(1 Pt 1): 14-7[Medline]. Spiegel JR, Hawkshaw M, Markiewicz A, et al: Acute laryngitis. Ear Nose Throat J 2000 Jul; 79 (7): 488[Medline]. Thompson L: Herpes simplex virus laryngitis. Ear Nose Throat J 2006 May; 85(5): 304[Medline]. Vaughan CW: Current concepts in otolaryngology: diagnosis and treatment of organic voice disorders. N Engl J Med 1982 Sep 30; 307(14): 863-6[Medline].
NOTE:

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Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER Acute Laryngitis excerpt

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