- Acute laryngitis is commonly due to infection but there are many rarer causes. The basic pathophysiology is inflammation of the mucosa lining the vocal folds and larynx. If infection is involved, white cells aggregate to remove infectious material from the area. Oedema of the laryngeal lining increases the amount of pressure required to produce sound, resulting in dysphonia or aphonia. Changes to the structure of the larynx may also result in a lower register of speech.
- Chronic laryngitis is usually due to environmental, toxic or mechanical factors. The term implies irreversible changes to the laryngeal mucosa. The ciliary tree is usually damaged, mainly on the posterior wall, with resultant pooling of mucus and the production of a reactive cough. Mucous across the vocal cords may result in laryngeal spasm. Depending on the cause, there may be hyperaemia, oedema, inflammation and various changes to the morphology of the laryngeal mucosal cells.
Accurate figures regarding acute laryngitis are not available, as the condition often goes unreported. The Royal College of General Practitioners reported an average incidence of 6.6 cases of laryngitis and tracheitis per 100,000 patients (all ages) per week in 2010.
Chronic laryngitis is a complex condition which is similarly under-reported and often goes unrecognised. One series reported an average age at presentation of 45 years and an equal incidence of men and women. There is a 2:1 incidence of men versus women, although the differential is thought to be decreasing due to the increase in women smoking. The typical presenting patient is an adult, in the sixth decade of life.
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- Symptoms of upper respiratory tract infection (cough, rhinitis, fever).
- Odynophonia (pain on speaking), dysphagia, odynophagia (pain on swallowing).
- Fatigue and malaise.
By definition, any patient with symptoms of acute laryngitis persisting for longer than three weeks should be deemed to have chronic laryngitis. In such patients, the following additional information should be sought:
- Personal history:
- Duration of symptoms, any relieving or aggravating factors.
- Symptoms suggestive of ill health - lung cancer, thyroid disease.
- Occupational history, especially exposure to irritant substances or temperature change.
- Voice abuse.
- Symptoms suggestive of gastro-oesophageal reflux disease (GORD) - eg heartburn, chest pain, otalgia, cough, wheezing, globus, throat clearing.
- History of asthma - this can sometimes be confused with vocal cord dysfunction; history is of throat rather than chest discomfort, often with additional atypical symptoms (voice difficulty, laryngeal stridor, wheeze worse in inspiration).
- History of allergy.
- Immunocompromised patients - consider candidal involvement.
- Medication history:
- Medications causing local drying, mucosal injury - antihistamines, decongestants, diuretics, antihypertensives, psychotropic drugs, inhaled steroids (don't forget to ask about over-the-counter medicines).
- Drugs increasing the tendency to develop GORD by decreasing the tone of the lower oesophageal sphincter - calcium-channel blockers, nitrates, beta-blockers, progesterone.
- Immunosuppressant therapy - consider candida.
- Inhalation treatments - thermal baths.
- Surgical history:
- History of intubation - recurrent laryngeal damage, particularly likely in thoracic and abdominal surgery.
- Surgery leading to anatomical alterations predisposing to GORD (again, thoracic and abdominal).
- Neck trauma.
- Ingestion of caustic substances.
- Travel history (for the possibility of parasitical infections).
- Family history:
- Social history:
Unless the clinician is experienced in the technique of indirect laryngoscopy (indirect examination of the larynx, using a laryngeal mirror), examination in the limited context of primary care is generally unhelpful, other than to exclude other conditions such as pharyngitis. Patients whose symptoms persist for more than three weeks should have indirect laryngoscopy.
- Any cause of chronic pharyngitis.
In addition to the factors outlined above (see 'history' headings under 'Presentation', above), the following should be considered:
- Bacterial - Staphylococcus aureus (the most common), followed by Haemophilus influenzae and pneumococcal species.
- Syphilis - usually occurs in the second and third stages.
- Rhinoscleroma - caused by the Gram-negative rod Klebsiella rhinoscleromatis.
- Viruses - play a minor role.
- Fungal infections - common, especially in immunocompromised patients, and patients taking inhaled steroids.
- Blastomycosis and histoplasmosis.
- Leishmaniasis and sporotrichosis.
- Lymphoma of the larynx
- Early chronic laryngitis.
- Reflux laryngitis.
- Spasmodic dysphonia.
- Chondronecrosis of the larynx.
- Contact granulomas.
- Glottic stenosis.
- Iatrogenic vocal fold scar.
- Subglottic stenosis in adults.
- Sulcus vocalis.
- Vascular lesions of the vocal fold.
- Vocal fold cysts.
- Idiopathic ulcerative laryngitis (prolonged ulceration of the mid-membranous vocal folds, cause unknown).
- Investigations are rarely helpful in primary care. A swab for microbiological analysis may be contributory if excessive exudate is present.
- Clinicians with the skill to perform indirect laryngoscopy will typically find redness and small dilated vasculature on the inflamed vocal folds.
- Laboratory tests:
- Lateral X-ray of the neck - may show supraglottic or retropharyngeal swelling, or soft tissue density in subglottic airway.
- Chest radiograph.
- CT and MRI scanning may be appropriate if detailed morphology of the larynx is required.
- Barium swallow study, double-contrast upper gastrointestinal series and manometry - may be required to exclude gastro-oesophageal reflux disease (GORD).
- Videostrobe - unit consists of a stroboscopic unit (light source and microphone), a video camera, an endoscope and a video recorder, useful in diagnosing vocal cysts, polyps and nodules.
- Gastro-oesophageal reflux disease (GORD).
- Infections - viral, bacterial, fungal, mycoplasmal.
- Chronic rhinitis (allergic and non-allergic).
- Autoimmune disease.
- Most cases are mild and self-limiting.
- Nondrug measures found to be helpful include inhaling humidified air and minimal use of the voice.
- Inhaling humidified air promotes moisture of the upper airway, helping to clear secretions and exudate.
- Use of antihistamines and corticosteroids is not supported by evidence. Indeed these treatments may cause temporary respite leading to overuse of the voice, as well as drying of the larynx.
- Antibiotics have a limited place in the initial management of acute laryngitis. A Cochrane review found no difference in clinical outcome in adult patients given penicillin V compared with placebo. Erythromycin promoted some benefit in terms of voice improvement but this was not thought to be clinically signficant.
- Antibiotics may be helpful in patients who have persistent symptoms or who have other problems such as immune system deficiency.
- Acute laryngitis is unusual in children under the age of 18. Failure to respond to symptomatic relief should raise the possibility of other conditions, such as tracheobronchitis, especially if there are other features such as dyspnoea.
- Supportive measures - these include hydration (approximately 2 litres per day), steam inhalation, avoidance of pollutants and cigarette smoke and avoidance or limitation of exposure to environmental or occupational sensitisers.
- Treat the underlying condition - eg gastro-oesophageal reflux disease (GORD) may need appropriate lifestyle advice, prokinetic drugs and proton pump inhibitors.
- Staphylococcus aureus is a common secondary infection and appropriate antibiotic therapy may be helpful. Initial therapy for suspected chronic bacterial infection should cover both aerobic and anaerobic organisms, eg co-amoxiclav.
- Hospital admission - be prepared to arrange hospital admission if the patient develops stridor, becomes systemically unwell, or is at risk of food aspiration.
- Surgery - the following may be contributory:
- Surgical relief of stenosis.
- Laser vaporisation.
- Laparoscopic reflux surgery.
- Acute laryngitis - complications are rare, as the disease is usually self-limiting. Damage to the vocal cords is possible in patients who try to overcompensate for the dysphonia.
- Chronic laryngitis - the main complications are voice loss, obstruction of the airways and chronic cough. Spread of infection to surrounding tissues and laryngeal stenosis, can occur with prolonged disease. Rarely, systemic spread may occur. An association with laryngeal carcinoma remains unproven.
- Irritant factors should be avoided - especially active or passive smoking.
- Patients on inhaled steroids should be advised regarding appropriate use, eg dose reduction, twice-daily dosing, mouth rinsing and use of spacers.
- Speech therapy may be necessary in cases of voice abuse.
- Lifestyle advice should be given to patients at risk of gastro-oesophageal reflux disease (GORD).
Further reading & references
- Schwartz SR, Cohen SM, Dailey SH, et al; Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009 Sep;141(3 Suppl 2):S1-S31.
- Shah RK, Acute Laryngitis, Medscape, Jul 2011
- Berliti S et al, Infectious or Allergic Chronic Laryngitis, Medscape, Aug 2011
- Van Houtte E, Van Lierde K, Claeys S; Pathophysiology and treatment of muscle tension dysphonia: a review of the J Voice. 2011 Mar;25(2):202-7. Epub 2010 Apr 18.
- Thibeault SL, Rees L, Pazmany L, et al; At the crossroads: mucosal immunology of the larynx. Mucosal Immunol. 2009 Mar;2(2):122-8. Epub 2009 Jan 7.
- Communicable and Respiratory Disease Report For England and Wales, Royal College of General Practitioners, 2001-2010
- Amiriak B et al, Reflux Laryngitis, Medscape, Dec 2010
- Ozbilen Acar G, Uzun Adatepe N, Kaytaz A, et al; Evaluation of laryngeal findings in users of inhaled steroids. Eur Arch Otorhinolaryngol. 2009 Nov 12.
- Simpson CB, Sulica L, Postma GN, et al; Idiopathic ulcerative laryngitis. Laryngoscope. 2011 May;121(5):1023-6. doi: 10.1002/lary.21659.
- Obourn C, Aynehchi B, Bentsianov B; Atypical presentation of laryngeal tuberculosis in a pediatric patient. Int J Pediatr Otorhinolaryngol. 2012 May;76(5):752-3. Epub 2012 Mar 6.
- Bryson PC et al, Stroboscopy, Medscape, Apr 2012
- Thompson L; Herpes simplex virus laryngitis. Ear Nose Throat J. 2006 May;85(5):304.
- Turley R, Cohen SM, Becker A, et al; Role of rhinitis in laryngitis: another dimension of the unified airway. Ann Otol Rhinol Laryngol. 2011 Aug;120(8):505-10.
- Hiraga A, Kamitsukasa I, Araki N, et al; Hoarseness in pellagra. J Clin Neurosci. 2011 Jun;18(6):870-1. Epub 2011 Apr 19.
- Van Houtte E, Van Lierde K, D'Haeseleer E, et al; Van Houtte E, Van Lierde K, D'Haeseleer E, et al; The prevalence of laryngeal pathology in a treatment-seeking population with Laryngoscope. 2010 Feb;120(2):306-12.
|Original Author: Dr Laurence Knott||Current Version: Dr Laurence Knott||Peer Reviewer: Prof Cathy Jackson|
|Last Checked: 13/06/2012||Document ID: 7128 Version: 3||© EMIS|
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