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Emergency and Acute Medicine – Laryngitis
Basic description
Laryngitis is inflammation of the laryngeal mucosa, most commonly caused by viral upper respiratory infection. Incidence peaks in late fall, winter, and early spring and parallels viral epidemics. Inflammation reduces normal vocal cord vibration, resulting in hoarseness and voice changes.
Etiology
Acute laryngitis is most often viral, including influenza A and B, parainfluenza, adenovirus, coronavirus, coxsackievirus, respiratory syncytial virus, measles, and rhinovirus. Bacterial causes are uncommon but include β-hemolytic streptococcus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Bordetella pertussis, diphtheria, tuberculosis, syphilis, and leprosy. Noninfectious causes include laryngopharyngeal reflux related to GERD, fungal infection (often with inhaled steroid use or immunocompromise), allergy, voice abuse, inhalation or ingestion of irritants or caustics, autoimmune disease, trauma, and idiopathic causes. In children, acute spasmodic laryngitis (spasmodic croup) is more often infectious, and foreign body must be considered in unimmunized patients.
Diagnosis: signs and symptoms
Patients typically present with hoarseness or abnormal voice quality, throat irritation or rawness, throat swelling, frequent throat clearing, cough, malaise, fever, and occasionally dysphagia. Physical examination may reveal hoarse voice, pharyngeal erythema or edema, regional lymphadenopathy, stridor in infants, or asymmetric breath sounds if a foreign body is present.
Essential workup
Acute laryngitis is usually a clinical diagnosis based on history and throat inspection and typically resolves within 7–10 days. Increased suspicion for epiglottitis is required in unimmunized patients or those with respiratory distress. Chronic laryngitis lasting longer than 3 weeks warrants evaluation for GERD, chronic infection, neurologic disorders, or malignancy, with referral for laryngeal visualization by otolaryngology.
Diagnostic tests and interpretation
Laboratory studies are generally unnecessary, as leukocytosis does not reliably distinguish viral from bacterial disease. Throat cultures are reserved for cases with exam findings suggestive of bacterial infection. Imaging is rarely required; fiberoptic laryngoscopy is preferred when visualization is necessary. Soft-tissue neck radiographs are reserved for suspected epiglottitis or foreign body when laryngoscopy is unavailable and the patient is stable.
Differential diagnosis
Asthma, epiglottitis, GERD, vocal cord nodules, laryngeal or thyroid malignancy, croup or laryngotracheobronchitis, and foreign-body aspiration should be considered.
Treatment: prehospital care
Supportive care is usually sufficient. Stridor suggests potential airway obstruction, particularly in children, and warrants urgent evaluation. Neck trauma–associated laryngitis requires otolaryngology assessment. Caustic ingestion raises concern for esophageal injury. Suspected epiglottitis requires transport in the upright position with supplemental oxygen and avoidance of unnecessary airway manipulation.
Initial stabilization and therapy
Stabilization is required only for patients with respiratory distress. Management should follow epiglottitis protocols, including supplemental oxygen and preparation for advanced airway management in a controlled setting.
Emergency department treatment and procedures
Management is primarily supportive. Antibiotics are not recommended for routine adult acute laryngitis, as evidence shows no benefit over placebo. Vocal rest is essential, avoiding whispering; patients should use a soft, relaxed voice if speaking is necessary. Humidified air, increased oral fluids, analgesics, and smoking cessation are recommended. Symptoms typically resolve within 7–10 days if viral. Inhaled steroids are controversial and not standard therapy.
Medications
Treatment is cause-specific. Acetaminophen or NSAIDs may be used for pain and fever. Guaifenesin may help if associated with upper respiratory infection. Proton pump inhibitors are indicated for GERD-related laryngitis. Antifungal therapy is used for candidal infection. For croup, a single dose of dexamethasone is indicated. Antibiotics are reserved for confirmed bacterial infection or high-risk patients.
Follow-up and disposition
Admission is required for tuberculous laryngitis, respiratory distress, suspected epiglottitis, neck trauma, anaphylaxis, or airway compromise. Most patients with uncomplicated laryngitis can be discharged if breathing is normal and hydration is adequate. Chronic or nonresolving symptoms require otolaryngology referral.
Pearls and pitfalls
Most acute laryngitis is viral, and antibiotics provide no benefit. Always consider life-threatening causes of altered voice such as epiglottitis. Laryngitis without upper respiratory symptoms may indicate GERD. Persistent hoarseness beyond 3 weeks warrants evaluation to exclude malignancy.
Basic description
Laryngitis is inflammation of the laryngeal mucosa, most commonly caused by viral upper respiratory infection. Incidence peaks in late fall, winter, and early spring and parallels viral epidemics. Inflammation reduces normal vocal cord vibration, resulting in hoarseness and voice changes.
Etiology
Acute laryngitis is most often viral, including influenza A and B, parainfluenza, adenovirus, coronavirus, coxsackievirus, respiratory syncytial virus, measles, and rhinovirus. Bacterial causes are uncommon but include β-hemolytic streptococcus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Bordetella pertussis, diphtheria, tuberculosis, syphilis, and leprosy. Noninfectious causes include laryngopharyngeal reflux related to GERD, fungal infection (often with inhaled steroid use or immunocompromise), allergy, voice abuse, inhalation or ingestion of irritants or caustics, autoimmune disease, trauma, and idiopathic causes. In children, acute spasmodic laryngitis (spasmodic croup) is more often infectious, and foreign body must be considered in unimmunized patients.
Diagnosis: signs and symptoms
Patients typically present with hoarseness or abnormal voice quality, throat irritation or rawness, throat swelling, frequent throat clearing, cough, malaise, fever, and occasionally dysphagia. Physical examination may reveal hoarse voice, pharyngeal erythema or edema, regional lymphadenopathy, stridor in infants, or asymmetric breath sounds if a foreign body is present.
Essential workup
Acute laryngitis is usually a clinical diagnosis based on history and throat inspection and typically resolves within 7–10 days. Increased suspicion for epiglottitis is required in unimmunized patients or those with respiratory distress. Chronic laryngitis lasting longer than 3 weeks warrants evaluation for GERD, chronic infection, neurologic disorders, or malignancy, with referral for laryngeal visualization by otolaryngology.
Diagnostic tests and interpretation
Laboratory studies are generally unnecessary, as leukocytosis does not reliably distinguish viral from bacterial disease. Throat cultures are reserved for cases with exam findings suggestive of bacterial infection. Imaging is rarely required; fiberoptic laryngoscopy is preferred when visualization is necessary. Soft-tissue neck radiographs are reserved for suspected epiglottitis or foreign body when laryngoscopy is unavailable and the patient is stable.
Differential diagnosis
Asthma, epiglottitis, GERD, vocal cord nodules, laryngeal or thyroid malignancy, croup or laryngotracheobronchitis, and foreign-body aspiration should be considered.
Treatment: prehospital care
Supportive care is usually sufficient. Stridor suggests potential airway obstruction, particularly in children, and warrants urgent evaluation. Neck trauma–associated laryngitis requires otolaryngology assessment. Caustic ingestion raises concern for esophageal injury. Suspected epiglottitis requires transport in the upright position with supplemental oxygen and avoidance of unnecessary airway manipulation.
Initial stabilization and therapy
Stabilization is required only for patients with respiratory distress. Management should follow epiglottitis protocols, including supplemental oxygen and preparation for advanced airway management in a controlled setting.
Emergency department treatment and procedures
Management is primarily supportive. Antibiotics are not recommended for routine adult acute laryngitis, as evidence shows no benefit over placebo. Vocal rest is essential, avoiding whispering; patients should use a soft, relaxed voice if speaking is necessary. Humidified air, increased oral fluids, analgesics, and smoking cessation are recommended. Symptoms typically resolve within 7–10 days if viral. Inhaled steroids are controversial and not standard therapy.
Medications
Treatment is cause-specific. Acetaminophen or NSAIDs may be used for pain and fever. Guaifenesin may help if associated with upper respiratory infection. Proton pump inhibitors are indicated for GERD-related laryngitis. Antifungal therapy is used for candidal infection. For croup, a single dose of dexamethasone is indicated. Antibiotics are reserved for confirmed bacterial infection or high-risk patients.
Follow-up and disposition
Admission is required for tuberculous laryngitis, respiratory distress, suspected epiglottitis, neck trauma, anaphylaxis, or airway compromise. Most patients with uncomplicated laryngitis can be discharged if breathing is normal and hydration is adequate. Chronic or nonresolving symptoms require otolaryngology referral.
Pearls and pitfalls
Most acute laryngitis is viral, and antibiotics provide no benefit. Always consider life-threatening causes of altered voice such as epiglottitis. Laryngitis without upper respiratory symptoms may indicate GERD. Persistent hoarseness beyond 3 weeks warrants evaluation to exclude malignancy.
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