laryngitis

DEFINITION: Inflammation of the laryngeal mucosa, particularly the vocal folds, leading to impaired vibration and dysphonia (hoarseness) or aphonia.

ACUTE LARYNGITIS (<3 weeks) - Etiology: Most commonly viral (rhinovirus, influenza, parainfluenza, adenovirus, coronavirus incl. SARS-CoV-2). Bacterial causes are less common (Moraxella catarrhalis, Haemophilus influenzae, Streptococcus pyogenes). Also vocal overuse/abuse (shouting, singing) and irritants. - Pathophysiology: Mucosal edema and erythema of the vocal folds increase mass and stiffness, altering vibration, so voice becomes hoarse/low-pitched or lost. - Presentation: Hoarseness, aphonia, throat discomfort, dry cough, often with a preceding URI. Fever is usually mild or absent. - Management: Supportive care (voice rest, hydration, humidification, analgesics). Antibiotics are NOT indicated for typical viral cases. Corticosteroids are generally not routine, though they may be used short-term for professional voice users with urgent needs. Self-limited, resolving in ~1–2 weeks.

CHRONIC LARYNGITIS (>3 weeks) - Causes: Laryngopharyngeal reflux (LPR)/GERD, smoking, alcohol, chronic irritants/allergens, chronic vocal abuse, inhaled corticosteroids (candidal laryngitis), chronic sinusitis/postnasal drip. - Exam: Laryngoscopy shows erythema, edema, posterior laryngeal (interarytenoid) changes with LPR; may show nodules, polyps, leukoplakia. - Key point: Hoarseness persisting >4 weeks, or any hoarseness in a smoker/heavy drinker (or with red flags such as hemoptysis, dysphagia, neck mass, weight loss) requires laryngoscopy to exclude laryngeal squamous cell carcinoma. - Treatment: Eliminate causes (smoking cessation, PPI/lifestyle for reflux, voice therapy, antifungals for candidiasis).

SPECIAL FORMS / DIFFERENTIALS - Croup (laryngotracheobronchitis): Parainfluenza virus in children 6 mo–3 yr; barking cough, inspiratory stridor, subglottic narrowing ("steeple sign" on AP neck X-ray). Treat with dexamethasone ± nebulized epinephrine. - Epiglottitis: Supraglottic inflammation (H. influenzae type b historically, now also Strep, Staph aureus); fever, drooling, muffled "hot potato" voice, tripod positioning, dysphagia, "thumbprint sign" on lateral neck X-ray. Airway emergency; secure the airway first. - Bacterial tracheitis: Staph aureus, toxic appearance, follows viral croup. - Laryngeal tuberculosis: Seen with advanced pulmonary TB; hoarseness and odynophagia. - Reinke edema: Polypoid swelling of the vocal folds in heavy smokers. - Vocal cord nodules ("singer's nodules"): Bilateral at the junction of the anterior 1/3 and posterior 2/3 of the vocal folds from voice overuse. - Recurrent laryngeal nerve palsy (e.g., thyroid surgery, apical lung tumor, aortic arch aneurysm): Hoarseness without inflammation. - Laryngeal papillomatosis: HPV 6/11; recurrent respiratory papillomatosis, hoarseness in children. - Laryngeal cancer: Squamous cell carcinoma; risk factors are tobacco and alcohol; persistent hoarseness.

BOARD PEARLS - Viral laryngitis is the most common cause of acute hoarseness; treatment is supportive. - Chronic hoarseness (>4 weeks) → laryngoscopy. - Chronic laryngitis + reflux: think LPR (hoarseness, throat clearing, globus, chronic cough). - Inhaled corticosteroid users can develop candidal laryngitis (rinse mouth after use). - Distinguish from croup (barking cough, steeple sign) and epiglottitis (drooling, thumbprint sign).