Laryngitis

Author Credentials 

Original Authors:
Anthony A. Rieder, MD
Albert L. Merati, MD
Robert J. Toohill, MD

Updated 2018:
Katherine A. Kendall, MD
Professor
Department of Otolaryngology
University of Utah
Salt Lake City, Utah

Module Summary

Chronic laryngitis is defined as chronic laryngeal inflammation leading to dysphonia. Secondary symptoms associated with chronic laryngitis include globus sensation, chronic throat clearing, and a feeling of post nasal drip. Determination of the underlying etiology of chronic laryngitis is the key to effective management. Past medical history and current social history is important to elucidation of the underlying cause. Physical examination reveals varying degrees of laryngeal edema, erythema, and hypervascularity and is not specific enough to be diagnostic. Associated findings include secretions, crusting and white lesions in the case of fungal infection. Empiric therapy, based on the past history and physical examination findings, is often the initial treatment but requires close follow-up and a plan for testing including pH with impedence, allergy testing, or biopsy should there be a failure of improvement with empiric treatment. Evaluation by Speech Pathology to manage secondary maladaptive vocal behaviors is often important for symptom resolution.
 

Module Learning Objectives 
  1. Manage the long-term sequelae of acute viral laryngitis, especially prolonged cough.
  2. Formulate a differential diagnosis of chronic laryngitis etiology.
  3. Describe the presenting symptoms and signs of chronic laryngitis.
  4. Plan a treatment strategy based on examination and test results.

Anatomy

Learning Objectives 
  1. Recognize that laryngeal inflammation can impact part or all of the larynx and that the distribution of laryngeal inflammation is not necessarily associated with the underlying etiology of the inflammation.
  2. Identify edema, erythema and hypervascularity as non-specific signs of laryngeal inflammation.

Pathogenesis

Learning Objectives 
  • Acute Laryngitis:
  • Chronic Laryngitis:
    • Define chronic laryngitis as the presence of laryngeal erythema and edema due to chronic irritation of the laryngeal tissues.
    • Recognize that virtually all chronic medical conditions that impact the larynx may cause some degree of chronic laryngitis.  
    • Formulate a differential diagnosis for the pathogenesis of non-specific laryngeal inflammation and be familiar with the proposed mechanisms of laryngeal irritation for each.
    • Allergic Rhinitis:
      • There is controversy regarding the impact of allergies on the larynx and dysphonia. Rhinitis patients have an increased incidence of dysphonia but the mechanisms involved in laryngeal symptoms is not well understood.  Physicians should be aware that dysphonia in patients with allergies is proposed to be caused by multiple mechanisms, including direct inflammation caused by allergens contacting the laryngeal mucosa, increased passage of mucus and other material through the larynx from both the upper and lower airways, and compensatory behaviors such as coughing and throat clearing that then cause secondary laryngeal edema. 
      • A “unified airway” concept purports that IgE mediated inflammation impacts both the upper and lower airways. There is a strong link between allergic rhinitis and the development of asthma.
      • References:
    • Inhaler use:
    • Laryngopharyngeal Reflux:
    • Bacterial infection:
      • Tissue infection with bacteria including methicillin resistant staph aureaus is becoming more common and results in prolonged vocal fold edema and erythema, typically with crusting.
      • Risk factors for developing bacterial laryngitis have yet to be elucidated.
      • References:

        Figure 2: Chronic Bacterial Laryngitis

      • Medications:
        • Drying medications may have a secondary impact on voice quality.
        • Patients taking an anticholinergic medication have an increased risk of dysphonia, presumably due to dessication of laryngeal secretions.
        • References:
      • Systemic diseases may impact the larynx either directly or indirectly, e.g., thyroid disorders, Wegener’s granulomatosis, sarcoidosis, amyloidosis, rheumatoid arthritis.
      • Other chronic infectious diseases, e.g., tuberculosis, syphilis, leprosy.
      • Muscle tension dysphonia, poor respiratory support for phonation.

Basic Science

Learning Objectives 
  1. Describe the inflammatory mechanisms in the laryngeal mucosa and epithelium that lead to chronic dysphonia.
  2. Discuss the theory regarding the laryngeal microbiome in the development of disease including chronic laryngitis due to reflux, irritant exposure, and bacterial infection. 
References 
  1. Jette ME, Dill-McFarland KA, Hanshew AS, Suen G, Thibeault SL. The human laryngeal microbiome: effects of cigarette smoke and reflux. Nature/Scientific Reports 2016 :35882 | DOI: 10.1038/srep35882 
  2. Kinnari TJ, Lampikoski H, Hyyrynen T, Aarnisalo AA. Bacterial biofilm associated with chronic laryngitis. Arch Otolaryngol Head Neck Surg. 2012;138(5):467-470.
  3. Thibeault S, Rees L, Pazmany L, Birchall MA. At the crossroads: mucosal immunology of the larynx. Mucosal Immunol. 2009:2(2):122-128.

Incidence

Learning Objectives 

Know the incidence of chronic laryngitis in the general population is difficult to determine secondary to vague diagnostic criteria and a myriad of underlying causes.

References 
  1. Stein DJ, Noordzij P. Incidence of chronic laryngitis. Ann Otol Rhinol Laryngol. 2013;122(12):771-774.

Patient Evaluation

Learning Objectives 
  1. Recognize the history typically associated with a diagnosis of chronic laryngitis.
  2. Be aware that secondary complaints such as chronic throat clearing, a globus sensation, “post nasal drip” may accompany dysphonia complaints in cases of chronic laryngitis.
  3. Evaluate the full past medical history to find associated conditions leading to laryngeal inflammation.
  4. Describe the findings associated with chronic laryngitis and discuss the implications of the physical examination on the underlying etiology of the inflammation. Recognize that physical examination findings are generally non-specific and often cannot distinguish the underlying etiology of the inflammation.
  5. Allergic laryngitis: thick-viscous endolaryngeal secretions and transient or chronic reactive vocal fold edema and hyperemia. 
  6. Fungal laryngitis may impact the true vocal folds or the entire larynx.
  7. Chronic bacterial laryngitis is associated with exudates and crusting of the larynx, especially the true vocal folds and sub-glottis.
  8. Dysphonia associated with inhaler use is often associated with dilated vessels and white plaques on the medial margins of the vocal folds.
  9. The reflux finding score is not specific enough to diagnose laryngopharyngeal reflux. Reflux laryngitis is often described as involving erythema of the posterior aspect of the larynx with infra-glottic edema.
References 
  1. De Bortoli N, Nacci A, Savarino E, Martinucci I, Bellini MN, Fattori B, Ceccarelli L, Costa F, Mumolo MG, Ricchiuti A, Savarino V, Berrettini S, Marchi S. How many cases of laryngopharyngeal reflux suspected by laryngsocpy are gastroesophageal reflux disease-related? World J Gastroenterol. 2012;18(32):4363-4370.

Measurement of Functional Status

Learning Objectives 
  1. Describe the commonly used measurement tools to evaluate the level of dysphonia in any patient population.
  2. Discuss the indications for allergy testing in the evaluation of chronic laryngitis.
  3. Be aware of the indications for pH probe testing with impedence in the evaluation of possible laryngopharyngeal reflux disease and discuss implications for response to medical therapy.
References 
  1. Rosen C, Lee A, Osborne J, Zullo T, Murray, T. Development and validation of the voice handicap index-10. Laryngoscope. 2004;14:1549-1556.
  2. Behlau M, Madazio F, Moreti F, Oliveira G, Dos Santos LM, Paulinelli BR, Couto Junior EB. Efficiency and cutoff values of self-assessment instruments on the impact of a voice problem. J Voice. 2016;30(4):506.
  3. Stackler RJ, Dworkin-Valenti JP. Allergic laryngitis: unraveling the myths. Curr Opin Otolaryngol Head Neck Surg. 2017 Jun;25(3):242-246.
  4. Cumpston EC, Blumin JH, Bock JM. Dual pH with multichannel intraluminal impedance testing in the evaluation of subjective laryngopharyngeal reflux symptoms. Otolaryngol Head Neck Surg. 2016;155(6):1014-1020.
  5. De Bortoli N, Nacci A, Savarino E, Martinucci I, Bellini MN, Fattori B, Ceccarelli L, Costa F, Mumolo MG, Ricchiuti A, Savarino V, Berrettini S, Marchi S. How many cases of laryngopharyngeal reflux suspected by laryngoscopy are gastroesophageal reflux disease-related? World J Gastroenterol. 2012 18(32):4363-4370.

Imaging

Learning Objectives 

Be aware that radiological studies are not indicated or helpful in the evaluation of chronic laryngitis.

Pathology

Learning Objectives 

Discuss the role of tissue biopsy and culture in the diagnosis of chronic bacterial laryngitis.

References 
  1. Carpenter PS, Kendall KA. MRSA chronic bacterial laryngitis: a growing problem. Laryngoscope. 2018 128(4):921-925.
  2. Thomas CM, Jette ME, Clary MS. Factors associated with infectious laryngitis: a retrospective review of 15 cases. Ann Otol Rhinol Laryngol. 2017; 126(5):388-395.

Treatment

Learning Objectives 
  1. Discuss strategies to remove inhaled irritants in the environment and propose healthy lifestyle and laryngeal hygiene measures with patients.
  2. Create a treatment algorithm based on likely etiology of the underlying laryngeal inflammation.
  3. Discuss the progress through the treatment algorithm and decision making based on response to treatment and test results.
  4. Consider evaluation by a Speech Pathologist if the patient has secondary maladaptive vocal behaviors.

Medical Therapies

Learning Objectives 
  1. Discuss treatment for suspected laryngopharyngeal reflux and expected response to therapy. Base empiric reflux treatment on a history of GERD associated symptoms and consider a change of treatment if no response in eight weeks with discontinuation of the reflux medications. Recommend pH and impedence testing if silent reflux is suspected.
  2. Manage allergic rhinitis and asthma as appropriate and consider allergy testing in patients in whom allergic etiology is suspected.
  3. Discuss treatment for bacterial laryngitis and expected response to therapy. Inform patients of the need for prolonged antibiotic therapy in most cases.
References 
  1. Cumpston EC, Blumin JH, Bock JM. Dual pH with multichannel intraluminal impedance testing in the evaluation of subjective laryngopharygeal reflux symptoms. Otolaryngol Head Neck Surg. 2016;155(6):1014-1020.
  2. Stackler RJ, Dworkin-Valenti JP. Allergic laryngitis: unraveling the myths. Curr Opin Otolaryngol Head Neck Surg. 2017 Jun;25(3):242-246.
  3. Carpenter PS, Kendall KA. MRSA chronic bacterial laryngitis: a growing problem. Laryngoscope. 2018 128(4):921-925.
     

Pharmacology

Learning Objectives 
  1. Choose appropriate therapy for the management of post-acute viral cough.
  2. Be familiar with the incidence of antibiotic resistance in cases of bacterial laryngitis and proposed antibiotic choices based on that incidence.
References 
  1. Dominguez LM, Simpson CB. Viral laryngitis: a mimic and a monster – range, presentation, management. Curr Opin Otolaryngol Head Neck Surg. 2015 Dec;23(6):454-8.
  2. Carpenter PS, Kendall KA. MRSA chronic bacterial laryngitis: a growing problem. Laryngoscope. 2018;128(4):921-925.
     

Surgical Therapies

Learning Objectives 

Discuss the role of biopsy in cases of chronic laryngitis unresponsive to empiric antibiotic treatment.

References 
  1. Carpenter PS, Kendall KA. MRSA chronic bacterial laryngitis: a growing problem. Laryngoscope. 2018;128(4):921-925.

Rehabilitation

Learning Objectives 

Consider evaluation by Speech Pathology in the management of secondary maladaptive vocal behaviors.

Case Studies

  1. A 45 year-old female who works as a 911 operator presents with a chief complaint of chronic dysphonia.  She has difficulty with work due to problems projecting her voice on the phone and a feeling of strain with speaking.  Her symptoms have been present for three months.  She is obese and has a history of reflux disease and DVT.  She is on warfarin for her history of DVT.  The patient’s examination is remarkable for bilateral vocal fold edema and erythema with crusting along the medial aspects of the vocal folds and significant supraglottic narrowing or squeeze during phonation.  What is your differential diagnosis?  What is the treatment plan?  How does her past medical history impact treatment? When will you see her back for re-evaluation?
    • (The patient physical findings are consistent with bacterial laryngitis and secondary muscle tension dysphonia.  Initial treatment considerations would include empiric antibiotic therapy including treatment for MRSA.  The patient is on warfarin and trimethoprim/sulfa will prolong the metabolism of warfarin necessitating adjustments in dose.  Initial therapy with Augmentin could be considered in order to avoid this drug interaction.  However, if the patient does not respond with significant improvement within three weeks, biopsy and tissue culture should be considered.  Speech Pathology evaluation and therapy to help eliminate secondary muscle tension is also indicated.)
  2. A 67 year-old female presents with complaints of chronic hoarse voice for five months.  She does not have significant vocal demands.  Her voice abnormalities wax and wane but she feels that her voice is never normal.  She has a history of asthma and uses an inhaler daily with a rescue inhaler as needed.  She is not very active secondary to her asthma.  She admits that she does a significant amount of throat clearing and she has a chronic frequent daily cough that she associates with her diagnosis of asthma.  However, she feels that her asthma is fairly well controlled other than the chronic coughing.  Examination reveals white lesions along the medial aspects of both vocal folds. What is the differential diagnosis?  Can a treatment algorithm be formulated? Should a multidisciplinary approach be taken? How frequent should there be follow-up?
    • (This patient may have vocal fold trauma from chronic coughing, fungal infection secondary to prolonged inhaler use, or primary laryngeal inflammation due to the inhaler use.  Her asthma is significant enough the she is not likely to be able to discontinue her inhaler.  A trail of antifungal medication for two weeks is indicated and Speech Pathology referral is appropriate to help manage the chronic cough and throat clearing.  If the patient does not respond to these initial therapies with significant improvement on physical examination, at a three-week follow-up visit, then medical cough suppression with a course of gabapentin could be considered.  Ultimately, if the patient fails to improve even with management of cough and treatment of fungal infection, then surgical excision for diagnostic and therapeutic purposes could be considered.)

Complications

Learning Objectives 

Recognize that persistent symptoms secondary to a failure of correct diagnosis and appropriate treatment is likely the most common complication of chronic laryngitis. Chronic dysphonia results in a decreased quality of life and absentee

References 
  1. Cohen SM, Dupont WD, Courey MS. Quality-of-life impact of non-neoplastic voice disorders: a meta-analysis. Ann Otol Rhinol Laryngol. 2006;115:128-34
  2. Cohen SM, Kim J, Roy N, Asche C, Courey M. The impact of laryngeal disorders on work-related dysfunction. Laryngoscope. 2012;122:1589-1594.

Review

Review Questions 
  1. What kind of symptoms are present in patients most likely to respond to empiric anti-reflux therapy?
  2. What are the proposed mechanisms for chronic laryngitis for patients with allergies and asthma?
  3. What are the laryngeal findings in a patient with bacterial laryngitis? Are they different for patients infected with MRSA compared to other pathogens?
  4. Discuss the management of chronic cough in post-acute viral infection.  What are the pros and cons of various medical treatment options?  Is therapy for cough suppression management effective?