Acute infectious laryngitis: A case series.
Although acute laryngitis is common, it is often managed by primary physicians. Therefore, video images documenting its signs are scarce. This series includes 7 professional voice users who previously had undergone baseline strobovideolaryngscopy (SVL) during routine examinations or during evaluations for other complaints and who returned with acute laryngitis. Sequential SVL showed not only the expected erythema, edema, cough, and dysphonia, but also new masses in 5 of the 7 subjects. All the signs returned to baseline. This series is reported to highlight the reversible structural changes that can be expected in patients with acute laryngitis and the value of conservative management.
Acute infectious laryngitis is one of the most common disorders of the larynx and is often associated with upper respiratory tract infections (URIs), as reported more than a decade ago in a Cochrane review. (1) Laryngeal inflammation can cause hoarseness, sore throat, and difficulty swallowing. These symptoms usually subside within 3 weeks but may persist much longer (months).
It can be difficult to distinguish between bacterial and viral origins. (1) Viral laryngitis can be caused by many organisms, including but not limited to, influenza virus, adenovirus, and even Varicella zoster virus. Acute bacterial laryngitis presents similarly; however, purulent secretions are observed more commonly in patients with a bacterial infection. (2) Treatment for viral causes remains supportive, with adequate hydration and at least relative voice rest, while the bacterial form may benefit from the addition of an antibiotic.
Most patients with URI symptoms are evaluated and treated by a primary care physician. It is much less common for the otolaryngologist to treat an acute episode unless there is a complicating feature (e.g., protracted course, persistent symptoms after the URI, recurrent episodes, etc.). For this reason, high-quality images of the larynx during an acute infection often are not available. We present a series of patients with acute infectious laryngitis and their coinciding laryngoscopic images to highlight salient features.
Each patient presented here was established within the practice and had had strobovideolaryngoscopy performed before, during, and after an acute episode of infectious laryngitis.
The examinations performed before the current visits often were performed routinely at the patients request, to establish the normal baseline appearance of their vocal folds when they were healthy. In some cases, they were performed incidentally during evaluation for other complaints, but none was performed for laryngitis or any other acute laryngeal problem. These examinations established the "normal" basline laryngoscopic appearance for each of these patients.
Patient 1. A 37-year-old woman presented with a history of cough for 1 week and a gradual onset of hoarseness that began 2 days before the visit. These symptoms progressed to aphonia for 3 days and a sensation of throat swelling. Strobovideolaryngoscopy (SVL) revealed a new right mid-membranous vocal fold mass, moderate erythema and edema of the true vocal folds and arytenoids, and thick mucopurulent secretions (figure 1, A). The proximal trachea also appeared inflamed. Acute laryngotracheitis was diagnosed, and amoxicillin-clavulanate and prednisone were prescribed for 7 days.
Follow-up SVL 8 days later demonstrated resolution of the patient's right vocal fold mass, and the true vocal folds were no longer erythematous. The appearance of her arytenoids and consistency of her secretions had returned to baseline (figure 1, B).
Patient 2. A 29-year-old man experienced hoarseness that progressed to aphonia 4 days before his office visit. Cough, increased mucus production, and a sensation of swelling of the throat were reported, as well. SVL revealed moderate edema and severe erythema of the arytenoids, and erythema and edema of the true vocal folds with increased vascularity (figure 2, A). Thick mucus was visualized in the larynx, as well asbilateral mid-membranous inflammatory masses with an exudative appearance. A diagnosis of acute infectious laryngitis was made, and amoxicillin-clavulanate was prescribed for 7 days.
SVL 3 weeks later demonstrated resolution of the acute changes, and only the baseline pathology remained, which included laryngopharyngeal reflux (LPR) and vocal fold scar (figure 2, B).
Patient 3. A 17-year-old female singer had a history of vocal fold nodules and reflux laryngitis. She reported a productive cough for the previous 24 hours. SVL revealed edema of the true vocal folds and erythema of the larynx. Thick yellow mucus was observed from within the trachea (figure 3, A). A diagnosis of acute laryngotracheitis was made, and the patient was started on amoxicillin-clavulanate for 10 days.
The patient did not return until 15 weeks later, at which time SVL confirmed resolution of the infection (figure 3, B).
Patient 4. A 35-year-old woman presented with acute hoarseness and cough of 1 to 2 weeks' duration. SVL revealed moderate erythema and edema of the arytenoids and Reinke edema. Severe inflammation was observed involving the true vocal folds, subglottis, trachea, and the interarytenoid region (figure 4, A). Purulent secretions were evident, and amoxicillin-clavulanate was prescribed for 7 days.
Follow-up 3 weeks later with SVL revealed improvement in Reinke edema, erythema of the larynx and trachea, and the consistency of secretions (figure 4, B).
Patient 5. A 34-year-old man presented with hoarseness and cough for 2.5 weeks. His voice had deteriorated gradually over the previous few days to a whisper. SVL revealed new lesions on the posterior third of each musculomembranous vocal fold that appeared inflammatory (figure 5, A). A diagnosis of acute laryngitis was made, and the patient was treated with amoxicillin for 14 days. Fluconazole and nystatin were prescribed empirically to treat suspected superimposed, fungal laryngitis, especially since prednisone also was prescribed for 2 weeks to help with the inflammation.
The patient returned 1 week later for follow-up. SVL revealed resolution of the true vocal fold lesions and accompanying erythema and edema (figure 5, B). The patient's hoarseness also had improved markedly.
Patient 6. A 31-year-old woman presented with sore throat, odynophagia, hoarseness, and a cough productive of yellow sputum for 1 week. She reported vocal fatigue, reduced projection, and loss of range when singing. She had been staying hydrated and taking a decongestant, expectorant, and cough suppressant. SVL revealed three areas of swelling along the vibratory margin of the left vocal fold with a "tongue and groove" effect along the contralateral vocal fold. There were prominent vessels along this patient's vocal folds, and her larynx appeared erythematous (figure 6, A). Decreased mucosal wave and vibration of the true vocal folds were observed. The patient was treated with amoxicillin-clavulanate for 10 days along with guaifenesin for congestion.
The patient returned 7 weeks later for follow-up. At that time, she reported that she had had a sore throat for the previous week and that she had begun coughing up yellow sputum. She was treated with levofloxacin for 7 days and oseltamivir for 5 days. When she returned 3 weeks later, follow-up SVL showed resolution of her inflammatory masses, and the mucosal wave and vibratory characteristics of the vocal folds had returned to baseline (figure 6, B).
Patient 7. A 29-year-old woman presented with an acute episode of hoarseness progressing to aphonia, which she had experienced 3 days before her appointment. She also reported a sore throat, odynophagia, and cough for 5 days. She had been taking a cough suppressant, antihistamine, decongestant, and acetaminophen to relieve her symptoms, and she had increased oral hydration. SVL revealed increased Reinke edema and new bilateral mid-membranous vocal fold masses (figure 7, A). The amplitude and wave form of the vocal folds were decreased. She was diagnosed with acute laryngitis and treated with amoxicillin-clavulanate for 10 days and a methylprednisolone taper.
At follow-up 1 week later, the patient's voice had improved markedly. She reported that she had been able to speak "normally" after 5 days of treatment. SVL revealed resolution of the inflammatory vocal fold masses, return to baseline of laryngeal erythema and edema, and the vibratory characteristics of the vocal folds had improved, (figure 7, B).
Summary of symptoms
On presentation, all 7 patients reported hoarseness, 6 had cough, 3 had increased mucus/phlegm, and 3 had aphonia. SVL revealed laryngeal edema and erythema in all 7 patients, a new vocal mass in 5 patients compared with their baseline examinations, increased mucus in 4 patients, and tracheal involvement in 3 patients. The duration of symptoms before and after the patients' initial visits is shown in figure 8.
These 7 patients provided novel insights into the presentation of acute infectious laryngitis. Of particular interest was the development of acute inflammatory vocal fold masses along the vibratory margin and increased laryngeal edema and erythema compared to baseline. Voice change and laryngeal edema and erythema were present in all 7 patients. Cough was a presenting symptom in 6, and new vocal fold masses along the vibratory margin were present in 5 patients. An increased amount of thick mucus involving the larynx was observed in 4 patients, with additional patients reporting a productive cough. The duration of symptoms ranged from 15 days to 35 days. The mean time to symptom resolution after initiation of medical therapy was 16 days. Follow up SVL confirmed resolution of the acute findings in all 7 patients.
Acute infectious laryngitis is characterized by inflammation of the larynx that usually resolves within 3 weeks. The condition often accompanies upper respiratory tract infections with symptoms that may include hoarseness, sore throat, odynophonia, odynophagia, dysphagia, dyspnea, cough, congestion, postnasal drip, and mucus. The hoarseness often is accompanied by lowering of pitch that persists for 3 to 8 days in most cases. (1) The voice may sound breathy and/or raspy, and compensatory muscle tension dysphonia often is present.
SVL frequently reveals erythema and edema of the larynx involving the true vocal folds, resulting in alteration of the mucosal wave and vibratory characteristics. Inflammatory masses also can develop on the true vocal folds, further exacerbating the dysphonia and altered pitch.
Acute infectious laryngitis is caused by numerous pathogens. Among these, viral pathogens are believed to be most prevalent, following patterns similar to those for URL They include parainfluenza, rhinovirus, influenza virus, and adenovirus. Bacterial pathogens that have been associated with acute laryngitis include Moraxella catarrhalis, Haemophilus influenzae, and Streptococcus pneumoniae, with M catarrhalis being the most common. (2) Extension to the larynx of an infection involving the upper aerodigestive tract can occur. In some cases, a sputum culture may be helpful to direct therapy.
The treatment for viral and bacterial laryngitis includes supportive measures. At least relative voice rest, humidification, analgesics, and hydration should be considered along with mucolytics, decongestants, and glucocorticoid steroids. In addition, antibiotics may be prescribed in cases in which a bacterial infection is suspected (e.g., tracheitis, purulent secretions, immunocompromised state, protracted course, positive culture, etc.). They also may be used when the etiology is uncertain but pressing voice commitments are imminent.
A Cochrane Review completed in 2015 investigated the benefits of antibiotic usage for acute laryngitis. (3) After reviewing the only two placebo-controlled, randomized trials that met their inclusion criteria, the authors concluded that antibiotics appeared to have no benefit; however, they acknowledged that one of the studies demonstrated a significant reduction in severity of reported vocal symptoms after 1 week on erythromycin (vs. placebo) and a significant reduction in cough after 2 weeks with antibiotics. (1)
Since the patients in our series were professional voice users, expeditious return to baseline vocal function was a primary concern. Therefore, prescribing an antibiotic was justified based on the conclusions of the study included in the Cochrane Review, as well as on the uncertainty of the etiology and the need for rapid return to safe phonation.
LPR, a chronic form of laryngitis, can have signs and symptoms that overlap with those of acute infectious laryngitis. The distinguishing features of reflux laryngitis include a longer duration of symptoms (usually over many weeks, months, or even years), exacerbating factors (symptoms with meals or certain foods and during specific activities), response to proton pump inhibitor/H2 blocker, and erythema/edema commonly most prominent on or isolated to the region of the arytenoids. (4) When the two pathologies coexist, it is prudent to allow the acute laryngitis episode to resolve before making a final assessment of the need for long-term treatment for the reflux, but acute treatment of LPR is advisable to decrease inflammation caused by both LPR and infection. When any uncertainty in the diagnosis remains, a 24-hour pH impedance test can be helpful.
Another form of chronic laryngitis, prolonged ulcerative laryngitis, also has been and reported by the senior author (RTS), among others. (5) Symptoms and abnormal SVL may persist for many weeks (up to 5 months or longer in some cases). Antibiotics and corticosteroids are ineffective, and the etiology remains unknown, although the senior author suspects that biofilms may play a role.
Acute infectious laryngitis presents commonly during URL Through SVL images, the changes along the musculomembranous vocal folds have been defined clearly and documented in this case series. Further investigation with prospective, randomized, controlled trials is needed to improve our understanding of ways to differentiate viral from bacterial causes, to determine whether the structural changes seen in this series of voice professionals also occur routinely in other patients, to help guide appropriate use or nonuse of antibiotics without inappropriate delays awaiting culture results (especially for voice professionals), and to identify the most effective treatment strategies in various patient populations.
Aaron J. Jaworek, MD; Kranthi Earasi, MD; Karen M. Lyons, MD; Srihari Daggumati, BS; Amanda Hu, MD, FRCSC; Robert T. Sataloff, MD, DMA, FACS
From the Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia (Dr. Jaworek, Dr. Lyons, and Dr. Sataloff); Specialty Physician Associates, Bethlehem, Pa. (Dr. Jaworek); Drexel University College of Medicine, Philadelphia (Dr. Earasi and Mr. Daggumati); and the Department Of Otolaryngology-Head and NeckSurgery, the University of British Columbia, Vancouver (Dr. Hu). The cases described in this article occurred at Drexel University College of Medicine. Corresponding author: Robert T. Sataloff, MD, DMA, FACS, 219 N. Broad St., 10th Floor, Philadelphia, PA 19107. Email: RTSataloff@PhillyENT.com
(1.) Reveiz L, Cardona AF, Ospina EG. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev 2007;2:CD004783
(2.) Dworkin JP. Laryngitis: Types, causes, and treatments. Otolaryngol Clin North Am 2008;41(2):419-36.
(3.) Reveiz L, Cardona AF. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev 2015;5:CD004783
(4.) Joniau S, Bradshaw A, Esterman A, Carney AS. Reflux and laryngitis: A systematic review. Otolaryngol Head Neck Surg 2007;136(5):686-92.
(5.) Sataloff RT. Common infections, inflammations and other conditions: Management in singers and actors. In: Sataloff RT. Professional Voice: The Science and Art of Clinical Care. 3rd ed. San Diego: Plural Publications; 2005:809.
Caption: Figure 1. Patient 1 during acute infectious laryngitis episode (A) and after resolution of the laryngitis (B).
Caption: Figure 2. Patient 2 during acute infectious laryngitis episode (A) and after resolution of the laryngitis (B).
Caption: Figure 3. Patient 3 during acute infectious laryngitis episode (A) and after resolution of the laryngitis (B).
Caption: Figure 4. Patient 4 during acute infectious laryngitis episode (A) and after resolution of the laryngitis (B).
Caption: Figure 5. Patient 5 during acute infectious laryngitis episode (A) and after resolution of the laryngitis (B).
Caption: Figure 6. Patient 6 during acute infectious laryngitis episode (A) and after resolution of the laryngitis (B).
Caption: Figure 7. Patient 7 during acute infectious laryngitis episode (A) and after resolution of the laryngitis (B).
Caption: Figure 8. Graph shows the duration of symptoms in the 7 patients before and after their visits. (Note: 6a and 6b represent two separate episodes in the same patient. The total duration of symptoms was not known for patients 3 and 6a.)
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Jaworek, Aaron J.; Earasi, Kranthi; Lyons, Karen M.; Daggumati, Srihari; Hu, Amanda; Sataloff, Rober|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Sep 1, 2018|
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