55

55
Acute Laryngitis
MARY T. CASERTA

A cute laryngitis is a common clinical syndrome encountered by gated in several reports from Sweden. In a case-control study of 40
primary care physicians. The symptoms are often described as the adults with hoarseness and symptoms of upper respiratory tract infec-
recent onset of hoarseness or a husky voice often associated with a dry tion, 55% of the patients and 14% of controls had M. catarrhalis iso-
cough.1 There may be voice breaks or episodes of aphonia, which lated from a nasopharyngeal culture.13 Haemophilus influenzae was the
frequently occur in the context of an upper respiratory tract infection second most frequently recovered bacterial pathogen from patients
with rhinorrhea and sore throat. The duration of symptoms is difficult with laryngitis (8% to 20%), which suggests that organism may also
to discern from the literature; however, in a study of 80 adults with play a role in this condition. Treatment of patients with M. catarrhalis
the common cold, hoarseness was reported for a median of 3 days, and with oral penicillin or erythromycin for 5 days failed to show any
5.5 days represented the 75th percentile.2 Although most reports objective clinical benefit over placebo, however, despite a significant
describe acute laryngitis as a mild and self-limited syndrome, a survey rate of bacteriologic eradication, casting doubt on the significance of
of intercollegiate athletes found substantial morbidity associated with the association.14,15
laryngitis.3 Students reported laryngitis significantly more often as a Uncommon causes of acute laryngitis include herpesviruses, parvo-
cause of missed practice compared with cough, nasal discharge, or virus B19, mucosal candidiasis, Coccidioides immitis, Cryptococcus neo-
myalgia, and as an adverse effect on their athletic performance. formans, Sporothrix schenckii, and group G β-hemolytic streptococci
The incidence of acute laryngitis reported in the literature varies in normal and immunocompromised patients.16-21 Clinical findings
and is highly dependent on the study methods used. In an older in patients with laryngitis secondary to herpes simplex virus 1
report of more than 3900 patients older than 5 years with acute respi- or 2, varicella-zoster virus, or cytomegalovirus include edema and
ratory infections, only 2% were given a primary diagnosis of laryngi- inflammation of the glottic or supraglottic region with vesicles or
tis.4 In other studies, 38% of patients with pneumonia reported ulcerative lesions with or without vocal cord paralysis.16
hoarseness as a symptom, as did 53% of adults with colds, and 67% Laryngitis secondary to tuberculosis (TB) and blastomycosis is
of children with bacterial tracheitis.2,5,6 Laryngitis has also been noted usually a complication of pulmonary infection.17,22 Although in the
in approximately 22% of adolescents or school-aged children with past, laryngeal TB was frequently detected in young patients with
nonstreptococcal sore throat.7 Despite this demonstration that laryn- recognized pulmonary TB, more recent reports have described changes
gitis affects patients of all ages, a report of more than 800 patients in the epidemiology and clinical features of TB of the larynx. In a study
seen in an ear, nose, and throat clinic showed that most patients with of 31 patients with biopsy-confirmed laryngeal TB, only 55% were
acute laryngitis presenting for care were women with a mean age of referred because of a previous diagnosis of pulmonary TB, whereas
38 years.8 In addition, the study showed that the frequency of laryn- 33% had odynophagia or a suspicion of carcinoma.23 The mean age of
gitis during the winter months was almost double that observed in patients with laryngeal TB was 60 years in a case series reported by
the warmer half of the year. Kandiloros and colleagues.24 Historically, patients with laryngeal TB
All of the major respiratory viruses have been etiologically associ- had a large burden of organisms in their sputum. In a more recent
ated with laryngitis. In the study of patients older than 5 years with a study from India, patients with laryngeal TB were no more likely to
primary diagnosis of laryngitis, 21% had infection with parainfluenza have positive sputum results than patients with pulmonary TB without
virus, 15% had rhinovirus, 3% had influenza virus, and 3% had adeno- laryngeal disease.22 Clinical findings reported in laryngeal TB range
virus.4 The risk of developing laryngitis with a particular type of respi- from the classic description of cranial nerve palsies with ulcerative
ratory infection is summarized in Table 55-1. McMillan and colleagues7 lesions of the posterior larynx to anterior tumor-like masses. Given
reported that laryngitis and cough were noted significantly more often this changing clinical picture, a high degree of diagnostic suspicion is
among patients with influenza (29%) than among patients with group warranted to make a diagnosis of laryngeal TB.
A β-hemolytic streptococcal infection (2.3%). In a retrospective review Laryngeal histoplasmosis is a complication of disseminated infec-
of an epidemic of influenza in the United Kingdom, the rate of laryn- tion and manifests as hoarseness of indolent onset without cough.
gitis or tracheitis reported by general practitioners peaked at approxi- Blastomycosis and histoplasmosis of the larynx can be mistaken for
mately 100 per 100,000 population, coincident with the peak of squamous carcinoma because of the indolent onset, gross appearance
influenza illness.9 Younger patients were significantly more likely to on laryngoscopy, and pseudoepitheliomatous hyperplasia on biopsy.
report hoarseness than elderly subjects in a study of human metapneu- Fever is low grade or absent. Diagnosis depends on demonstration of
movirus infection.10 Hoarseness was reported in 91% of young adults the fungi in the submucosa. Hoarseness may also be noted as a com-
with human metapneumovirus infection compared with 42% of sim- ponent of other laryngeal infections, such as croup, acute epiglottitis,
ilar-age subjects with respiratory syncytial virus infection. Among or supraglottitis. These conditions are discussed separately (in
older adults admitted to the hospital for respiratory disorders, hoarse- Chapters 56 and 59). Other noninfectious causes of acute laryngitis
ness was reported by 25% of subjects with illness resulting from include voice abuse, gastroesophageal reflux disease, and laryngeal
rhinovirus or coronavirus.11 Hoarseness or laryngitis has not been malignancy.
reported as a symptom in patients with severe acute respiratory syn- The diagnosis of acute laryngitis caused by an upper respiratory
drome secondary to human pneumonia–associated coronavirus.12 infection can often be made by history alone. Examination of the
Bacterial respiratory infections have also been associated with acute larynx reveals hyperemic and erythematous true and ventricular vocal
laryngitis. Several authors have noted the presence of hoarseness in folds resulting from edema and vascular engorgement of the mucous
patients with acute streptococcal pharyngitis, as noted in Table 55-1. membranes.25 Treatment needs to be directed at the underlying infec-
Laryngitis secondary to diphtheria has been virtually eliminated in the tious cause of hoarseness, but generally is symptomatic in nature, with
United States, although diphtheria continues to be an important cause voice rest, analgesic therapy, and humidification.25 As noted previ-
of laryngeal disease worldwide. The possible etiologic role of Moraxella ously, studies evaluating the use of antibiotics for patients with acute
(Branhamella) catarrhalis in adults with acute laryngitis was investi- laryngitis have not shown objective benefit, and a more recent
823
824 Part II  Major Clinical Syndromes

TABLE Frequency of Laryngitis Associated with Common

Cochrane review concluded that antibiotics should not be prescribed
55-1 Respiratory Pathogens for patients with typical laryngitis.26 Long-term sequelae of laryngitis
Rhinovirus 25%-29%11,28
are uncommon, but prolonged hoarseness has been noted most fre-
Influenza 28%-35%7,11,28
quently after infection with uncommon pathogens.
Parainfluenza 8.5%29
Superior laryngeal neuralgia has also been described as a rare com-
plication of acute laryngitis.27 This disorder is characterized by painful
Adenovirus 22%-35%30
paroxysms of the throat induced by head turning, swallowing, or voice
Coronavirus 25%11
straining, and is associated with a trigger point on the lateral aspect of
Mycoplasma pneumoniae 3%-37%5,31
the neck overlying the thyrohyoid membrane. Various treatments,
Chlamydophila pneumoniae 30%31
including injections of local anesthetic, have been used to treat this
Group A β-hemolytic streptococcus 2.3%-19%7,28
complication.
Human metapneumovirus 4%-91%10,32

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