ENT · Upper Respiratory Infections
The facts most likely to be tested
The most common etiology of acute laryngitis is a viral upper respiratory infection.
The hallmark clinical presentation is hoarseness or dysphonia lasting less than three weeks.
Laryngitis is a clinical diagnosis that does not require routine laryngoscopy in patients with uncomplicated symptoms.
The primary management for acute laryngitis is vocal rest and hydration.
Persistent hoarseness lasting longer than two to three weeks requires laryngoscopy to rule out laryngeal malignancy.
Antibiotics are not indicated for acute laryngitis as the condition is almost exclusively viral or inflammatory in origin.
Vocal cord nodules are the most common cause of chronic hoarseness in patients with a history of vocal abuse or chronic strain.
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A 42-year-old male school teacher presents to the clinic complaining of a progressive loss of voice over the past 10 days. He reports a recent upper respiratory infection that has since resolved, but his hoarseness persists. He denies fever, difficulty swallowing, or shortness of breath. Physical examination reveals a normal oropharynx and no cervical lymphadenopathy. He is a non-smoker and has no history of gastroesophageal reflux disease.
What is the most appropriate next step in management?
Vocal rest and supportive care
The patient presents with classic symptoms of acute viral laryngitis; since the duration is less than three weeks and there are no red flags, conservative management is the standard of care.
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Etiology / Epidemiology
Most commonly viral (URI). Voice overuse and irritant exposure are primary non-infectious triggers.
Clinical Manifestations
Classic hoarseness and dysphonia lasting <3 weeks. Absence of systemic symptoms is typical.
Diagnosis
Primarily a clinical diagnosis. Laryngoscopy is reserved for symptoms >3 weeks.
Treatment
Primary management is vocal rest. Avoid antibiotics as they provide no benefit.
Prognosis
Self-limiting; usually resolves within 7-10 days. Persistent symptoms require malignancy workup.
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Epidemiology & Etiology
Acute laryngitis is most frequently caused by respiratory viruses like rhinovirus or influenza. Non-infectious causes include vocal strain, GERD, or inhaled irritants. It is a common diagnosis in patients presenting with acute upper respiratory symptoms.
Pertinent Anatomy
The larynx houses the vocal cords, which become inflamed and edematous during infection. This swelling disrupts normal cord vibration, leading to the characteristic change in voice quality.
Pathophysiology
Inflammation of the laryngeal mucosa leads to edema of the lamina propria. This mechanical change increases the mass of the vocal cords, altering their frequency of vibration. The resulting dysphonia is the hallmark of this inflammatory process.
Clinical Manifestations
Patients present with hoarseness and a sensation of a 'lump' in the throat. Red flags include stridor, dyspnea, or dysphagia, which suggest airway compromise or epiglottitis. If symptoms persist >3 weeks, consider laryngeal carcinoma or vocal cord nodules.
Diagnosis
Diagnosis is clinical based on history and physical exam. Laryngoscopy is the gold standard for persistent hoarseness to rule out structural lesions or malignancy. No routine laboratory or imaging studies are indicated for acute cases.
Treatment
Management focuses on vocal rest and hydration. Antibiotics are not indicated for viral etiology and should be avoided. If GERD is suspected, proton pump inhibitors may be utilized as an adjunct.
Prognosis
Most cases resolve spontaneously within 1-2 weeks. If hoarseness persists beyond 3 weeks, referral to ENT for visualization is mandatory to exclude malignancy.
Differential Diagnosis
Epiglottitis: presents with drooling, tripod positioning, and high fever
GERD: associated with chronic throat clearing and nocturnal cough
Vocal cord nodules: associated with chronic voice abuse in singers/teachers
Laryngeal cancer: suspected if hoarseness persists >3 weeks in smokers
Croup: characterized by a barking cough and inspiratory stridor