Laryngitis

In this article:

• What Is laryngitis
• Symptoms
• When to see a doctor
• Seek immediate medical attention if you
• Seek immediate medical attention if your child
• Causes
  • Acute laryngitis
  • Allergic laryngitis
  • Chronic laryngitis
• Risk Factors
• Complications
• Prevention
• Diagnosis
• Pulmonary examination
• Laboratory Findings
• Imaging studies
• References

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What Is laryngitis

Laryngitis is an inflammation of the voice box called larynx. It is unusual to have a laryngitis separately from the upper respiratory infections. Upper respiratory infections (URIs) are infections of the mouth, nose, throat, larynx (voice box), and trachea (windpipe).

Laryngitis can be acute and chronic. Acute laryngitis can be an emergency, if the tissues around the voice box swell so much that the breathing is troubled. It happens frequently with some viral infections in kids. Another common name for this condition is croup.

Acute laryngotracheobronchitis (LTB) is an infection-induced inflammatory condition affecting the larynx, trachea, and bronchi. It occurs most often in children ages 6 months to 6 years, with the peak age at 2 years.

Laryngitis can be non-infectious when it is caused by the strain of the vocal cords. Most often it happens after public events when a person yells or shouts for a prolonged period of time. Then hoarseness may develop due to irritation and inflammation of the tissues surrounding vocal cords.

Most cases of the laryngitis actually resolve on their own with only supportive treatment. but sometimes, especially in small children, hospitalization and intravenous treatment in required. 

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Symptoms

Common symptoms of the laryngitis:

1. Hoarseness
2. Sore throat
3. Difficulty swallowing
4. Stridor (high-pitch noise in the throat while breathing)
5. Difficulty breathing

If laryngitis is a part of the viral illness, other signs specific to that virus may be present:

1. Malaise (not feeling well)
2. Fever (sometimes very high)
3. Headache
4. Cough 
5. Nose congestion or runny nose.

If croup is a part of allergic reaction, symptoms develop fast require emergency epinephrine treatment:

1. Itchy throat, mouth
2. Red face, hives
3. Swollen lips, eyelids
4. History of known allergic reactions
5. Feeling of “impending doom” 
6. Altered consciousness and blackout (syncope)

Laryngeal symptoms resulting from chronic allergic laryngitis are not specific and include hoarseness, throat clearing, coughing and globus sensation (sensation of foreign body in a throat). 

Although no specific laryngoscopic signs are pathognomonic for allergic laryngitis, findings associated with allergic laryngitis include dense endolaryngeal mucus, hyperemia and vocal fold edema. These signs and symptoms are also common in patients with laryngopharyngeal reflux (LPR) 

When to see a doctor

URI is very common in children. If you are comfortable managing it at home you should not see a doctor. If you are an adult, most likely you have had laryngitis not once and you also know what to do without doctor’s appointment. Yet, some laryngitis requires a clinic or emergency room visit.

Seek immediate medical attention if you:

• Exposed to a known allergen (especially food or insect bite) that caused anaphylaxis or severe reaction before. If you have any worrisome symptoms and difficulty breathing, use epi-pen right away, and then call 911
• Have a high fever, severe headache and stridor
• Cannot breathe normally

Seek immediate medical attention if your child:

• Has a high fever with stridor
• Develops barky cough 
• Cannot breathe right, struggles to breathe, has blue lips
• Does not respond appropriately, becomes limp (in babies)
• Does not drink liquids and does not pee (dehydration)

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Causes

Acute laryngitis

In about 3% of children, viral infections of the airways that develop in early childhood lead to narrowing of the laryngeal lumen in the subglottic region resulting in symptoms such as hoarseness, a barking cough, stridor, and dyspnea. These infections may eventually cause respiratory failure. 

The disease is often called acute subglottic laryngitis (ASL). Terms such as pseudocroup, croup syndrome, acute obstructive laryngitis and spasmodic croup are used interchangeably when referencing this disease. Although the differential diagnosis should include other rare diseases such as epiglottitis, diphtheria, fibrinous laryngitis and  bacterial tracheobronchitis, the diagnosis of ASL should always be made on the basis of clinical criteria.

Allergic laryngitis

Acute allergic laryngitis may be caused by:

• Allergenic foods
• Insect stings
• Allergy to cats, dogs

Chronic laryngitis

Here are most common causes of the chronic laryngitis:

• Environmental allergy
• Gastro-esophageal reflux (GERD)
• Voice overstrains 
• Vocal cord warts, polyps and tumors
• Inhaled medication side effect (some asthma medications that are powder inhalers may cause laryngitis by direct irritation).

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Risk Factors

Croup (infectious laryngitis) has certain risk factors:

• Young child (less than 5 years old)
• Seasonality (croup is common during winter months)
• Daycare or many siblings at home
• Known contact with another sick child

Diphtheria or pertussis should be suspected in unvaccinated children. 

Acute allergic laryngitis risk factors:

• Known history of allergic reactions
• Exposure to known food allergen, environmental allergen, or insect sting
• History of previous anaphylaxis (systemic allergic reaction)

Risk factors of chronic laryngitis:

• Known environmental allergy (cat, dust mites, molds etc.)
• Voice-related work or activity (singing, drama, social work etc.)
• Known voice cord injury
• GERD

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Complications

Croup is mostly a self-limited disease with complete uncomplicated resolution. Severe croup, as may occur with influenza type A, may require tracheotomy or intubation in approximately 13% of patients and have an associated mortality of 0% to 2.7%. 

A small percentage of children with prolonged intubation or severe disease may develop subglottic stenosis. A few follow-up studies have shown an increase in hyperactive airways in children with a history of croup.

Hoarseness and voice changes is a significant social problem and must be timely addressed to avoid permanent vocal cord damage.

Systemic allergic reaction must be managed urgently with epinephrine injection to avoid anaphylaxis and death.

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Prevention

Prevention of laryngitis is based on its possible causes:

• Infection prevention by proper hygiene
• Voice hygiene (no loud screaming or shouting, voice rest)
• Allergy treatment and hypoallergenic measures
• Avoiding known allergens

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Diagnosis

Diagnosis of an infectious laryngitis is mostly clinical. Hoarseness of voice followed by paroxysms of nonproductive, harsh, seal-like cough that ends with a characteristic inspiratory stridor. Fever, rhinorrhea, sore throat, and cough usually precede this. Symptoms may vary in intensity and last approximately 3 to 4 days if mild.

Acute laryngotracheobronchitis (LTB) symptoms increase fast, and require hospitalization:

• Patients appear apprehensive and tend to lean forward
• The child may have tachypnea and might be using accessory respiratory muscles, lips turn blue or purple
• Inspiratory or expiratory stridor is loud

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Pulmonary examination

• may reveal rhonchi, crepitations, or wheezing
• On exam by the doctor breath sounds may be diminished if upper airway obstruction is severe and air entry is greatly decreased

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Laboratory Findings

• The white blood cell count may be normal or mildly elevated.
• Noninvasive pulse oximetry to monitor the oxygen saturation is recommended. Arterial blood gas assessment shows hypoxemia and/or hypercapnia, depending on the severity of the disease.

Microbiologic diagnosis can be established by serology, viral or bacterial cultures from the pharynx, or rapid antigen detection enzyme immunosorbent assays such as for RSV, COVID-19, parainfluenza, or influenza type A. 

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Imaging studies

Anterior-posterior radiograph view of the neck shows the subglottic obstruction. Anterior-posterior views of the neck show edematous subglottic walls converging to create a characteristic “steeple sign.”

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References

Acute subglottic laryngitis. Etiology, epidemiology, pathogenesis and clinical picture. Mazurek H, Bręborowicz A, Doniec Z, Emeryk A, Krenke K, Kulus M, Zielnik-Jurkiewicz B.Adv Respir Med. 2019;87(5):308-316. doi: 10.5603/ARM.2019.0056.PMID: 31680234 Free article.

Allergic laryngitis: chronic laryngitis and allergic sensitization. Campagnolo A, Benninger MS.Braz J Otorhinolaryngol. 2019 May-Jun;85(3):263-266. doi: 10.1016/j.bjorl.2019.02.001. Epub 2019 Mar 4.PMID: 30898484 Free article. Review. 

Upper respiratory infections. Grief SN.Prim Care. 2013 Sep;40(3):757-70. doi: 10.1016/j.pop.2013.06.004. Epub 2013 Jul 12.PMID: 23958368 Free PMC article. Review.

Hoarseness-causes and treatments. Reiter R, Hoffmann TK, Pickhard A, Brosch S.Dtsch Arztebl Int. 2015 May 8;112(19):329-37. doi: 10.3238/arztebl.2015.0329.PMID: 26043420 Free PMC article. 

Acute infectious laryngitis: A case series. Jaworek AJ, Earasi K, Lyons KM, Daggumati S, Hu A, Sataloff RT.Ear Nose Throat J. 2018 Sep;97(9):306-313. doi: 10.1177/014556131809700920.PMID: 30273430 Free article.

Laryngitis and aerosols. Stollard GE.Br Med J. 1970 Feb 28;1(5695):568. doi: 10.1136/bmj.1.5695.568.PMID: 5435212 Free PMC article.