Acute and Chronic Laryngitis: Differential Diagnosis, Treatment and Voice Rehabilitation

Acute laryngitis (<3 weeks) usually develops as part of a viral upper respiratory infection. Rhinovirus is the main cause (common cold), with influenza + parainfluenza + RSV + coronavirus adding. Pathophysiology: viral epithelial invasion → mucosal oedema + inflammation → vocal fold vibration impaired → hoarseness.

Classic presentation: URI 1-3 days earlier (rhinorrhoea, sore throat), then hoarseness develops. Hoarseness typically peaks 5-7 days, resolves fully 10-14 days. Throat tenderness, dry cough, vocal fatigue (after long talking), low fever may accompany.

Paediatric acute laryngitis — croup (laryngotracheobronchitis): common 6 months - 3 years. Parainfluenza types 1-2 main cause. Clinical: barking (seal-bark) cough, stridor (inspiratory), hoarseness, respiratory distress (chest-neck retraction). Severity scored by Westley score. Treatment: humidification + hydration + hot shower steam in mild; in moderate-severe dexamethasone (oral or IM, 0.15-0.6 mg/kg) + nebulised epinephrine (racemic or L-epinephrine). If respiratory failure — hospitalisation + intubation.

Differential: bacterial laryngotracheitis (high fever, severe respiratory distress, ill-appearance — antibiotic + admission), epiglottitis (rare post Hib vaccine — paediatric emergency, severe laryngeal oedema, intubation risk), foreign body aspiration (age 1-3, sudden onset, asymmetric breath sounds), angioedema (allergic, sudden swelling, urticaria), acute spasmodic croup (sudden night onset, mild, not viral).

Treatment principles — adult acute laryngitis: (1) Voice rest — gentle voice (no whispering — glottis does not close, large effort required, harms vocal folds more in acute laryngitis); keep speech minimal but not silent; (2) Hydration — 2-3 L/day; (3) Humidification — humidifier or hot shower steam; (4) Smoking — quit, at least acute period; (5) Reduce alcohol + caffeine — dehydration, irritant; (6) Avoid cold/dry environment; (7) Antibiotic — Cochrane review: no benefit for routine antibiotic in acute laryngitis; only if bacterial secondary suspected (purulent sputum + fever + leucocytosis — amoxicillin); (8) Systemic steroid — special cases (professional voice user with critical performance, severe laryngeal oedema, acute spasmodic state); short course (3-5 days) prednisolone 30-60 mg; (9) Antiviral — only flu A/B + early (within 48 hours) oseltamivir.

Approach in professional voice users: opera singer, professional singer, stage actor, teacher, preacher, call-centre worker — critical. Urgent evaluation — laryngeal exam (FNL), stroboscopy (vocal fold mucosal wave), decision: performance cancellation (safest), short systemic steroid + strict vocal rest + voice therapist supervision (joint decision), antibiotic (if bacterial suspected), inhaled therapy (mucosal moisture). Mismanagement → permanent vocal fold damage (haemorrhage, polyp, nodule).

Prevention: avoid exposure (crowds + cold/URI), hand hygiene, annual influenza vaccine, immune support (sleep, nutrition, stress), regular voice health checks (6-monthly FNL) in voice professionals, proper vocal technique (professional voice coaching).

Complications: acute → chronic transition (often with LPR + voice misuse background), vocal fold haemorrhage (strenuous voice on viral infection background), vocal fold polyp/nodule development (long-term poor technique + acute exacerbations). Related service: our laryngology and voice surgery unit.

Chronic laryngitis (>3 weeks of laryngeal mucosal inflammation) has different aetiologic groups — management is cause-specific. Diagnostic algorithm: detailed history + laryngoscopy + cause-specific work-up + biopsy in selected cases.

Laryngopharyngeal reflux (LPR): commonest cause of chronic laryngitis (>50%). Gastric content reaches larynx — pepsin + acid + bile → mucosal irritation. Differs from classic GERD: horizontal reflux (LPR — day, upright) vs vertical reflux (GERD — night, supine). Hence classic GERD symptoms (heartburn, regurgitation) absent in 30-50% of LPR. Symptoms: hoarseness (especially morning), throat clearing (constant "ahem"), chronic cough, laryngeal fullness (globus), vocal fatigue, postnasal drip sensation. Reflux Symptom Index (RSI, Belafsky 2002) — 9 symptoms 0-5 points, total >13 suspect LPR.

LPR laryngoscopic findings (Reflux Finding Score — RFS): posterior laryngeal erythema + hyperplasia, vocal fold oedema, diffuse laryngeal oedema, ventricular obliteration (subglottic thickening), endolaryngeal mucus, granuloma (especially vocal process), thick endolaryngeal mucus. RFS >7 LPR-positive. Imaging: usually not needed (pH-metry not standard — 24-hour dual-channel pH + impedance more sensitive; if needed).

LPR treatment: high-dose PPI (esomeprazole 40 mg BD, pantoprazole 40 mg BD) for 3-6 months — chronic laryngitis needs longer + higher doses than classic GERD. Lifestyle: reduce fatty/spicy/acidic foods, no late meals (3-4 hours before bed), head of bed elevated 15-30 cm, weight loss (BMI >25), quit smoking-alcohol, no tight clothing. Refractory case — surgery (Nissen fundoplication).

Smoking: second main factor in chronic laryngitis. Direct mucosal irritation + heat + carcinogen chemistry. Smoker with chronic laryngitis carries 5-10× laryngeal cancer risk. Cessation essential. Passive smoke also relevant.

Voice misuse — phonotrauma: chronic loud/strained voice — teacher, voice artist, call-centre, telesales, preacher, coach, sports cheering, parents. Chronic microtrauma to vocal fold mucosa — nodule (bilateral mid-third, mirror appearance), polyp (unilateral, larger), cyst (subepithelial), Reinke's oedema (smoking + voice misuse — vocal fold pol fold).

Other causes: (1) Atrophic laryngitis — elderly with dry mucosa, thick mucus crusts; treatment moisture + saliva support + voice therapy; (2) Fungal laryngitis — commonly Candida, in immunosuppressed or post inhaled steroid + antibiotics; antifungal (fluconazole 200 mg/day 14 days); (3) Tuberculous laryngitis — in endemic areas + AIDS; granulomatous lesion, ulceration; AFB positivity + biopsy; antituberculous DOT; (4) Sarcoidosis — granulomatous laryngitis, ACE elevated, biopsy; (5) Wegener's granulomatosis (GPA) — subglottic stenosis + epistaxis + skin + lung; ANCA positive, biopsy; immunosuppressant; (6) Rheumatoid laryngitis — crico-arytenoid joint involvement, hoarseness + airway narrowing; biologic.

Vocal fold lesions may develop secondary to chronic laryngitis: nodule (bilateral, symmetric, "singer's nodule" — voice therapy may suffice; refractory — microlaryngoscopic excision), polyp (unilateral, may develop after acute haemorrhage — excision), cyst (subepithelial, no response to voice therapy — excision), granuloma (vocal process — after LPR or intubation; PPI + voice therapy, surgery if needed).

Hoarseness >3 weeks + smoking/alcohol — laryngeal cancer SCREENING. Risks: male > female, age >50, heavy smoking + alcohol (especially combined), HPV (more oropharyngeal, less laryngeal but possible), chronic laryngeal irritation. Clinical suspicion → FNL + stroboscopy + biopsy if needed (under microlaryngoscopy) + neck evaluation. Step-by-step details: reflux laryngitis page.

Chronic laryngitis treatment is multidisciplinary — ENT + speech-language therapist + gastroenterologist (if LPR) + pulmonologist (chronic cough + asthma) + psychologist (stress component in voice professionals).

Step 1 — cause management: LPR → high-dose PPI long-term + lifestyle (above); smoking → cessation (nicotine replacement, varenicline, bupropion + counselling); voice misuse → voice therapy; fungal → fluconazole; immune-mediated → specific treatment.

Step 2 — voice therapy (Speech-Language Therapist — SLT): backbone of chronic laryngitis treatment. 6-12 sessions (weekly or fortnightly). Components: (1) Vocal hygiene education — water (2-3 L/day), reduce caffeine-alcohol, quit smoking, voice rest breaks (5-10 minutes silent each hour), change throat-clearing habit (sip water, gentle cough); (2) Posture + breath support — diaphragmatic breathing, shoulder-neck relaxation, correct posture; (3) Vocal function exercises (Stemple VFE) — vocal fold resonance + flexibility; (4) Resonance therapy (LMRVT) — soft resonance focused; (5) Easy onset — avoid hard glottic closure; (6) Occupational vocal technique — specific design for teachers/professionals.

Step 3 — surgery (refractory or structural lesion): microlaryngoscopy excision of vocal fold lesion (nodule, polyp, cyst, granuloma). Modern techniques: cold steel microinstruments (subepithelial sparing), CO2 laser (selective lesion, haemostasis), KTP laser (microvascular lesion — useful when bleeding risk high). Postop voice rest 5-10 days + continuation of voice therapy + cause management.

Laser + biologic treatments: recurrent respiratory papillomatosis (HPV-induced — surgery + intralesional bevacizumab, systemic bevacizumab); refractory LPR (sodium alginate, magaldrate, sucralfate — alternatives); biologics (autoimmune laryngitis — TNF-α inhibitor, rituximab).

Voice therapy success: nodule + benign vocal lesion — voice therapy alone resolves 70-85%, especially early. Refractory/structural lesion (cyst, polyp) — voice therapy combined with surgery pre/post.

Professional voice user (artist, teacher, broadcaster): special rehab programme — voice coaching, vocal hygiene, function exercises, pre/post-performance routines, stress management (performance anxiety). Regular (6-12 monthly) FNL + stroboscopy follow-up.

Voice analysis parameters — surveillance: (1) Voice Handicap Index (VHI-30) — QoL 0-120, clinically meaningful change >18 point decrease; (2) Acoustic — F0 (fundamental frequency), jitter, shimmer, HNR (harmonics-to-noise ratio); (3) Aerodynamic — maximum phonation time (MPT), s/z ratio; (4) Perceptual — GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain — 0-3 each); (5) Stroboscopy — mucosal wave symmetry, closure, vibration amplitude.

Follow-up: chronic laryngitis treatment 4-6 weeks first review, 3 months second, 6 months third, then 6-12 monthly. Risk group (smoking + alcohol + age >50) — annual laryngoscopy advised.

Lifestyle add-ons: adequate sleep (vocal folds recover at night), regular exercise (general health + weight + reflux reduction), stress management (neck-shoulder tension affects voice), adequate room humidity (40-60% ideal — dry air irritates larynx).

Turkish voice disorder practice: major university hospital ENT + voice surgery/laryngology units, private voice clinics (Istanbul Memorial, Acıbadem, Anadolu; Ankara Bayındır, Hacettepe), coordinated with speech-language therapists. Specific programmes for voice professionals. We share patient experiences on our second opinion service.