Acute Laryngitis

Acute inflammation of the laryngeal mucosa lasting less than 3 weeks, producing hoarseness through disruption of the vibratory properties of the vocal folds.

Why inflammation produces hoarseness

The vocal fold has a layered structure: squamous epithelium, the superficial lamina propria known as Reinke space, which is a loose gelatinous layer with few fibroblasts and permits the mucosal wave, the intermediate and deep lamina propria forming the vocal ligament, and the thyroarytenoid muscle. Inflammation causes oedema and cellular infiltration of Reinke space, increasing the mass and stiffness of the cover and impairing the mucosal wave. This raises phonation threshold pressure, lowers fundamental frequency, and produces the characteristic rough, breathy, low pitched voice.

The critical clinical consequence is that phonation against an inflamed, stiff fold requires greater subglottic pressure and greater adductory force, which causes further trauma. This is the mechanism by which vocal use during acute laryngitis produces vocal fold haemorrhage, mucosal tear and, in the longer term, benign lesions. Voice rest is therefore not a comfort measure but a treatment to prevent structural injury.

Aetiology

Infective, the great majority:

Viral, in 90 percent or more: rhinovirus, influenza, parainfluenza, adenovirus, respiratory syncytial virus, coronavirus, SARS-CoV-2.
Bacterial superinfection or primary bacterial laryngitis with Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pyogenes, which is uncommon.
Fungal laryngitis with Candida, in inhaled corticosteroid users, the immunocompromised, and after antibiotics.

Non infective:

Vocal misuse and abuse: shouting, screaming, prolonged loud speaking, singing without training, cheering at events.
Laryngopharyngeal reflux.
Inhalational injury: smoke, chemicals, thermal injury, chlorine.
Allergic and irritant exposure.
Inhaled corticosteroids, both directly and through candidal infection.
Radiotherapy.
Trauma, including intubation.

Hoarseness or dysphonia, which is the cardinal symptom, ranging from mild roughness to complete aphonia.
Voice fatigue and reduced vocal range, with loss of the upper register noticed particularly by singers.
Throat pain and odynophonia, that is pain on phonation.
Dry cough and throat clearing.
Globus sensation.
Preceding or coexisting upper respiratory infection with coryza, sore throat and cough.
Fever and malaise in infective disease.
Symptoms resolve within 7 to 14 days in the great majority.

Red flags requiring urgent assessment

Stridor, respiratory distress, inability to lie flat or a tripod posture, which indicate airway compromise and which mandate immediate assessment in a setting with airway support. In an adult, severe odynophagia with a relatively normal oropharynx and a muffled voice is supraglottitis until proven otherwise.
Drooling and inability to swallow saliva.
Severe odynophagia disproportionate to visible findings.
Haemoptysis.
Dysphagia and weight loss.
A neck mass.
Hoarseness persisting beyond 3 weeks, which is the threshold for laryngoscopy in every patient and beyond which the diagnosis is no longer acute laryngitis. In a smoker or drinker this requires urgent referral on a suspected cancer pathway.
Hoarseness in a smoker of any duration.
Recent thyroid, cardiac, thoracic or cervical spine surgery, or a history of malignancy, indicating possible recurrent laryngeal nerve injury.

Examination

Assess voice quality: rough, breathy, strained, aphonic, and note pitch and loudness.
Assess the airway: stridor, work of breathing, ability to lie flat, drooling.
Examine the oropharynx and neck.
Flexible nasolaryngoscopy where symptoms are severe, atypical, prolonged, or where any red flag is present. In uncomplicated acute laryngitis with a clear viral illness and no red flags, laryngoscopy is not required at first presentation.
Laryngoscopic findings in acute laryngitis: erythematous, oedematous vocal folds with dilated vessels, loss of the normal pearly white appearance, mucus stranding, and incomplete glottic closure from oedema. Look specifically for a vocal fold haemorrhage, which appears as a red submucosal blush and which mandates absolute voice rest.

Clinical in typical cases with a short history, an obvious viral illness and no red flags.
Flexible nasolaryngoscopy is mandatory for hoarseness persisting beyond 3 weeks, for any red flag, for professional voice users where the diagnosis alters management, and for recurrent episodes.
Videostroboscopy where available, which assesses the mucosal wave and detects subtle lesions, scarring and vibratory asymmetry not visible on standard laryngoscopy. It is particularly valuable in professional voice users.
Throat swab for bacterial and fungal culture where bacterial or candidal laryngitis is suspected.
Full blood count and inflammatory markers where systemic illness is present.
Lateral soft tissue neck radiography or, better, direct visualisation for suspected supraglottitis, though imaging must never delay airway management.
Contrast enhanced computed tomography of the neck where deep neck infection or abscess is suspected.
Chest imaging where an intrathoracic cause of vocal fold palsy is possible, particularly in a smoker with hoarseness, since a left recurrent laryngeal nerve palsy may be the first sign of a bronchial carcinoma.
Biopsy of any suspicious lesion.

Differential diagnosis and the discriminating feature

Supraglottitis and epiglottitis: severe odynophagia out of proportion to oropharyngeal findings, muffled hot potato voice rather than hoarseness, drooling, and rapid progression. The voice is muffled rather than rough, because the supraglottis is swollen while the vocal folds are relatively spared. This is the distinction that matters most and it is regularly missed.
Croup in a child: barking cough, inspiratory stridor, preceded by coryza, typically aged 6 months to 3 years.
Laryngopharyngeal reflux: chronic rather than acute, with throat clearing, globus, morning hoarseness and posterior laryngeal changes.
Vocal fold haemorrhage: sudden severe hoarseness after a single episode of vocal strain, with a visible submucosal haemorrhage.
Vocal fold palsy: breathy voice with weak cough and aspiration, with an immobile fold on endoscopy.
Laryngeal carcinoma: progressive hoarseness in a smoker, with referred otalgia, dysphagia, weight loss and a neck mass.
Angioedema, hereditary or drug induced, particularly from angiotensin converting enzyme inhibitors, which produces rapid airway swelling.
Inhalational and thermal injury.
Muscle tension dysphonia and functional aphonia, in which the voice is aphonic or strained but cough and laugh are normal.

Voice care, which is the core of treatment

Voice rest, which for most patients means relative rest with reduced, quiet, conversational voice use rather than absolute silence. Absolute voice rest for more than 3 days causes deconditioning and is generally unnecessary.
Absolute voice rest of 3 to 7 days is indicated for a documented vocal fold haemorrhage or mucosal tear, where continued phonation risks permanent scarring.
Avoid whispering, which increases laryngeal muscle tension and adductory force and is more traumatic than quiet speech. Patients are frequently advised to whisper and should be told the opposite.
Avoid throat clearing, which produces a violent forced adduction of the folds, and substitute a hard swallow or a sip of water.
Avoid shouting, singing and speaking over background noise.
Amplification devices for teachers and others who must speak.

Hydration and humidification

Systemic hydration with adequate water intake, which thins mucus and lowers phonation threshold pressure.
Steam inhalation or a humidifier, which is the most useful symptomatic measure.
Nebulised saline.
Avoid caffeine, alcohol and dehydrating environments.

Symptomatic treatment

Paracetamol 1 g every 6 hours and ibuprofen 400 mg every 8 hours for pain.
Avoid nonsteroidal anti inflammatory drugs and aspirin in a patient with vocal fold haemorrhage or at high risk of it, such as a singer with an acute injury, given the antiplatelet effect.
Simple linctus or honey for cough, and suppress cough actively where it is severe, since repeated coughing traumatises the folds.
Avoid antihistamines and other drying agents, which thicken secretions and worsen the mucosal wave.
Smoking cessation, and avoidance of secondhand smoke.

Antibiotics

Not indicated for acute laryngitis, which is overwhelmingly viral. They do not improve symptoms or shorten the illness and should not be prescribed reflexively.
Reserve for documented bacterial infection, purulent secretions with systemic illness, immunocompromise, or an associated bacterial pharyngitis or sinusitis.
Where indicated, co amoxiclav 625 mg three times daily for 7 days, or clarithromycin 500 mg twice daily in penicillin allergy.

Corticosteroids

Not routine, and repeated use has real consequences.
A short course of prednisolone 30 to 40 mg daily for 3 to 5 days, or a single dose of dexamethasone 8 to 10 mg, is justified for an important professional vocal commitment that cannot be cancelled, for airway oedema, and for severe symptoms in a performer.
Explain to the professional voice user that corticosteroid reduces oedema and allows a better voice, but does not repair the mucosa, and that performing on a steroid masked injured larynx risks haemorrhage and permanent scarring. The decision to perform must be an informed one, and it is legitimate to advise cancellation.
Avoid repeated courses.

Fungal laryngitis

Suspect in inhaled corticosteroid users with white plaques or a persistently erythematous larynx, and confirm with biopsy or culture where accessible.
Fluconazole 100 to 200 mg daily for 2 to 3 weeks.
Review inhaler technique, add a spacer, and reinforce rinsing and spitting after each dose.

Reflux

Where laryngopharyngeal reflux is contributing, lifestyle modification with weight loss, avoidance of late meals, alcohol, caffeine and fatty food, head of bed elevation, and a proton pump inhibitor such as omeprazole 20 mg twice daily 30 to 60 minutes before meals for 8 to 12 weeks, with alginate after meals and at bedtime.

Supraglottitis in an adult, when that is the diagnosis

Admit for airway observation in a monitored setting with anaesthetic and otolaryngology input available.
Do not lie the patient flat and do not perform distressing examination.
Intravenous ceftriaxone 2 g every 12 hours, plus metronidazole where abscess is suspected, and dexamethasone 8 to 10 mg every 8 hours.
Nebulised adrenaline as a temporising measure.
Prepare for a difficult airway, with awake fibreoptic intubation or tracheostomy under local anaesthesia as the plan, with the surgeon scrubbed and the neck prepared before any induction.
Contrast computed tomography once the airway is secure or clearly safe, to identify an epiglottic or supraglottic abscess requiring drainage.

Follow up and the three week rule

Most acute laryngitis resolves within 2 weeks with conservative treatment.
Any hoarseness persisting beyond 3 weeks requires flexible laryngoscopy without exception. This is the single most important rule in the management of dysphonia, and failure to apply it is the commonest reason for delayed diagnosis of laryngeal carcinoma.
Refer professional voice users early, since they require videostroboscopy, speech and language therapy input and precise advice about return to performance.
Recurrent acute laryngitis requires laryngoscopy, assessment of reflux, allergy and vocal technique, and referral for voice therapy.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Acute Rhinosinusitis

Also known as: Acute sinusitis

Inflammation of the nasal and paranasal sinus mucosa of less than 12 weeks duration, with complete resolution of symptoms. The nose and sinuses share a continuous mucosa, which is why rhinosinusitis rather than sinusitis is the accurate term.

Pathophysiology

Viral upper respiratory infection produces mucosal oedema at the osteomeatal complex, the narrow common drainage pathway for the maxillary, anterior ethmoid and frontal sinuses. Obstruction of the ostium impairs ciliary clearance, lowers intrasinus oxygen tension and raises carbon dioxide, and produces a stagnant secretion pool that favours bacterial proliferation. Ciliary beat frequency falls, mucus becomes more viscous, and the cycle perpetuates.

Anatomical drainage, which determines symptom localisation and complication risk

Maxillary, anterior ethmoid and frontal sinuses drain into the middle meatus through the osteomeatal complex.
Posterior ethmoid and sphenoid sinuses drain into the sphenoethmoidal recess and superior meatus.
The nasolacrimal duct drains into the inferior meatus.
The lamina papyracea separating the ethmoid from the orbit is paper thin and dehiscent in a proportion of people, which is why the ethmoid is the source of most orbital complications, particularly in children.
The frontal sinus posterior table abuts dura, and its diploic veins communicate with the dural venous sinuses, explaining intracranial complications and Pott puffy tumour.

Classification by duration and course

Acute viral rhinosinusitis, or common cold: symptoms less than 10 days.
Acute post viral rhinosinusitis: symptoms increasing after 5 days or persisting beyond 10 days, with less than 12 weeks total.
Acute bacterial rhinosinusitis: a subset of post viral disease, occurring in only 0.5 to 2 percent of viral upper respiratory infections in adults and 5 to 10 percent in children.
Recurrent acute rhinosinusitis: four or more episodes per year with complete resolution between.

Microbiology of bacterial disease

Streptococcus pneumoniae, non typeable Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pyogenes, Staphylococcus aureus, and anaerobes in odontogenic disease. Nosocomial sinusitis in intubated and nasogastric tube fed intensive care patients involves Pseudomonas, Klebsiella and Staphylococcus aureus.

Predisposing factors

Viral infection, allergic rhinitis, anatomical variants including concha bullosa, a deviated septum, Haller cells and a large agger nasi cell, nasal polyps, dental disease and dental procedures, immunodeficiency, ciliary dyskinesia, cystic fibrosis, smoking, swimming and diving, nasal foreign body in children, and nasogastric or nasotracheal intubation.

Cardinal symptoms, requiring nasal obstruction or discharge plus at least one of facial pain or pressure and reduction or loss of smell:

Nasal blockage, congestion or obstruction.
Anterior or posterior nasal discharge, which may be clear, mucoid or purulent. Purulent discharge alone does not indicate bacterial infection, since neutrophil influx in viral disease produces the same colour change.
Facial pain, pressure or fullness, localised over the affected sinus and worse on bending forward.
Hyposmia or anosmia.

Site specific pain patterns

Maxillary: cheek and upper dental pain, sometimes with referred pain to the upper molars.
Frontal: forehead pain above the eye, often worse in the morning and on bending.
Ethmoid: pain between and behind the eyes, with medial canthal tenderness.
Sphenoid: vertex, occipital or deep retro orbital pain, frequently misdiagnosed as migraine or tension headache. Isolated sphenoid disease is the classical missed diagnosis.

Features suggesting bacterial rather than viral disease, at least three of:

Discoloured discharge with unilateral predominance.
Severe local pain with unilateral predominance.
Fever above 38 degrees Celsius.
Raised C reactive protein or erythrocyte sedimentation rate.
Double sickening, meaning deterioration after an initial improvement, which is the most useful single feature.

Red flags requiring urgent assessment and imaging

Periorbital oedema or erythema.
Displaced globe, proptosis.
Double vision, ophthalmoplegia, reduced visual acuity or colour vision, relative afferent pupillary defect.
Severe unilateral or bilateral frontal headache.
Frontal swelling, indicating Pott puffy tumour.
Signs of meningitis, focal neurological deficit, seizure, reduced consciousness.
Immunocompromise with facial pain, black nasal crusting or eschar, which suggests invasive fungal disease.

Examination

Anterior rhinoscopy showing mucosal oedema, purulent discharge in the middle meatus, and any polyps or foreign body.
Percussion tenderness over the affected sinus.
Examine the eyes fully: acuity, colour vision, pupils, eye movements and proptosis.
Examine the dentition and percuss the upper molars and premolars.
Assess for neck stiffness and neurological signs.

Uncomplicated acute rhinosinusitis is a clinical diagnosis. Imaging is neither necessary nor helpful and is positive in most people with a simple cold.

Nasal endoscopy where the diagnosis is uncertain, in unilateral disease, in recurrent disease, and in immunocompromised patients. It permits assessment of the middle meatus and directed culture.
Endoscopically guided middle meatal swab where culture is needed, which correlates well with antral puncture. A nasal vestibule swab is useless and grows skin flora.
Antral puncture for culture in intensive care patients, immunocompromised patients and treatment failures.
C reactive protein and full blood count where bacterial disease or a complication is suspected.
Blood cultures in septic patients.
Contrast enhanced computed tomography of the sinuses, orbit and brain, urgently, for any orbital or intracranial red flag. It defines subperiosteal and orbital abscess, bone erosion, and intracranial collections.
Magnetic resonance imaging with contrast for suspected intracranial extension, cavernous sinus thrombosis and to characterise soft tissue.
Non contrast computed tomography of the sinuses is reserved for recurrent disease, treatment failure and preoperative planning, and should not be performed during an acute uncomplicated episode.
Dental panoramic radiography or cone beam computed tomography where an odontogenic source is suspected, which accounts for around 10 to 40 percent of maxillary sinusitis and which will not resolve until the tooth is treated.

Differential diagnosis and the discriminating feature

Migraine and tension headache: no nasal obstruction or discharge, with photophobia, nausea and a positive family history. A large proportion of self diagnosed sinus headache is migraine.
Trigeminal neuralgia: brief lancinating pain in a trigeminal division, triggered by touch.
Dental disease: localised to a tooth, reproduced by percussion.
Temporomandibular dysfunction: joint tenderness, pain on chewing.
Nasal foreign body in a child: unilateral foul purulent discharge, which is the presentation until proven otherwise.
Invasive fungal sinusitis in the immunocompromised: pain out of proportion, mucosal anaesthesia, pale or black necrotic turbinate mucosa. A neutropenic or diabetic patient with facial pain requires immediate endoscopy and biopsy.
Sinonasal malignancy: unilateral obstruction, bleeding, cheek numbness in the infraorbital distribution, loosening teeth.
Granulomatosis with polyangiitis: crusting, septal perforation, saddle nose, haematuria.

Most acute rhinosinusitis is viral and self limiting. Antibiotics are massively overprescribed and provide marginal benefit in unselected patients.

Symptomatic treatment, which is the mainstay

Intranasal corticosteroid, which has the best evidence of any single agent for acute rhinosinusitis: mometasone furoate 200 micrograms per nostril twice daily, or fluticasone propionate 100 micrograms per nostril twice daily, for 14 to 21 days. Teach correct technique with the spray directed laterally toward the ipsilateral outer canthus, away from the septum, since septal directed spraying causes epistaxis and perforation and reduces efficacy.
Nasal saline irrigation with high volume isotonic or hypertonic solution, 240 mL per nostril once or twice daily, which improves mucociliary clearance and symptom scores.
Analgesia: paracetamol 1 g every 6 hours, maximum 4 g in 24 hours; ibuprofen 400 mg every 8 hours with food, maximum 2.4 g in 24 hours.
Topical decongestant: xylometazoline 0.1 percent or oxymetazoline 0.05 percent, one to two sprays per nostril twice daily for a maximum of 5 days. Beyond this, rebound congestion and rhinitis medicamentosa develop.
Oral decongestant: pseudoephedrine 60 mg three times daily for up to 5 days, avoided in hypertension, ischaemic heart disease, arrhythmia, hyperthyroidism, prostatic obstruction, narrow angle glaucoma and with monoamine oxidase inhibitors.
Steam inhalation, which is comforting but has little objective evidence and causes scald injuries in children.
Antihistamines have no role unless allergic rhinitis coexists, and their drying effect thickens secretions.
Mucolytics have weak evidence.

Antibiotics

Indications, rather than routine prescription:

Severe symptoms with fever above 38 degrees Celsius and severe unilateral facial pain.
Symptoms worsening after initial improvement, that is double sickening.
Symptoms failing to improve after 10 days.
Immunocompromise, poorly controlled diabetes, cystic fibrosis.
Any suspected complication, where intravenous therapy is required.

Regimens:

Amoxicillin 500 mg to 1 g orally three times daily for 5 to 7 days as first line in adults where local resistance permits. In children, amoxicillin 40 to 50 mg/kg per day divided twice or three times daily.
Co amoxiclav 625 mg orally three times daily, or 1 g twice daily, for 5 to 7 days, preferred where beta lactamase producing Haemophilus and Moraxella are prevalent, in recent antibiotic exposure, in treatment failure, in severe disease, and in odontogenic infection where anaerobic cover matters. Children: 45 to 90 mg/kg per day of the amoxicillin component divided twice daily.
Doxycycline 200 mg on day 1 then 100 mg daily, for 5 to 7 days, in penicillin allergy in adults. Avoid in children under 8 years and in pregnancy.
Clarithromycin 500 mg twice daily or azithromycin as alternatives, accepting substantial pneumococcal resistance in many settings.
Levofloxacin 500 mg daily or moxifloxacin 400 mg daily are reserved for severe disease or failure of first line therapy in penicillin allergic patients, given quinolone adverse effects.
Add metronidazole 400 mg three times daily where an odontogenic source or anaerobic infection is likely, unless co amoxiclav is being used.
Duration is 5 to 7 days in adults and 10 days in children. Longer courses confer no benefit in uncomplicated disease.
Failure at 72 hours requires reassessment, endoscopically guided culture and imaging rather than a further blind course.

Odontogenic sinusitis

Will not resolve with sinus treatment alone. Requires dental assessment with extraction, root canal treatment or removal of a displaced root or implant, together with antibiotics with anaerobic cover. Refer to maxillofacial or dental services in parallel with medical treatment.

Surgical intervention in acute disease

Rare and reserved for:

Failure of maximal medical therapy with persistent severe symptoms.
Any orbital or intracranial complication.
Immunocompromised patients with suspected invasive fungal disease, where urgent endoscopic biopsy and debridement is required.
Antral washout or endoscopic drainage for a sinus empyema.

Orbital complications and their management

Classified by extent:

Preseptal cellulitis: lid oedema and erythema with normal acuity, normal eye movements and no proptosis. Treated with oral or intravenous antibiotics depending on severity, with close observation.
Orbital cellulitis: proptosis, chemosis, painful and restricted eye movements, with the potential for visual loss. Admit. Intravenous ceftriaxone 2 g every 12 hours in adults or 50 mg/kg every 12 hours in children plus metronidazole 500 mg every 8 hours or 7.5 mg/kg every 8 hours, with vancomycin where methicillin resistant Staphylococcus aureus is a concern. Add intranasal decongestant and steroid. Hourly visual acuity, colour vision and pupil checks. Urgent ophthalmology involvement.
Subperiosteal abscess: requires contrast computed tomography. Small medial abscesses in children under 9 years without visual compromise may be managed medically with close observation for 24 to 48 hours. Drainage is indicated for visual deterioration, large abscess, non medial location, age over 9 years, failure to improve within 48 hours, or any doubt.
Orbital abscess and cavernous sinus thrombosis require immediate surgical drainage and intensive care management. Cavernous sinus thrombosis presents with bilateral eye signs, cranial nerve III, IV, V1, V2 and VI palsies, and requires anticoagulation discussion.
Endoscopic drainage of the ethmoid with abscess evacuation is the usual approach, with an external Lynch incision reserved for lateral or superior collections.

Intracranial complications

Meningitis, extradural and subdural empyema, frontal lobe abscess, and superior sagittal or cavernous sinus thrombosis. Pott puffy tumour is a frontal subperiosteal abscess with underlying osteomyelitis, presenting as a boggy frontal swelling, and always indicates the need for imaging of the brain since intracranial extension coexists in around half. Management is combined neurosurgical and rhinological, with high dose intravenous ceftriaxone plus metronidazole plus vancomycin, drainage of collections, and endoscopic or open sinus surgery for source control.

Follow up and prevention

Review non resolving cases at 10 to 14 days with endoscopy.
Investigate recurrent disease with computed tomography between episodes, allergy testing, immunoglobulin levels and specific antibody responses, and consider ciliary and cystic fibrosis testing.
Smoking cessation, treatment of allergic rhinitis, influenza and pneumococcal vaccination, and correction of significant anatomical obstruction reduce recurrence.

Acute Laryngitis

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management