Types of Acute Laryngitis

Key Glossary Terms

Laryngitis
Inflammation of the voice box (larynx); can result from many causes; specific cause needs to be identified for correct diagnosis and proper treatment plan

Inflammation
Response to injury that results in swelling, redness, and/or pain

Glossary

This section contains information on the following types of laryngitis:

• Infectious Laryngitis
  • Bacterial Laryngitis
  • Viral Laryngitis
  • Fungal Laryngitis
• Contact Laryngitis
  • Inhaled Pollutants
  • Tobacco Smoke and Other Kinds of Smoke
  • Inhaled Medications
  • Inhaled Caustic Compounds
• Mechanical Laryngitis
  • Vocal Abuse and Misuse
  • Laryngeal Trauma
• Allergic Laryngitis
• Laryngitis Sicca
• Thermal Laryngitis

When the larynx is infected with bacteria, viruses, or fungi/molds, an acute laryngitis may result. The laryngitis is a direct response of the larynx to the presence of these foreign organisms. The redness and swelling occur as the body's way of trying to rid the larynx of the infectious materials.

Bacterial laryngitis occurs as a result of bacterial infection of the larynx.

The bacteria that cause the infection are usually inhaled through the air from another person who carries the organisms (usually someone who is either sick with or recovering from an upper respiratory tract infection).

The infection usually begins with the following symptoms:

• sore throat
• fever
• painful swallowing
• cough
• hoarseness

Other symptoms of upper respiratory tract infection may be present as well. Common symptoms of upper respiratory tract infections include:

• cough
• fever
• nasal drainage
• nasal congestion
• facial pressure
• facial pain
• sore throat
• hoarseness
• headache
• earache
• ear fullness
• ear popping
• swollen glands in the neck

In rare instances, the inflammation can progress to make breathing difficult. Difficulty breathing can be accompanied by noisy breathing (stridor), which can occur on breathing in, on breathing out, or in both phases of breathing.

Red Flag

• Noisy breathing (stridor) is a sign of obstruction or narrowing of the laryngeal or tracheal parts of the airway.
• Stridor is a sign of difficulty passing air, and its presence represents a medical emergency.
• A person with stridor should be evaluated immediately by a physician skilled in airway management, such as an otolaryngologist, an emergency department physician, or a general surgeon.

Examination of the larynx usually reveals redness and swelling throughout the larynx. The epiglottis in particular may be involved more than in other forms of laryngitis; it will have a bright red color and swelling that may be severe enough to limit the passage of air through the larynx. There may be signs of pus in the larynx, which "nails down the diagnosis" for bacterial infection–however, the absence of pus is a more common finding.

• Treatment of acute bacterial laryngitis usually involves the use of antibiotics, either by mouth or given intravenously. Intravenous antibiotics are usually given when the infection is severe enough to cause difficulty breathing (stridor). Usually bacterial laryngitis will resolve with adequate treatment with antibiotics.
• The inhalation of humidified air helps to soothe the irritation and to keep the larynx moist and lubricated.
• Steroids are sometimes administered when severe swelling of the larynx results in partial airway obstruction and breathing difficulty.
• In rare cases, the swelling may be so severe that imminent airway obstruction is possible, which may result in the inability to breathe. In such cases, a tube may be placed either through the neck (tracheotomy) or through the larynx (endotracheal intubation) to bypass the obstruction and to allow sufficient passage of air into the lungs.

Viral laryngitis is caused by a viral infection of the larynx.

Viruses usually are inhaled from respiratory droplets in the air produced by people who are "carrying" the virus.

Viral laryngitis usually is characterized by:

• general fatigue
• malaise
• low-grade fevers
• general body aches
• cough
• hoarseness
• sore throat
• throat dryness

Other symptoms of upper respiratory tract infection may also be present, depending on the sites involved with the infection.

Usually, mild redness and swelling is present throughout all structures of the larynx, without predilection for any one structure in particular.

• In adults: Viral laryngitis usually does not cause airway obstruction in adults.
• In children: Children with viral-induced obstruction of the subglottic larynx may have difficulty breathing, characterized by noisy breathing (stridor) and/or a cough that sounds like a small dog barking–often referred to as a "croupy cough."
• In infants: Because the larynx of the infant has a smaller diameter, infants are more prone to breathing difficulty with viral infections than are adults. Typically, the subglottic larynx (the part of the larynx below the vocal folds, which also is the narrowest part of the larynx in infants) is the part of the larynx that may become sufficiently inflamed to cause airway obstruction.

Fungal laryngitis is inflammation of the larynx caused by the growth of disease-causing fungal organisms. Fungal organisms cause molds. The most common cause of fungal laryngitis is Candida Albicans, the fungus that causes thrush. Other fungi/molds may also cause laryngitis, including Histoplasma, Blastomyces, Aspergillus, and other less common organisms.

Key Information

Histoplasmosis and Blastomycosis are more common in areas of North America in which these organisms are endemic. Blastomyces is endemic in the Southwest United States, and Histoplasma is endemic in the Midwestern United States. Aspergillus and Candida species are found throughout North America.

Immune Compromised Patients are Prone to Fungal Infections. Fungal laryngitis usually occurs in patients in whom the body's natural defense mechanisms against infection are compromised. When the body's immune system is suppressed, fungi, which usually do not cause infection, may penetrate the natural blood and tissue barriers and cause infection of the larynx and other parts of the upper respiratory tract. When this occurs, inflammation occurs in the form of laryngitis.

• People who use steroid inhalers, who take steroids systemically (i.e. either ingest them by mouth or take them intravenously), or who are on immunosuppressant medications (e.g., to prevent rejection of transplanted organs or treat severe arthritis) are prone to fungal infections. Steroids and other immunosuppressants are anti-inflammatory medications that suppress the body's natural response to injury (including infection, laceration, ulceration, and trauma). In doing so, they also suppress the body's natural ability to protect itself against infection by fungal organisms.
• Certain disease states decrease the body's ability to fight infection. These most commonly include disorders of the blood (such as leukemia and lymphoma), infection with HIV, chronic kidney disease, and chronic liver disease.

Fungal infections are usually slow-paced; therefore, symptoms of fungal laryngitis are typically of "gradual onset"–coming on slowly rather than suddenly.

Fungal laryngitis may have one or more of the following symptoms:

• sore throat
• difficulty swallowing
• hoarseness
• cough
• ear pain
• scratching or itching sensation in the throat
• dry throat

If these symptoms occur in a person who is immunocompromised by any mechanism (including the use of inhaled steroids to treat asthma), fungal laryngitis needs to be investigated.

Fungal laryngitis is usually diagnosed visually, because typical-looking fungal lesions are visible in the voice box or larynx, mouth cavity, and/or throat. Depending on the fungal organism involved, different parts of the larynx may be involved more than others.

Some specific case scenarios:

• Candida typically involves the entire larynx, but may be more prominent on the vocal folds. Candidal infection usually causes the formation of a white plaque, often called a "pseudomembrane," which does not scrape off easily.
• Histoplasma and Blastomycoses often cause a more severe inflammatory reaction called a granulomatous reaction.

Key Information

A note on granulomatous reaction. A granulomatous reaction is an infiltration into affected tissue of specialized blood cells called macrophages, which are specifically designed to engulf foreign material and fight infection. This reaction produces a characteristic appearance under the microscope commonly described as "granuloma" or "mutli-nucleated granulomas." These are not to be confused with the "granulomas" that form on the vocal process of the arytenoids in response to trauma and reflux–which, in actuality, are not true granulomas but are chronic inflammatory or granulation tissue.

• Aspergillus infection of the larynx typically produces a diffuse laryngitis, characterized by significant redness and occasionally areas of ulceration.

A culture of the infecting organism can confirm the diagnosis and identify the cause of the fungal infection. Cultures also allow testing that will reveal the type of antifungal agent that will most effectively fight the infection. Cultures can be taken by swabbing plaques or areas of ulceration or by biopsy of the affected tissue.

Key Information

A Note on Biopsy
Biopsy of the vocal folds for the purpose of obtaining culture material is avoided whenever possible to minimize scar formation within the vocal folds. Biopsy is usually performed for granulomatous lesions when carcinoma is suspected. When possible, biopsy is performed in an area of the larynx that is not intimately involved in voice production.

Treatment of fungal laryngitis usually involves the use of anti-fungal medication, such as:

• nystatin
• fluconozole
• ketoconozole
• itraconozole
• other anti-fungal drugs

Medication selection depends on the organism involved and its sensitivity to the available medications. Drug sensitivity is determined by testing the fungus grown from the culture taken from the lesions.

Patients should consult their physician regarding medication. Patients should also discuss possible side effects from medications.

Contact laryngitis occurs when the larynx is exposed to chemical irritants.

Reflux of gastric juices from the stomach (laryngopharyngeal or gastroesophageal reflux), inhaled pollutants, tobacco smoke, inhaled medications, or ingested caustic compounds may all cause contact laryngitis. (For more information, see Reflux Laryngitis.)

Aerosolized pollutants contain various chemical structures that cause laryngitis by irritating the laryngeal mucosa when they are inhaled. These pollutants may include substances such as:

• paints
• oven cleaners
• insecticides
• solvents
• tar
• smoke

These substances cause direct mucosal irritation and are hygroscopic (they absorb water), which dries the laryngeal mucosa (lining).

• The irritation and dryness produced by the pollutants causes redness and an itching or scratching sensation in the larynx, which may lead to a cough.
• The absorption of water from the vocal fold mucosa limits the vibratory function of the vocal folds, producing a hoarse voice.
• Coughing and sore throat usually result from the drying effect, as well as from the inflammation that develops.

On examination, the larynx will appear diffusely red, with minimal to no edema (swelling) initially. The drying effect of the chemical irritants reduces the amount of fluid, and hence swelling does not occur.

• Treatment involves both removal of the individual from the offending environment and hydration.
• Hydration can be accomplished by drinking water as well as by inhaling the mist from steam or mist humidifiers. With hydration, edema may later ensue, resulting in a temporary worsening of hoarseness.
• Once the inflammatory response begins to subside, the redness and swelling will decrease as well and the hoarseness will disappear.

Tobacco smoke is a form of inhaled pollutant. In addition to tar, nicotine, and carbon monoxide, tobacco smoke contains numerous other toxic compounds that are irritating to the laryngeal mucosa (lining).

• Upon initial exposure to tobacco smoke (including second hand smoke), the larynx will be dry and red.
  • Symptoms will include cough, hoarseness, and a dry tickle in the throat.
  • If exposure to the tobacco smoke is limited and does not recur, the redness and swelling will begin to subside over the course of the next 48-72 hours. The voice may remain hoarse until the swelling has resolved.
• With repeated or chronic exposure to tobacco smoke, the larynx does not have time to heal after the swelling begins, and the vocal folds and the remainder of the larynx remain red and swollen from inflammation.
  • The swelling may be mild or severe, and occurs in the key vibrating layer of the vocal folds (the superficial lamina propria, or Reinke's space). (For more information, see Anatomy and Physiology of Voice Production.)
  • The voice usually is of lower pitch than normal, more "husky" in sound, rough or raspy, and hoarse as a result of the swelling.
  • The severity of the symptoms varies with the amount of swelling present.

Smoking other substances, such as marijuana or crack cocaine, may cause a contact laryngitis in a similar fashion as tobacco smoke. In addition, in some instances, crack cocaine may cause a heat-induced laryngitis.

Orally inhaled medications, such as those used to treat asthma, may cause a contact laryngitis, a fungal laryngitis or both. When laryngeal irritation occurs, it is through the same drying mechanism as caused by the inhaled pollutants. Fungal or mold infections of the larynx can occur with the use of steroid inhalers, as described in the section on fungal laryngitis.

Contact laryngitis from oral inhalers can occur with any of the commonly prescribed medications, including:

Contact laryngitis results from laryngeal sensitivity to the propellant used in the inhalers, the preservative, or to the active ingredient itself. Often patients with contact laryngitis from oral inhalers can be treated with alternative medications (i.e., pills) and/or inhaled medications that do not use propellants (i.e., turbo-inhaler).

Red Flag

Any and all airway problems require immediate attention.

Ingested caustic compounds such as bleaches, detergents, lye, acids, and bases can cause an acute or delayed laryngitis if the ingested substance comes in contact with the larynx.

Such ingestions usually occur accidentally in young children or as suicide attempts in adolescents and adults. Usually, the ingested substance will only briefly come into contact with the larynx as it is swallowed, causing only minimal inflammation. The one exception to this rule is the ingestion of low phosphate or nonphosphate detergents, which can cause a significant degree of swelling of the larynx with very minimal contact. Such detergents contain compounds that easily destroy chemical bonds in the tissues of the body, resulting in destruction of the lining tissue and initiation of an intense inflammatory response. Such swelling may be delayed in appearance and occur as late as 24 hours after ingestion. When it occurs, the swelling may be severe enough to cause breathing difficulty.

Red Flag

Any and all airway problems require immediate attention.

Most household bleaches are not concentrated enough to cause a significant degree of swelling of the airway or damage to the esophagus. However, they may cause swelling and redness in the larynx if they come in contact with it, through a contact laryngitis-type mechanism.

Ingestion of acids, such as hydrochloric acid or sulfuric acid, causes permanent injury to the tissues in which the acid comes in contact. Usually, injury is limited to the esophagus because it is the structure exposed to the acid for the longest period of time. Following the death of the tissue to which the acid is exposed, inflammation occurs in the surrounding tissue. This inflammation is the body's attempt to begin healing from the exposure. The inflammation can result in swelling of the laryngeal tissues, which may cause breathing difficulty.

Red Flag

Any and all airway problems require immediate attention.

Lye and bases cause permanent and deep injury to the tissues with which they come in contact. Such injury usually affects the esophagus, but can affect the larynx if it is exposed to the base or lye for prolonged periods of time. The injury results in both the death of the involved tissue (usually to a more severe degree than that seen with acid ingestion) as well as surrounding inflammation. The inflammation may result in swelling severe enough to cause breathing difficulty.

Red Flag

Any and all airway problems require immediate attention.

Symptoms of laryngitis from caustic ingestion may include:

• difficulty swallowing
• hoarseness
• a sensation of something stuck in the throat
• dry throat
• throat tickle
• difficulty breathing
• painful swallowing
• sore throat

• Treatment of laryngitis caused by caustic ingestion first involves removing any remaining material from the larynx and throat with a wash or irrigation with water.
• The airway is assessed for signs of inflammation that might suggest impending airway obstruction, using a flexible laryngoscope or indirect laryngoscopy (mirror visualization of the larynx).
• If the larynx appears severely swollen, a breathing tube may be placed into the airway through the mouth, nose, or neck.
• Administration of intravenous steroids may be recommended to help limit swelling and possibly avoid intubation.
• The esophagus is usually most severely affected by such ingestions; treatment of esophageal injury is emphasized.

Red Flag

Ingestion of Caustic Agents Produces Many Potentially Life-Threatening Problems
Caustic ingestions may result in perforation (holes) in the esophagus in the most severe cases, which may result in infection in the surrounding structures from leakage of esophageal materials into the chest. The heart, lungs, and abdominal cavity may become infected by such leakage.

Assessment and treatment of esophageal injuries may include the use of esophagoscopy (in which the esophagus is viewed with a telescope), dye-enhanced swallow studies (in which the patient swallows a dye contrast and x-rays are taken to evaluate leakage), and the use of steroids, depending on the time of assessment relative to the time of ingestion.

Mechanical laryngitis results from trauma from voice use (phonotrauma), caused by vocal abuse and misuse syndromes, external or internal blunt or penetrating trauma to the larynx, or coughing.

Vocal abuse and misuse result in forceful closure of the vocal folds. The pressure exerted during such closure causes injury to the underlying tissues, which incites an inflammatory reaction. The result is localized swelling and redness of the vocal folds.

• Occasionally the false vocal folds also get swollen and red as in dysphonia plica ventricularis.
• The swelling of the vocal folds results in hoarseness and/or raspiness of the voice.

Long-term repeated trauma can result in scar tissue formation within the vocal folds, thickening of the vocal folds, vocal fold lesions, and a transformation of the epithelium to tougher tissue (hyperkeratosis or parakeratosis). (For more information, see Vocal Fold Lesions.)

Hyperkeratosis and parakeratosis involve the production of keratin in the vocal fold epithelium. Keratin is the substance in skin that gives it its toughness and ability to withstand most minor injuries. Keratin is not usually produced by or present in the vocal folds, which are not usually exposed to excessive trauma. With repeated trauma, such as through vocal abuse or misuse, the vocal folds begin to produce keratin in an attempt to protect themselves. The presence of keratin in the vocal folds is termed parakeratosis. The presence of excessive amounts of keratin in the vocal folds is termed hyperkeratosis. The presence of either parakeratosis or hyperkeratosis implies chronic injury to the vocal folds. (For more information, see Laryngeal Atypia and Early Cancer.)

Treatment of mechanical laryngitis from vocal abuse or misuse includes a short period of reduced voice use or voice rest and sometimes voice therapy to correct the underlying vocal behavior.

Laryngeal trauma (external or internal; blunt or penetrating) can result in swelling of the vocal folds, causing acute laryngitis.

• Internal blunt trauma can result from pressure on the vocal folds from an indwelling breathing tube. In such cases, mild swelling of the vocal folds and the back part of the voice box or larynx (the regions where the breathing tubes usually lie) may occur, resulting in stiffness of the mucosal wave and hoarseness.
• Internal blunt trauma can also result from manipulation in and around the larynx during medical procedures such as intubation, esophagoscopy, direct laryngoscopy, and bronchoscopy. Such manipulation can result in mild swelling of the vocal folds and hoarseness that may last from 1 to 7 days.

External blunt trauma to the larynx may result from blows to the neck from assault, stage fight injuries during a show, elbow-to-neck injuries while playing basketball, strangulation, or other injuries to the neck (such as falling on the handlebar of a bicycle or hitting the steering wheel during an automobile accident). Such events may injure the laryngeal cartilages and the tissues within the larynx. The injury that ensues may involve mild to extensive swelling (laryngitis). With laryngitis, the voice is hoarse and may be raspy or breathy, depending on the presence of other injuries.

Red Flag

Hoarseness may be a warning sign of more severe injury
Laryngitis after trauma to the neck can be a signal of more severe injuries to the larynx, such as fracture or mucosal disruption, and should be investigated promptly by a laryngologist or otolaryngologist.

Early care important in traumatic injury
Professional voice users should be especially vigilant about seeking care early, as treatment of traumatic injuries is best performed immediately (within 24 - 48 hours of injury). Beyond this time frame, scarring and abnormal healing may begin.

Penetrating injuries to the larynx can cause laryngitis surrounding the site of the injury. Such injuries may occur as a result of surgery on the vocal folds, stab wounds to the neck, or gunshot wounds.

Laryngitis results from a puncture to the mucosal layer of the vocal folds and contact with the underlying tissues, which stimulates an inflammatory reaction. The laryngitis may cause hoarseness, raspiness, inability to produce sound at certain pitches, sore throat, and sometimes difficulty breathing.

Red Flag

Any and all airway problems require immediate attention.

The hoarseness, raspiness, and inability to produce sound at certain pitches are due to vocal fold swelling, which limits the vibratory abilities of the vocal fold. Treatment of the penetrating injury itself varies, depending on the cause of the injury.

Laryngitis is best treated by a period of voice rest or light voice use. Keeping the vocal folds lubricated during healing can minimize friction on the vocal folds to prevent scarring in the surgical site to aid the healing process. Lubrication can be accomplished with the ingestion of water, the use of steam or mist humidifiers, the minimization of reflux, and the avoidance of medicines or beverages that tend to deplete the body of fluids. (For more information, see Reflux Laryngitis.)

Allergic laryngitis is laryngeal inflammation in response to inhaled allergens, such as pollen, dust, mold, or animal dander.

Allergens are inhaled and stimulate an allergic response in the lining of the larynx and/or blood cells. These allergens either bind to surface antibodies in the larynx or are recognized by blood cells in the larynx as foreign. The allergens stimulate the blood cells to release histamine, which then incites an inflammatory response.

The allergic inflammatory response causes the increased production of mucous, which is usually thick. The thick, viscous mucous absorbs water and dries the vocal folds.

The result is an increase in the shearing forces and friction on the vocal folds during phonation, which causes redness and inflammation of the vocal folds (similar to that produced with mechanical and dehydration laryngitis).

The laryngitis that occurs from allergic exposure usually involves diffuse inflammation of the entire larynx in a pattern similar to that seen with contact laryngitis. The entire larynx will appear red, with mild to moderate swelling. Mucous production is usually increased and thick, resulting in the appearance of an increased amount of phlegm on the vocal folds.

People with allergic laryngitis often have symptoms including:

• hoarseness that is worse during and several hours after exposure to the allergen
• itchy throat
• excess phlegm or mucous in the throat
• feeling of dry throat
• cough
• itchy sensation in the throat
• sneezing

Because the nose and eyes are also sensitive to inhaled allergens, they usually also show signs of inflammation. Signs and symptoms of allergies in the nose and eyes may include:

• nasal drainage
• nasal congestion
• difficulty breathing through the nose
• excess sneezing
• itchy nose
• itchy eyes
• excess tearing of the eyes
• red eyes

• Inflammation from allergic laryngitis will persist until the allergen is completely removed from the system. If repeated or persistent exposure to the allergen occurs, the laryngitis will persist. Antihistamine medications can help lessen the response to future exposures. However, antihistamine medications that are less likely to have drying side effects, such as loratidine, fexofenidine, cetirizine, and desloratide, should be used.
• Attention to hydration is essential in the treatment of allergic laryngitis. The excess mucous that is produced is very thick and viscous in nature, in comparison to the normal mucous that is produced to help lubricate the vocal folds. Drinking water can change the composition of this thick mucous, helping to make it thinner and a better lubricant for the vocal folds.
• In some instances, medications such as guaifenesin are needed to help thin the mucous. Guaifenesin is found in many cough syrup preparations, but in doses that are too small to have any significant effects on mucous thickness. Pill forms of guaifenesin work well in cases of allergic laryngitis to help thin the mucous secretions.
• Humidification of the air with a steam or mist humidifier also helps to maintain good hydration in the larynx.

Key Information

Patients should consult their physician regarding medication. Patients should also discuss possible side effects from medications.

Laryngitis caused from dryness (laryngitis sicca) can result from any process that causes a drying of the vocal folds.

Common causes of laryngitis sicca include:

• dehydration
• dry atmosphere
• mouth breathing
• medications with dehydrating side effects

Dehydration can result from insufficient fluid intake (such as occurs in sick or debilitated persons), excessive ingestion of caffeinated beverages, excessive ingestion of alcoholic beverages, and the use of diuretic medications. Medications with dehydrating side effects include antihistamines, anticholinergics, benzodiazepines, diuretics, and sleep and anxiety pills.

During phonation, the vocal folds vibrate in a wave-like motion to produce sound. Without adequate lubrication, the gliding, vibratory movement of the vocal folds during phonation is limited, which can result in a cough and inflammation of the vocal folds. Persistent lack of lubrication can cause vocal fold friction, which can in turn cause mechanical laryngitis. (For more information, see Anatomy and Physiology of Voice Production.)

Hoarseness, vocal fatigue, and lower-pitched voice result from decreased vibratory capacity of the vocal folds as they try to vibrate over the swelling.

Treatment of dehydration laryngitis involves increasing fluid intake, avoiding drying medications or beverages, and the use of steam/mist humidifiers. Guaifenesin is a medication designed to thin the mucous secretion in the throat. Some patients experience great benefit from this medication and others do not. It is commonly used to treat many types of laryngitis, including laryngitis sicca.

Thermal laryngitis results from a heat injury to the laryngeal mucosa (lining tissue), usually during smoke inhalation from a closed-space fire or from self-induced injuries, such as with smoking crack cocaine through a crack pipe. The heat from such exposures causes a burn injury, resulting in inflammation.

Symptoms from such exposures may include:

• sore throat
• difficulty swallowing
• hoarseness
• deepening of the voice
• ear pain
• huskiness or raspiness to the voice
• (in severe cases) difficulty breathing

The inflammatory response usually consists of redness and swelling of the entire larynx, especially the epiglottis and arytenoids.

Treatment of such injuries involves the use of adequate hydration, including oral ingestion of water, intravenous fluids when swallowing is difficult, and the inhalation of humidified air. Steroids and/or placement of a breathing tube into the airway (either through the mouth, nose, or neck) may be used when swelling is severe to ensure that breathing is not compromised.