EDUCATION CLINICAL REVIEW Laryngitis • Link to this article online for CPD/CME credits John M Wood,1 Theodore Athanasiadis,2 Jacqui Allen3 1Otolaryngology, Head Neck Laryngitis describes inflammation of the larynx, and a variety SOURCES AND SELECTION CRITERIA of causes result in the presentation of common symptoms. Surgery, Princess Margaret Hospital We searched Medline, PubMed, and the Cochrane Database for Children, Subiaco, WA, Australia Laryngitis may be acute or chronic, infective or inflamma- 2 of Systematic Reviews, using the search terms “laryngitis”, Adelaide Voice Specialists, tory, an isolated disorder, or part of systemic disease, and Adelaide, SA 5000, Australia “laryngeal inflammation”, and “dysphonia”. In addition 3North Shore Hospital, Auckland, often includes symptoms such as hoarseness. Commonly, we searched for specific conditions: “laryngopharyngeal New Zealand laryngitis is related to an upper respiratory tract infection and reflux”, “sarcoidosis”, “pemphigoid”, and “tuberculosis”. Correspondence to: T Athanasiadis can have a major impact on physical health, quality of life, Studies were limited to adult populations and where [email protected] and even psychological wellbeing and occupation if symp- possible included systematic reviews and randomised Cite this as: BMJ 2014;349:g5827 toms persist.1 Overall, laryngitis incorporates a cluster of controlled trials; we also included case reports to emphasise doi: 10.1136/bmj.g5827 non-specific laryngeal signs and symptoms that can also be important problems. thebmj.com caused by other diseases. Consequently diagnosis can be dif- Previous articles in this ficult and requires correlation of history, examination, and, globus pharyngeus (feeling of a lump in the throat), fever, series if necessary, specialised assessment, including visualisation myalgia, and dysphagia. • Managing the care of the larynx and stroboscopy. Acute laryngitis is typically of adults with Down’s diagnosed and managed at the primary care level. In at risk How common is it? syndrome populations, or those with persisting symptoms, referral to a The prevalence of laryngitis is difficult to estimate. A (BMJ 2014;349:g5596) specialist otolaryngologist should be considered. The aim of review conducted by the Royal College of General Practi- this review is to assist non-specialists in assessing and man- tioners in the United Kingdom in 2010 reported an aver- • Managing common aging people with laryngitis and to identify the cohort that age incidence of 6.6 cases of laryngitis and tracheitis per symptoms of cerebral requires specialist input. 100 000 patients (all ages) per week.5 palsy in children (BMJ 2014;349:g5474) What is laryngitis? How is it assessed? • Bariatric surgery for The larynx is a complex organ that is important for airway Laryngeal symptoms may have many causes. They are obesity and metabolic protection and maintaining safe swallowing and positive usually driven by four broad disease processes: inflamma- conditions in adults pressure in the pulmonary system. It is integral to cough, tion, neoplastic and structural abnormalities, imbalance in (BMJ 2014;349:g3961) straining, and swallowing, and has immunological2 and muscle tension, and neuromuscular dysfunction.6 Laryn- • Diagnosis and even hormonal3 functions. Disease related changes in the geal symptoms arise from one or a combination of these management of larynx can impair some or all of these functions. The term processes. A careful history and examination is crucial in prolactinomas and non- laryngitis is descriptive and refers to inflammation of the determining the primary factor and helping to identify other functioning pituitary larynx. It is typically used to describe acute infective laryn- factors leading to persisting symptoms. 4 adenomas gitis, one of the most common diseases of the larynx. How- The first consideration in the initial assessment of patients (BMJ 2014;349:g5390) ever, a multitude of other causes of laryngeal inflammation with laryngeal symptoms should be airway patency. Patients • Vitamin B12 deficiency present with similar signs and symptoms. Typically, laryn- with stridor or respiratory distress need urgent assessment (BMJ 2014;349:g5226) gitis includes dysphonia, air wasting (excessive loss of air in a setting where airway support can be provided quickly through the incompletely closed glottis resulting in a breathy if needed. voice), and pain or discomfort in the anterior neck, and it Having assessed the airway, the history should cover the may include other symptoms such as cough, throat clearing, nature and chronology of voice symptoms, any exacerbating and relieving factors, and the patient’s voice use and require- SUMMARY POINTS ments. In addition to the description of vocal problems, it is important to ask about associated symptoms of dysphagia, The cause of laryngitis is varied and determines odynophagia, otalgia, reflux, globus pharyngeus, weight appropriate treatment loss, pulmonary health, and choking. Box 1 outlines the Acute laryngitis is common and generally self limiting red flag symptoms that should prompt an urgent referral to Clinicians should re-visit the diagnosis and ensure exclude malignancy. Contributing medical conditions or the endoscopic examination has been performed if effects of treatment should be considered, as should lifestyle symptoms persist or red flag symptoms develop factors, including smoking, diet, and hydration. The impact Initial assessment must consider airway patency and on quality of life and psychosocial wellbeing should also be rule out malignancy addressed. Patients with compromised immunity may be at Investigations include a general head and neck examina- increased risk of infectious causes tion covering the oral cavity, oropharynx, and neck, and an The impact of laryngopharyngeal reflux is becoming assessment of the patient’s voice. This can be done by way widely recognised, with research focused on improving of a simple scale: grade 1 (subjectively normal voice), grade diagnosis and treatment 2 (mild dysphonia), grade 3 (moderate dysphonia), grade 4 (severe dysphonia), and grade 5 (aphonic), with addi- the bmj | 11 October 2014 27 EDUCATION CLINICAL REVIEW tant sites (for example, lung, tonsils) are often suggestive Box 1 | Red flag symptoms for early referral (adapted from Schwartz et al7) of bacterial disease. Historically, diphtheria was associated with a pathognomonic grey membranous cast that could • Stridor—emergency referral actually cause airway obstruction. With vaccination this is • Recent surgery involving the neck or recurrent laryngeal nerve rarely seen nowadays. Viral illness may manifest blisters, • Recent endotracheal intubation particularly herpes zoster, and can be associated with nerve • Radiotherapy to the neck paresis involving the lower cranial nerves. Equally, erythema • History of smoking and pain disproportionate to the mucosal appearances can • Professional voice user (for example, singer, actor, teacher) be representative of viral disease. Fever may be present in • Weight loss both, as can systemic symptoms. Reaction to antibiotics can • Dysphagia or odynophagia indicate viral disease in retrospect—for example, production of rash when amoxicillin is given in the presence of Epstein • Otalgia Barr virus infection. • Serious underlying concern by clinician Unusual causes of bacterial laryngitis in developed nations include mycobacterial and syphilitic disease, although tional qualifiers used as necessary—for example, breathy, these are still seen in developing countries or areas with strained. Alternatively, a widely used grading system is the large immigrant populations.12 Diagnosis can be difficult, GRBAS (grade, roughness, breathiness, asthenia, strain) as lesions may appear ulcerative, mimic neoplasia or can- scale. It is a simple and reproducible method to assess voice didiasis, or have a non-specific inflammatory appearance. change and quality. This tool grades hoarseness, roughness, Ultimately tissue diagnosis is essential to assess for tumour, breathiness, aesthenia (weakness), and strain on a scale of which is considerably common, or to identify acid-fast bacilli 0-3, with 0 representing normal, 1 mild degree, 2 moder- on microscopy. Suspicion should be high in patients from ate degree, and 3 high degree.8 Either scale may be used by developing countries with high rates of tuberculosis and practitioners to track changes in voice over time and also those who are immunocompromised.13 allows other practitioners to understand the degree of voice Supraglottitis and epiglottitis—Owing to the rapid pro- dysfunction from notation. gression of airway compromise, especially in children, much of the literature on acute bacterial laryngitis concerns What are the causes of acute laryngitis? supraglottitis and epiglottitis, particularly in the context of Acute laryngitis is commonly caused by infection (viral, bac- H influenzae.14 Patients present with rapidly progressing terial, or fungal) or trauma.9 Inflammation and oedema of odynophagia, dysphagia, hoarseness, drooling, and stri- the larynx impairs vibration of the vocal folds, with resulting dor. This constellation of symptoms indicates a high risk symptoms.9 Inflammation may involve any area within the of impending airway compromise and requires emergency larynx, including the supraglottis (epiglottis, arytenoids, assessment and airway management. Treatment for less and false vocal folds), the glottis (true vocal folds), and severe cases includes humidification through