The larynx is also known as the VOICEBOX of the human body.
Inside the larynx are the vocal cords. The vocal cords are two folds of mucous membrane which are responsible for an individual’s characteristic voice production and quality.
Normally, the vocal cords open and close smoothly, and form sounds through their movement and vibration. These vocal cords also act as the gateway of the airway/trachea.
Laryngitis is a common inflammatory clinical condition of the larynx (or Voicebox) or in simple terms Infection of the voice box.
This can be a result of overuse, irritation, or infection of the larynx.
Laryngitis occurs most commonly due to a virus associated with an upper respiratory tract infection. It may also occur secondary to infections of the upper and lower respiratory tract such as tonsillitis or chest infections.
In laryngitis, the vocal cords become inflamed, swollen, or irritated.
The sound of an individual voice is produced by the closing and opening of vocal cords as well as by the passing of air between these vocal cords. However, during an infection, the swelling of the vocal cords causes distortion of the sounds produced by the air passing over them, which will be heard as HOARSE VOICE to the listener. In severe cases of laryngitis, many-a-times voice can become not just hoarse but almost temporarily lost or undetectable.
TYPES OF LARYNGITIS
There are 2 types of Laryngitis:
- ACUTE LARYNGITIS
(In Acute Laryngitis, there will be sudden onset of HOARSENESS OF VOICE which will mostly be triggered after an upper respiratory tract infection like acute rhinitis, pharyngitis, or tonsillitis.
And the hoarseness will NEVER persist for more than a couple of weeks)
2. CHRONIC LARYNGITIS
(Hoarseness of voice persisting for MORE THAN 3 WEEKS is known as Chronic Laryngitis)
SYMPTOMS OF LARYNGITIS
#ACUTE LARYNGITIS signs and symptoms can include:
- Hoarseness of voice.
Patient may complain that his/her voice has become HUSKY, or RASPY, or GRAVELLY, or CROAKY, or COARSE, etc. - Weak voice or voice loss
- Tickling sensation in throat
- Sensation of discomfort in throat
- Sensation of phlegm stuck in throat
- Excess phlegm production
- Sore throat
- Dry throat
- Dry cough
- Associated symptoms of COMMON COLD like runny nose, sneezing, sore throat, cough, fever, etc.
# CHRONIC LARYNGITIS signs and symptoms can include:
1. ALTERATION IN VOICE QUALITY in the form of HOARSENESS. This condition is also known by the term DYSPHONIA (or Abnormal Voice).
2. The voice tends to be ROUGH or COARSE and may have an overall REDUCTION IN PITCH.
3. Hoarseness will have an insidious onset and may be present for several months or years.
4. The hoarseness is persistent with the voice being seldom if ever, normal but it is rare for there to be aphonia (Aphonia means absolute or total loss of voice).
Other Clinical Features of Chronic Laryngitis are –
A) Hoarseness and easily tired voice
B) Painful or strained speaking
C) Constant hawking sensation or a sensation of something being stuck in the throat
D) Dryness and intermittent tickling in the throat
E) Clearing the throat repeatedly
F) Discomfort in the throat or Throat ache
G) Persistent dry, irritating, and non-productive cough
H) Hyperemia of the larynx-
- Vocal cords appear dull red,
- Flecks of viscid, and
- mucus on vocal cords and inter arytenoid region.
(I) Difficulty in swallowing (dysphagia)
(J) Bad Breath
(K) Unusual taste or bitter taste
(L) Water brash/Sour eructations or indigestion.
CAUSES OF LARYNGITIS
CAUSE OF ACUTE LARYNGITIS can be divided into INFECTIOUS AND NON-INFECTIOUS CAUSES
(I) INFECTIOUS CAUSES such as Viral, Bacterial, and Fungal.
(II) NON-INFECTIOUS CAUSES such as vocal abuse, allergy, thermal or chemical burns to the larynx due to inhalation or ingestion of various substances, or laryngeal trauma such as endotracheal intubation.
(I) INFECTIOUS CAUSES
1. VIRAL INFECTION similar to those that cause a common cold.
The common viruses responsible for the common cold are:
a) Rhinovirus (most common in adults)
b) Parainfluenza viruses.
c) Adenovirus
d) Picornavirus and its subgroups such as rhinovirus, Coxsackie, and ECHO viruses
e) Respiratory syncytial virus (RSV)
f) Influenza virus
2. BACTERIAL INFECTION
The suspicion of the bacterial cause of acute laryngitis should be reserved for cases where there is clinical suspicion of bacterial infection. The most common bacteria responsible are-
- Streptococcus pneumoniae,
- Haemophilus influenzae, and
- Moraxella catarrhalis
Typically, these Acute bacterial laryngitis patients may have persistent and more severe laryngitis or other associated infections of the upper or lower respiratory tract.
3. FUNGAL INFECTION
Fungal infection of the larynx aka MYCOTIC LARYNGITIS or FUNGAL LARYNGITIS is usually secondary to fungus spores inhalation in an immunosuppressed patient who is already having laryngeal mucosal disruption.
Fungal infection of the larynx can also occur in patients using inhaled steroid medications for asthma or other conditions, such as Budecort®, Pulmicort®, Flohale®, etc.
The most common fungus causing laryngitis are –
- Candida albicans
- Aspergillus
- Coccidioidomycosis,
- Blastomycosis
- Histoplasmosis
(II) NON-INFECTIOUS CAUSES
1 . VOCAL ABUSE or OVERUSE such as YELLING / SCREAMING / SHOUTING, CRYING LOUDLY, HOOTING, LOUD, and LONG-HOURS OF SINGING, etc.
2. Heavy/Binge Smoking
3. Rhinosinusitis
4. Allergy episode
5. Laryngopharyngeal reflux
6. Trauma to the larynx, eg. Roadside accident, assault, fall from height, endotracheal intubation trauma during any surgery, etc.
7. Chemical or Thermal burns to the larynx due to inhalation or ingestion of various chemicals or substances, such as found in goldsmiths or ironsmiths, miners, and chemical industries workers, etc.
RISK FACTORS FOR LARYNGITIS
(I) Infection in paranasal sinuses, teeth, tonsils, and lungs.
(II) Occupational factors: Exposure to dust and fumes, such as –
- Goldsmiths or Ironsmiths,
- in Miners, and
- Chemical industries workers.
(III) Smoking and Alcohol
(IV) Chronic coughing or clearing of the throat
(V) Vocal abuse
(VI) Gastroesophageal reflux disease (GERD) or Laryngopharyngeal reflux (LPR) aka REFLUX LARYNGITIS
(VII) Inadequate hydration.
DIAGNOSING LARYNGITIS or HOARSENESS OF VOICE
The following techniques are frequently used to make a confirmatory diagnosis of Laryngitis:
[A] Indirect Laryngoscopy-
In a procedure, the doctor can visually examine your vocal cords by using a small hand-held mirror to look into the inside of your voicebox.
[B] Laryngeal Endoscopy –
A 90 degrees rigid rod-like endoscope is introduced in the oral cavity till the uvula or back of the throat, and it gives a clear endoscopic view of the vocal cords and the surrounding structures in the TV monitor.
[C] Fiber-optic laryngoscopy –
The doctor may use a flexible endoscope instead of the above-mentioned rigid rod-like endoscope aka flexible fiber-optic laryngoscope to visualize the voice box.
This involves inserting a thin, flexible tube-like endoscope with a tiny camera and light at the tip of the endoscope, through your nose or mouth, and into the back of your throat.
Then your doctor can watch the motion of your vocal cords as you speak.
[D] STROBOSCOPY –
A stroboscope is a device that emits light in pulses, the frequency of which can be set by the examiner. If the frequency of pulses is the same at which vocal cords are moving, the vocal cords will appear stationary giving the doctor more time to study the cords and their movement.
If the frequency of pulses is more or less than that of vocal cord movements, the cords are seen in slow motion. Stroboscopes are synchronized with rigid or fibreoptic endoscopes and the vocal cord movements can be recorded on video.
[E] Biopsy –
If your doctor sees a suspicious area on endoscopy, he/she may do a biopsy.
Biopsy means taking a very small sample of tissue from the suspicious area of the vocal cords and sending this sample for histopathological examination under a microscope.
Apart from histopathological examination, the biopsy tissue in a laryngitis patient should also be sent for –
- Usual tissue stains
- Special fungal stains
- Acid-fast bacilli smears
- Fungal and acid-fast bacilli cultures.
OTHER IMPORTANT CONDITIONS THAT CAN MIMIC ACUTE or CHRONIC LARYNGITIS
- TUBERCULOSIS
- LEPROSY
- SARCOIDOSIS
- AUTOIMMUNE DISORDERS
- ACID REFLUX
- CANCER
- VOCAL CORD DISORDERS like VOCAL POLYP, VOCAL NODULE, VOCAL CORD PARALYSIS
- RESPIRATORY PAPILLOMATOSIS (it’s a wart-like growth or tumor on the surface of the vocal cords)
WHEN TO SEEK IMMEDIATE MEDICAL ATTENTION
1. If the patient develops DIFFICULTY IN BREATHING or RESPIRATION or STRIDOR
2. There is no improvement in hoarseness or further deterioration of voice
3. If the patient starts coughing up blood in saliva or sputum
4. Persisting fever
5. Persisting pain in the throat
6. Persisting difficulty in swallowing
TREATMENT OF LARYNGITIS
(i) HOME REMEDIES FOR LARYNGITIS OR HOARSENESS OF VOICE
(ii) MEDICINES
(I) HOME REMEDIES FOR LARYNGITIS or HOARSENESS OF VOICE
1) DO NOT GARGLE AT ALL
The most frequently done thing that damages or further deteriorate the voice quality in the majority of Acute/Chronic Laryngitis patients is “GARGLING”.
YES……U HEARD RIGHT……A patient with Acute or Chronic Laryngitis should NEVER DO GARGLES with anything be it lukewarm saltwater, or betadine® gargles.
See….the basic logic behind this is …….Laryngitis is the inflammation and infection of the vocal cords. The vocal cords are already congested and swollen. So, the cords should be given enough rest so as to decrease the congestion and the swelling.
BUT…….when a patient gargles……unknowingly he/she is putting a lot of pressure/stress on the already damaged or diseased vocal cords, leading to an accentuation of the hoarseness.
In a few unfortunate cases…….the gargling if done during the acute stage of laryngitis carry the potential of permanently damaging the vocal cords by causing hemorrhage in the already congested vocal cords.
Hence, DO NOT GARGLE IF SUFFERING FROM LARYNGITIS OR HOARSENESS OF VOICE.
(Gargling is mainly advised to patients who suffer from Pharyngitis or Sore Throat……NOT for patients who suffer from Laryngitis or Sore Voice)
2) VOICE REST
Give rest to your voice as much as possible.
Avoid talking or singing absolutely for 1-2 days and DO NOT talk or sing too loudly or for too long.
If you need to speak before large groups, try to postpone the event, or if postponing is not an option hire a speaker who will convey your words on your behalf, or use a microphone or megaphone.
3) Drink plenty of fluids
4) Steam Inhalation (should be done in moderation)
Plain steam inhalation can be done once or twice in a day or can be done with Tr. Benzoin Co, oil of eucalyptus or pine. These are soothing and loosen viscid secretions.
(II) MEDICINES FOR LARYNGITIS or HOARSENESS OF VOICE
(I) MANAGEMENT OF INFECTIONS of sinuses, tonsils, teeth, and respiratory system (such as bronchitis, bronchiectasis, tuberculosis)
- VIRAL LARYNGITIS is mostly self-limiting, and usually DO NOT require ANTIVIRALS
- BACTERIAL LARTYNGITIS will require ANTIBIOTICS
There is some evidence that ERYTHROMYCIN may reduce voice disturbance in the first week and therefore may be considered in patients who are professional voice users such as singers, performers, teachers, speakers, etc.
The choice of antibiotic depends on any associated infections but MACROLIDES (e.g. erythromycin or clarithromycin) have been shown to be effective.
- FUNGAL/MYCOTIC LARYNGITIS will require ANTIFUNGAL treatment.
Systemic antifungal therapy is necessary for immunocompromised patients. Antifungal agents suppress fungal growth, making recurrent infection likely unless the underlying predisposing factors are addressed and corrected.
Suitable agents include FLUCONAZOLE, KETOCONAZOLE, ITRACONAZOLE, AMPHOTERICIN-B.
Each agent has its own characteristics:
– Fluconazole for 3–4 weeks is the preferred agent for candida infection.
– Itraconazole is particularly effective for aspergillus infections at a dose of 100–400 mg daily, monitored by regular blood levels.
– Ketoconazole is the agent of choice for histoplasmosis and blastomycosis.
– Amphotericin B needs to be administered intravenously and also has significant adverse effects on the kidney, heart, and liver.
(II) CORTICOSTEROIDS: They help in reducing vocal cord inflammation. eg. Prednisolone®, Medrol®, Defcort®, etc.
Steroids are most useful in –
- Laryngitis following thermal or chemical burns.
- When laryngitis is associated with difficulty in respiration/breathing/or stridor (can be seen in anyone but very commonly seen in toddlers with CROUP or Acute Laryngotracheobronchitis)
- When there’s an urgent need to treat laryngitis – for eg. if a professional singer has a full sold out concert planned and he looses his/her voice while training for the concert just few days before the main performance.
(III) COUGH SUPPRESSANTS like Dextromethorphan, Levocloperastine, Levodropropizine, Codeine, etc.
To suppress troublesome irritating cough which also puts stress over the vocal cord with every bout of coughing.
(IV) EXPECTORANTS like Guaifenesin.
Expectorants aim to make coughing up mucus easier, they do not actually stop coughing. This is important because a productive cough should not be suppressed because it is the body’s way of removing excess mucus, foreign particles, or microorganisms from the airways.
Expectorants also help to relieve chest congestion that occurs because of a Cold, the Flu, or Allergies.
GUAIFENESIN is mostly used for the treatment of chesty, wet, productive, or phlegmy coughs, which typically occur with a cold.
(V) MUCOLYTICS such as Bromhexine, N-acetylcysteine, Ambroxol, etc can be used to loosen up the viscid secretions in the throat and the chest.
Proton-pump inhibitors like Lansoprazole, Omeprazole, Pantoprazole, or Rabeprazole can be given to decrease the acid-reflux symptoms.
(VI) PAINKILLERS like Ibuprofen, Diclofenac, Aceclofenac, Nimesulide, Paracetamol, etc
To relieve local pain and discomfort in the throat
(VII) Avoid smoking, alcohol or pollution, dust, fumes, and chemicals.
(VIII) Voice (speech) therapy.
A patient should undergo speech therapy to learn to correct way of using his/her vocal cords so as to decrease the chances of worsening the voice.
(IX) DECONGESTANTS like Phenylephrine, Chlorpheniramine maleate, Pseudoephedrine, etc.
The use of decongestants is a debate amongst clinicians. Many prefer giving decongestants as they believe that these will decrease the congestion of the vocal cords. Whereas there are few other clinicians who believe that these medications can dry out your throat.
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