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 six categories of 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:

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

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 generally given when the infection is severe enough to cause difficulty breathing (stridor). Bacterial laryngitis tends to resolve itself with adequate treatment with antibiotics.

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

Viruses usually are contracted by inhaling respiratory droplets released into the air by people who are "carrying" the virus.

Viral laryngitis usually is characterized by:

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

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

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 that may also cause laryngitis include 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 southwestern 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 whose natural defense mechanisms against infection are compromised. When the body's immune system is suppressed, certain fungi that 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, take steroids systemically (i.e., either ingest them by mouth or take them intravenously), or 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). As such, they also suppress the body's natural ability to protect itself against infection by fungal organisms.

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:

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 (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:

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 "granulomas" 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; these, in actuality, are not true granulomas but are chronic inflammatory or granulation tissue.

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 an anti-fungal medication such as:

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 with their physician the 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 lining when inhaled. These pollutants include substances such as:

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

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

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).

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 (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 inhaled medications, including:

Contact laryngitis results from laryngeal sensitivity to the propellant, the preservative, or to the active ingredient of the inhaler. 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 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 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:

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.

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 toughness and the ability to withstand most minor injuries. Keratin is not usually produced by or present in the vocal folds, as they 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.

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 to 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, thus preventing scarring in the surgical site and aiding 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.

The symptoms of allergic laryngitis include:

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:

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 loratadine, fexofenadine, cetirizine, and desloratadine, 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 sicca is caused by dryness and can result from any process that causes a drying of the vocal folds.

Common causes of laryngitis sicca include: