Rosen & Barkin's 5-Minute Emergency Medicine Consult (416 page)

• Blood tests are not generally indicated:
  
  • An elevated WBC count is not a reliable way to distinguish between bacterial and viral illness
    
• Throat culture:
  
  • Indicated when exam suggests a bacterial infection such as significant exudate in the throat or on the vocal folds
    

Soft-tissue neck films:

• Rarely indicated because fiberoptic laryngoscopy provides a more comprehensive assessment
  
• Mostly used if epiglottitis or foreign body suspected, though high-risk patients should not be sent to radiology
  

Fiberoptic laryngoscopy:

• Red, inflamed vocal cords, with rounded edges
  
• Occasionally hemorrhage or exudates
  
• Endolaryngeal pus is more common in bacterial laryngitis than viral
  
• Demonstration of laryngeal pseudomembrane to distinguish diphtheria from other infectious forms of laryngitis
  

• Asthma
  
• Epiglottitis
  
• Esophageal reflux
  
• Vocal nodules
  
• Laryngeal or thyroid malignancy
  
• Croup/laryngotracheobronchitis
  
• Foreign-body inhalation or other trauma
  

TREATMENT

Supportive care and ambulance transport are not generally indicated

Stabilization is only required if the patient shows signs of respiratory distress:

• The patient should be managed for epiglottitis
  
• Supplemental oxygen via a nonrebreather mask
  
• Orotracheal intubation when time permits in the OR
  
• The neck should be prepped and the equipment ready for a surgical airway
  

• Antibiotics are not 1st-line therapy in adults with acute laryngitis:
  
  • In a systematic review of randomized controlled trials investigating the use of antibiotics vs. placebo, antibiotics offered no objective improvement in symptoms over placebo
    
• Vocal rest (avoid whispering, as it promotes hyperfunctioning of the larynx):
  
  • If patient must speak, use a soft sighing voice
    
• Humidified air
  
• Increase fluid intake
  
• Analgesics
  
• Smoking cessation
  
• Symptoms usually resolve in 7–10 days, if viral cause
  
• Use of inhaled steroids for laryngitis is controversial and not part of current best practices.
  

Depends on cause of laryngitis.

• Mucolytics like guaifenesin if related to upper respiratory infection or allergy
  
• Acetaminophen or NSAIDs for symptomatic relief if associated with viral syndrome
  
• Proton pump inhibitors for GERD-related laryngitis:
  
  • Esomeprazole magnesium: 20–40 mg (peds: 10 mg for patients 1–11 yr) PO daily
    
  • Omeprazole: 20 mg PO BID
    
• Diflucan for candidal laryngitis
  
• If caused by croup: Dexamethasone (0.6 mg/kg) PO or IM ×1
  
• Antihistamines can dry out the vocal cords, make it harder to clear secretions and exudate
  
• Cochrane Review found no benefit in using antibiotics to treat acute laryngitis
  
  • Antibiotics may be considered in high-risk patients or in cases where a positive Gram stain and culture has been obtained
    

FOLLOW-UP

• Tuberculous laryngitis:
  
  • Highly contagious requiring isolation
    
• Signs of epiglottitis, respiratory distress, neck trauma, or anaphylaxis
  
• Respiratory compromise
  

Most patients with uncomplicated laryngitis can be discharged if they have no difficulty breathing and are able to keep adequately hydrated.

Refer patients with chronic laryngitis to otolaryngologist. Patients with >3 wk of laryngitis without obvious benign cause should be evaluated with laryngoscopy to rule out more serious conditions such as carcinoma.

• With otolaryngology if not improved in 2–3 wk
  
• With primary care or gastroenterology if symptoms of GERD
  

• Most acute laryngitis is of viral origin
  
  • Antibiotics likely with no benefit
    
• Consider life-threatening causes of altered phonation such as epiglottitis
  
• Laryngitis not associated with upper respiratory infection may be related to GERD
  
• Patients with chronic or nonresolving laryngitis should follow up with otolaryngologist
  

• Behrman RE, Kliegman R, Jenson H, eds.
  Nelson Textbook of Pediatrics
  . 18th ed. Philadelphia, PA: WB Saunders; 2007.
  
• Dworkin JP. Laryngitis: Types, causes, and treatments.
  Otolaryngol Clin North Am.
  2008;41:419–436.
  
• Heidelbaugh JJ, Gill AS, Van Harrison R, et al. Atypical presentations of gastroesophageal reflux disease.
  Am Fam Physician
  . 2008;78:483–488.
  
• Mehanna HM, Kuo T, Chaplin J, et al. Fungal laryngitis in immunocompetent patients.
  J Laryngol Otol
  . 2004;118:379–381.
  
• Reveiz L, Cardona AF, Ospina EG. Antibiotics for acute laryngitis in adults.
  Cochrane Database Syst Rev
  . 2007;(2):CD004783.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Croup
  
• Epiglottitis
  

CODES

• 464.00 Acute laryngitis without mention of obstruction
  
• 464.01 Acute laryngitis with obstruction
  
• 476.0 Chronic laryngitis
  

BASICS

• Direct transfer of severe forces to the larynx
  
• Simple mucosal tears to fractured and comminuted cartilage:
  
  • Epiglottis, thyroid, arytenoid, cricoid, corniculate, and cuneiform cartilages
    

• Rare: 1/5,000–1/42,000 ED visits
  
• <1% of all blunt trauma
  
• Directly related mortality is 2–15%
  
• Blunt or penetrating trauma to the anterior neck associated with motor vehicle or motorcycle crash, assault, or recreational activities.
  
• Typical mechanism is hyperextension of neck with a direct blow to the exposed anterior neck.
  
• “Clothesline” injury is a classic mechanism (victim struck in neck by cord, wire, or branch hung across path of travel).
  
• Iatrogenic injuries from intubation are becoming more common with an aging population.
  

Bicycle handlebars:

• Extended neck hits the bar, compressing structures between the bar and vertebral column.
  

DIAGNOSIS