Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

with potential airway compromise

1st line – secure airway + supportive care

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INITIAL
|
with potential airway compromise
1st line – 

secure airway + supportive care

If there is respiratory distress, the patient should be assessed in a controlled environment with the facility to perform safe intubation. Emergency tracheotomy may be required if, through swelling, a normal intubation is not possible.

Children presenting with symptoms and signs of epiglottitis (e.g., high fever, sore throat, toxic appearance, drooling, tripod positioning, difficulty breathing, and irritability) should be examined in a controlled setting, such as the operating room, where intubation is performed if there is any doubt about the airway.

If the patient is an adult, flexible laryngoscopy may be performed. Any manipulation of the supraglottic area should be avoided. If necessary, intubation can be performed during flexible laryngoscopy with direct visualization.[19]

Acute respiratory distress is unlikely in complicated acute laryngitis in the absence of an underlying risk factor, such as subglottic stenosis or bilateral vocal fold paralysis.

Patients with diphtheria are at imminent threat of airway compromise. They require hospitalization, close observation, and serial fiberoptic indirect laryngoscopies. The airway should be secured in case of developing obstruction from progression of the exudates. Palatal and pharyngeal paralysis may necessitate nasogastric tube feeding.

Plus – corticosteroid

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INITIAL
|
with potential airway compromise
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

Corticosteroids are administered to alleviate edema in all patients with potential airway compromise. Evidence in the literature for corticosteroid use for acute laryngitis is incomplete.[17][30][31][32][33][34][35]​​​​​​ One study compared inhaled corticosteroid versus oral corticosteroid. There was a significant improvement in edema in the inhaled corticosteroid cohort compared with the oral corticosteroid cohort.[31] In another study, oral corticosteroid therapy was shown to reduce proinflammatory markers and increase anti-inflammatory markers in a human phonotrauma model.[17] The authors of the study concluded that this provides a biologic basis supporting the use of corticosteroids in acute vocal fold inflammation associated with phonotrauma.

Practice may vary between physicians, but some patients may continue on a tapering dose of oral corticosteroid as the intravenous dose is discontinued.

Duration of therapy varies according to symptoms and response.

Primary options

dexamethasone sodium phosphate: children and adults: consult specialist for guidance on dose

Plus – isolation + antibiotics + diphtheria antitoxin

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INITIAL
|
with potential airway compromise
|
with suspected diphtheria
Plus – 

isolation + antibiotics + diphtheria antitoxin

Treatment recommended for ALL patients in selected patient group

Once the diagnosis is suspected, treatment should be started without delay. Patients should be isolated.

Early administration of diphtheria antitoxin is crucial. It can be administered before laboratory confirmation of infection.[38]​ Antibiotics are essential for eradicating the organism and eliminating its spread. See Diphtheria.

ACUTE

viral

1st line – supportive care + vocal hygiene

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ACUTE
|
viral
1st line – 

supportive care + vocal hygiene

Supportive care includes analgesics as required.

Vocal hygiene is the most important component of the treatment regimen. It includes, but is not limited to, voice rest, increased hydration, humidification, and limited caffeine intake.[14]

Voice rest for viral laryngitis, in particular, cannot be overemphasized. Advice regarding the duration of voice rest suggested may differ among physicians but is usually between 3 and 14 days.[36]

Singers should not sing or do vocal exercises during this period.

Heavy voice use in an already injured larynx can lead to the formation of further pathologies, such as scarring or hemorrhage of the vocal folds and muscle tension dysphonia.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours as required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours as required, maximum 4000 mg/day

Consider – mucolytic and/or cough suppressant

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ACUTE
|
viral
Consider – 

mucolytic and/or cough suppressant

Treatment recommended for SOME patients in selected patient group

Despite a lack of conclusive trials, mucolytics have been used widely to decrease the viscosity of the secretions.

This may restore the watery quality of the mucus in the glottis that is essential for the lubrication of the true vocal folds.[37]

Thick mucus also triggers throat clearing, which in turn increases vocal fold edema and injury, leading to vocal fold pathologies.

Patients with cough may be prescribed cough suppressants. Cough and cold medications that include opioids, such as codeine or hydrocodone, should not be used in children aged 18 years or younger as the risks (slowed or difficult breathing, misuse, abuse, addiction, overdose, and death) outweigh the benefits when used for cough in these patients.[41]

Primary options

guaifenesin: children ≥2 years of age: 12 mg/kg/day orally (immediate-release) given in 4-6 divided doses; adults: 1200 mg orally (extended-release) twice daily

and/or

codeine sulfate: adults: 15-30 mg orally every 4-6 hours when required, maximum 120 mg/day

suspected bacterial: nondiphtheria and nontuberculous

1st line – antibiotics

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ACUTE
|
suspected bacterial: nondiphtheria and nontuberculous
1st line – 

antibiotics

Antibiotics are indicated only when a bacterial infection is suspected.[27][28]​​

A Cochrane review on antibiotics for acute laryngitis in adults found that there appears to be no clinically significant benefit to the use of antibiotics to treat acute laryngitis, although no definitive recommendations could be made.[28] [ Cochrane Clinical Answers logo ] The use of antibiotics could lead to increased rates of resistant organisms as well as undue adverse risks and costs.[28]

Most acute laryngitis cases are viral.

Treatment course: 14 days (10 days in adults).

Primary options

penicillin V potassium: children: 25-50 mg/kg/day orally given in divided doses every 6-8 hours, maximum 3000 mg/day; adults: 500 mg orally twice daily

Secondary options

erythromycin base: children: 30-50 mg/kg/day orally given in divided doses every 6-8 hours, maximum 2000 mg/day; adults: 500 mg orally twice daily

Plus – supportive care + vocal hygiene

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ACUTE
|
suspected bacterial: nondiphtheria and nontuberculous
Plus – 

supportive care + vocal hygiene

Treatment recommended for ALL patients in selected patient group

Supportive care includes analgesics as required.

Vocal hygiene is an important component of the treatment regimen. It includes, but is not limited to, voice rest, increased hydration, humidification, and limited caffeine intake.[14]

Advice regarding the duration of voice rest suggested may differ among physicians but is usually between 3 and 14 days.[36]

Singers should not sing or do vocal exercises during this period.

Heavy voice use in an already injured larynx can lead to the formation of further pathologies, such as scarring or hemorrhage of the vocal folds and muscle tension dysphonia.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours as required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours as required, maximum 4000 mg/day

Consider – mucolytic and/or cough suppressant

Back
ACUTE
|
suspected bacterial: nondiphtheria and nontuberculous
Consider – 

mucolytic and/or cough suppressant

Treatment recommended for SOME patients in selected patient group

Despite a lack of conclusive trials, mucolytics have been used widely to decrease the viscosity of the secretions.

This may restore the watery quality of the mucus in the glottis that is essential for the lubrication of the true vocal folds.[37]

Thick mucus also triggers throat clearing, which in turn increases vocal fold edema and injury, leading to vocal fold pathologies.

Patients with cough may be prescribed cough suppressants. Cough and cold medications that include opioids, such as codeine or hydrocodone, should not be used in children aged 18 years or younger as the risks (slowed or difficult breathing, misuse, abuse, addiction, overdose, and death) outweigh the benefits when used for cough in these patients.[41]

Primary options

guaifenesin: children ≥2 years of age: 12 mg/kg/day orally (immediate-release) given in 4-6 divided doses; adults: 1200 mg orally (extended-release) twice daily

and/or

codeine sulfate: adults: 15-30 mg orally every 4-6 hours when required, maximum 120 mg/day

confirmed diphtheria

1st line – continued isolation + antibiotics + diphtheria toxoid

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ACUTE
|
confirmed diphtheria
1st line – 

continued isolation + antibiotics + diphtheria toxoid

Patients should be isolated during the treatment period and remain isolated until two cultures from the nasopharynx and throat taken at least 24 hours apart and more than 24 hours after completing antibiotics are negative.[29][39]​​​​

Antibiotic regimen, started presumptively, should be completed.

See Diphtheria.

Consider – analgesia

Back
ACUTE
|
confirmed diphtheria
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

Supportive care may include analgesics.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours as required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours as required, maximum 4000 mg/day

Consider – mucolytic and/or cough suppressant

Back
ACUTE
|
confirmed diphtheria
Consider – 

mucolytic and/or cough suppressant

Treatment recommended for SOME patients in selected patient group

Despite a lack of conclusive trials, mucolytics have been used widely to decrease the viscosity of the secretions.

This may restore the watery quality of the mucus in the glottis that is essential for the lubrication of the true vocal folds.[37]

Thick mucus also triggers throat clearing, which in turn increases vocal fold edema and injury, leading to vocal fold pathologies.

Patients with cough may be prescribed cough suppressants. Cough and cold medications that include opioids, such as codeine or hydrocodone, should not be used in children aged 18 years or younger as the risks (slowed or difficult breathing, misuse, abuse, addiction, overdose, and death) outweigh the benefits when used for cough in these patients.[41]

Primary options

guaifenesin: children ≥2 years of age: 12 mg/kg/day orally (immediate-release) given in 4-6 divided doses; adults: 1200 mg orally (extended-release) twice daily

and/or

codeine sulfate: adults: 15-30 mg orally every 4-6 hours when required, maximum 120 mg/day

tuberculosis

1st line – isolation and antituberculosis therapy

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ACUTE
|
tuberculosis
1st line – 

isolation and antituberculosis therapy

Full respiratory isolation is needed.

The detailed treatment of tuberculosis is beyond the scope of this topic. See  Pulmonary tuberculosis

Patients with suspected tuberculosis require referral to an infectious disease or pulmonary specialist for antituberculosis therapy and care.

Plus – supportive care + vocal hygiene

Back
ACUTE
|
tuberculosis
Plus – 

supportive care + vocal hygiene

Treatment recommended for ALL patients in selected patient group

Vocal hygiene is a component of the treatment regimen.

It includes increased hydration, humidification, and limited caffeine intake.[14]

Supportive care may include analgesics.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours as required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours as required, maximum 4000 mg/day

Consider – mucolytic and/or cough suppressant

Back
ACUTE
|
tuberculosis
Consider – 

mucolytic and/or cough suppressant

Treatment recommended for SOME patients in selected patient group

Despite a lack of conclusive trials, mucolytics have been used widely to decrease the viscosity of the secretions.

This may restore the watery quality of the mucus in the glottis that is essential for the lubrication of the true vocal folds.[37]

Thick mucus also triggers throat clearing, which in turn increases vocal fold edema and injury, leading to vocal fold pathologies.

Patients with cough may be prescribed cough suppressants. Cough and cold medications that include opioids, such as codeine or hydrocodone, should not be used in children aged 18 years or younger as the risks (slowed or difficult breathing, misuse, abuse, addiction, overdose, and death) outweigh the benefits when used for cough in these patients.[41]

Primary options

guaifenesin: children ≥2 years of age: 12 mg/kg/day orally (immediate-release) given in 4-6 divided doses; adults: 1200 mg orally (extended-release) twice daily

and/or

codeine sulfate: adults: 15-30 mg orally every 4-6 hours when required, maximum 120 mg/day

fungal

1st line – referral to otolaryngology specialist

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ACUTE
|
fungal
1st line – 

referral to otolaryngology specialist

The detailed treatment of fungal laryngitis is beyond the scope of this topic.

Patients with fungal laryngitis are managed by otolaryngology specialists.

Patients using inhaled corticosteroids should be advised to rinse the mouth with water before and after inhalation.

The dose of corticosteroid should be reduced if at all possible to the lowest dose required. Referral to an otolaryngology specialist may still be required.[40]

vocal strain

1st line – speech therapy + vocal hygiene

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ACUTE
|
vocal strain
1st line – 

speech therapy + vocal hygiene

The mainstay of treatment for vocal strain, including for professional voice users, is generally speech therapy by an experienced voice therapist.[2][22]​​​ For these patients with vocal strain, vocal hygiene is essential. This includes, but is not limited to, voice rest, increased hydration, humidification, and limited caffeine intake.[14]

Voice rest is important because heavy voice use in an already injured larynx can lead to the formation of further pathology, such as scarring or hemorrhage of the vocal folds and muscle tension dysphonia. The duration of voice rest suggested may differ depending on each physician's usual practice, but is usually between 3 and 14 days.[36] Singers should not sing or do vocal exercises during this period. 

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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