Guideline sources The following summarized guidelines for the evaluation and management of laryngitis are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA 2021; 2018; 2015), the American College of Gastroenterology (ACG 2021), the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN/NASPGHAN 2018), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2018), the American Association of Family Physicians (AAFP 2018; 2012), the Finnish Pediatric Society (FPS/FMSD 2016), and the Royal Australian College of General Practitioners (RACGP 2008). 1 2 3 4 5 6 7 8 9 10 Guidelines 1. Diagnostic investigations Clinical assessment: https://web.pathway.md/diseases/reccMoJS7OGspyhA7 1/6 6/29/23, 5:52 AM Laryngitis Pathway Identify dysphonia in patients with altered voice quality, pitch, loudness, or vocal effort impairing communication or reducing the quality of life. B Elicit medical history and perform a physical examination to assess for underlying causes of dysphonia and factors modifying management, B as well as to identify factors requiring expedited laryngeal evaluation including but not limited to: recent surgical procedures involving the head, neck, or chest recent endotracheal intubation presence of concomitant neck mass respiratory distress or stridor history of tobacco abuse professional voice use. B Viral testing (influenza, low season): consider testing for influenza in outpatients with acute respiratory symptoms (with or without fever) especially in immunocompromised and high-risk patients, during low influenza activity season. C Show 2 more Viral testing (influenza, flu season): test for influenza in high-risk patients, including immunocompromised patients presenting with influenza-like illness, pneumonia, or nonspecific respiratory illness (such as cough without fever) during influenza activity (defined as the circulation of seasonal influenza A and B viruses among persons in the local community), if the testing result will influence clinical management. B Show 5 more Viral testing (COVID-19): obtain SARS-CoV-2 NAAT in symptomatic patients in the community suspected of having COVID-19, even when the clinical suspicion for COVID-19 is low. B Show 2 more Diagnostic imaging: do not obtain CT or MRI before visualizing the larynx in patients with a primary voice complaint. D 2. Diagnostic procedures Laryngoscopy: consider performing diagnostic laryngoscopy at any time in patients with dysphonia. C Show 2 more 3. Medical management Nebulized epinephrine: administer nebulized racemic epinephrine for symptom relief in pediatric patients with laryngitis. A Corticosteroids: https://web.pathway.md/diseases/reccMoJS7OGspyhA7 2/6 6/29/23, 5:52 AM Laryngitis Pathway As per AAO-HNSF 2018 guidelines, do not use routine corticosteroids in patients with dysphonia before visualizing the larynx. D As per FMSD 2016 guidelines, administer oral corticosteroids for symptom relief in pediatric patients with laryngitis. A Antibiotics: As per AAO-HNSF 2018 guidelines, do not use antibiotics routinely for the treatment of patients with dysphonia. D As per IDSA 2015 guidelines, avoid using antibiotics in patients with upper respiratory infections as antibiotic treatment is ineffective, inappropriate, and potentially harmful. D As per AAFP 2012 guidelines, do not use antibiotics for the treatment of acute laryngitis. D 4. Nonpharmacologic interventions Mist therapy: do not offer mist therapy to relieve the symptoms of laryngitis. D Voice therapy: offer voice therapy in patients with dysphonia from a cause amenable to voice therapy. B 5. Therapeutic procedures Botulinum toxin injections: offer botulinum toxin injections, or refer to a clinician who can administer botulinum toxin injections, for the treatment of dysphonia caused by spasmodic dysphonia or other types of laryngeal dystonia. B 6. Surgical interventions Indications for surgery: offer surgery as a therapeutic option in patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions not responding to conservative management, or glottic insufficiency. B 7. Specific circumstances Patients with reflux laryngitis (evaluation): obtain evaluation for non-GERD causes in patients with possible extraesophageal manifestations before ascribing symptoms to GERD. B Show 8 more Patients with reflux laryngitis, management: As per ACG 2021 guidelines: Consider offering a trial of twice-daily PPIs for 8-12 weeks before obtaining additional testing in patients with both extraesophageal and typical GERD symptoms. C https://web.pathway.md/diseases/reccMoJS7OGspyhA7 3/6 6/29/23, 5:52 AM Laryngitis Pathway Perform surgical or endoscopic antireflux procedures in patients treated for extraesophageal reflux disease only if objective evidence of reflux is present. B As per AAO-HNSF 2018 guidelines, do not use antireflux medications for the treatment of isolated dysphonia solely based on symptoms attributed to suspected GERD or laryngopharyngeal reflux, without visualization of the larynx. D Patients with reflux laryngitis (pediatric patients): avoid using PPIs or H2RAs in patients with extraesophageal symptoms (cough, wheezing, asthma), except in the presence of typical GERD symptoms and/or diagnostic testing suggestive of GERD. D Patients with acute laryngotracheitis, diagnosis: As per AAFP 2018 guidelines, diagnose croup based on clinical findings of barking cough, stridor, and hoarseness. Avoid obtaining diagnostic testing. B As per RACGP 2008 guidelines, suspect croup in pediatric patients presenting with abrupt onset of barking cough, inspiratory stridor, and hoarseness. B Show 5 more Patients with acute laryngotracheitis (severity assessment): Do not use the loudness of the stridor as an indicator of the severity of croup. Recognize that patients with preexisting conditions causing narrowing of the upper respiratory tract, such as Down syndrome, are at higher risk of severe croup. D Measure oxygen saturation at presentation to the hospital, and in patients with signs of severe or life-threatening croup. B Patients with acute laryngotracheitis (setting of care): consider managing pediatric patients with mild croup by a general practitioner and send them home for observation if the general practitioner is confident the parent/carer can adequately manage the child's illness. C Show 4 more Patients with acute laryngotracheitis, humidified air: As per AAFP 2018 guidelines, do not offer humidified air inhalation to improve symptoms in patients with moderate croup. D As per RACGP 2008 guidelines, do not offer mist, humidified air, D or cold air for the treatment of patients with croup. D Patients with acute laryngotracheitis (oxygen supplementation): Administer oxygen in pediatric patients with severe or life-threatening croup. B Allow pediatric patients with croup to adopt the position they find most comfortable. B Patients with acute laryngotracheitis, corticosteroids: As per AAFP 2018 guidelines, administer corticosteroids in patients with croup of any severity. A As per RACGP 2008 guidelines, consider administering corticosteroids in pediatric patients with mild croup. B Show 2 more Patients with acute laryngotracheitis, nebulized epinephrine: https://web.pathway.md/diseases/reccMoJS7OGspyhA7 4/6 6/29/23, 5:52 AM Laryngitis Pathway As per AAFP 2018 guidelines, administer nebulized epinephrine in patients with moderate-to- severe croup. A As per RACGP 2008 guidelines: Administer nebulized epinephrine as first-line therapy in pediatric patients with severe or life- threatening croup. B Use four 1 mL ampoules (total 4 mL) of 1 mg in 1 mL (1:1, 000) epinephrine solution undiluted. Nebulize the solution with oxygen where possible. B 8. Patient education General counseling: counsel patients with dysphonia on control/preventive measures. B 9. Follow-up and surveillance Serial clinical assessment: document resolution, improvement, or worsening symptoms of dysphonia or change in the quality of life in patients with dysphonia after treatment or observation. B Clinical findings Symptoms Past medical history Aphonia Acute otitis media Change in voice Acute rhinosinusitis Cough Allergic rhinitis Dysphagia GERD Fever Immunocompromising condition Globus sensation Otitis media with effusion Headache Sleep apnea Hoarseness Upper respiratory tract infection Odynophagia Vocal cord nodule Throat pain Medication history Past events ACEIs Recent intubation Antipsychotics Bisphosphonates Social history Corticosteroids Tobacco use Neurological exam Voice overuse Dysphonia Head and neck exam https://web.pathway.md/diseases/reccMoJS7OGspyhA7 5/6 6/29/23, 5:52 AM Laryngitis Pathway Pharyngitis Respiratory exam References 1. Rachel Rosen, Yvan Vandenplas, Maartje Singendonk et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Mar;66 3 516 554. Open 2. Stachler RJ, Francis DO, Schwartz SR et al. Clinical Practice Guideline: Hoarseness Dysphonia) (Update). Otolaryngol Head Neck Surg. 2018 Mar;158 1_suppl):S1 S42. Open 3. D Mazza, F Wilkinson, T Turner et al. Evidence based guideline for the management of croup. Aust Fam Physician. 2008 Jun;37 6 Spec No):14 20. Open 4. Dustin K Smith, Andrew J McDermott, John F Sullivan. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97 9 575 580. Open 5. Kimberly E Hanson, Angela M Caliendo, Cesar A Arias et al. The Infectious Diseases Society of America Guidelines on the Diagnosis of COVID 19 Molecular Diagnostic Testing. Clin Infect Dis. 2021 Jan 22;ciab048. Open 6. Infectious Diseases Society of America. Choosing Wisely: Recommendations of the Infectious Diseases Society of America. Choosing Wisely. 2015 Feb. Open 7. Uyeki TM, Bernstein HH, Bradley JS et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Infect Dis. 2018 Dec 19. Open 8. Roger Zoorob, Mohamad A Sidani, Richard D Fremont et al. Antibiotic use in acute upper respiratory tract infections. Am Fam Physician. 2012 Nov 1;86 9 817 22. Open 9. Terhi Tapiainen, Janne Aittoniemi, Johanna Immonen et al. Finnish guidelines for the treatment of laryngitis, wheezing bronchitis and bronchiolitis in children. Acta Paediatr. 2016 Jan;105 1 44 9. Open 10. Philip O Katz, Kerry B Dunbar, Felice H Schnoll-Sussman et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2021 Nov 22. 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