Dear friends
Welcome back to our TGIF Dr Euan blog post!
Have you been troubled by sore throats and voice problems? Perhaps you are a teacher and keep losing your voice? By the end of the workday, your neck hurts and you can hardly speak; or perhaps you have an acute episode of fever, sore throat and a hoarse voice?
Perhaps you have a condition called ..... LARYNGITIS; that's a weird kind of word but great for scrabble! Well, today we are going to look deeper into Laryngitis and consider what causes it and what you should do if you suspect you have it.
Q: What is the Larynx, Doc?
The larynx is the upper part of your respiratory tract and is located in your neck. If you place your index finger on your chin and move downwards along the midline, you can actually feel the various landmarks of your own larynx (voice box). The most easily felt is the Adam's Apple.
This is followed by the Cricoid cartilage and the tracheal rings below. It explains how we sometimes have to do an emergency airway procedure called a CRICO-THYROTOMY (coat hanger op on board the aeroplane) to save a life!
You may want to see this link for the event back in 1995:
Doctors Operate on Woman on Plane with Coat Hanger, Bottle
The Larynx serves important functions of respiration and voice production which forms our main mode of communication: SPEECH. Without our larynx, we would be mute and unable to speak or sing.
Illustration to show the Anatomy and Structure of the Larynx, made up of its various cartiliginous components (from Anaesthesia UK)
Illustration to show the side view of the Larynx, and the various cartilages and the upper airway for voice production
Q: What is Laryngitis?
Laryngitis describes any inflammation of the larynx, and a variety of causes result in the presentation of common symptoms. Laryngitis may be acute or chronic, infective or inflammatory, an isolated disorder, or part of systemic disease, and often includes symptoms such as hoarseness.
Most commonly, laryngitis is related to an upper respiratory tract infection (URTI) and can have a major impact on physical health, quality of life, and even psychological wellbeing and occupation if symptoms persist.
Overall, laryngitis incorporates a cluster of non-specific laryngeal signs and symptoms that can also be caused by other diseases. Consequently, diagnosis can be difficult to obtain and requires a correlation of history, examination, and, if necessary, specialist assessment, including direct visualisation of the larynx and video stroboscopy.
Acute laryngitis is typically diagnosed and managed at the primary care level with your GP, the common symptoms include hoarseness, sore throat, pain on speaking or swallowing, fever and sometimes cough with phlegm.
In at-risk populations or those with persistent symptoms, a referral to a specialist otolaryngologist should be considered, so that an accurate diagnosis can be made.
Q: What are some RED FLAG symptoms that you should take note of and seek urgent attention?
If you have any of the following issues, please go to your GP or to the A & E for an assessment of your airway:
• Stridor—emergency referral
• Recent surgery involving the neck or recurrent laryngeal nerve
• Recent endotracheal intubation
• Radiotherapy to the neck
• History of smoking
• Professional voice user (for example, singer, actor, teacher)
• Weight loss
• Dysphagia or odynophagia
• Otalgia
• Any serious underlying concern by a clinician
Q: What are the causes of CHRONIC Laryngitis?
By this, we mean that your symptoms are persisting beyond 3 months duration, with little or no improvement.
In this case, there are many possible causes to be considered and it is recommended that you seek a specialist opinion. Some possible causes include:
Inflammatory cause:
Allergic
It may be unclear whether symptoms are related to allergic rhinitis or asthma or primarily from the larynx. Diagnosis can be difficult: non-specific findings, and sometimes it can be hard to differentiate from laryngopharyngeal reflux (LPR)
Laryngopharyngeal reflux (LPR). A non-specific cluster of laryngeal manifestations. Evidence of different pathophysiology to gastro-oesophageal reflux disease.
Autoimmune cause:
Autoimmune disorders:
Chronic laryngitis may be a manifestation of systemic diseases such as rheumatoid arthritis, pemphigoid, systemic lupus erythematosus (SLE) and amyloidosis. A high degree of suspicion is needed in the setting of other systemic symptoms, such as arthritis, cutaneous changes, and mucous membrane lesions
Rheumatoid arthritis:
The prevalence of laryngeal symptoms in people with rheumatoid arthritis is reported to be between 30% and 75%. This may include crico-arytenoid joint fixation, recurrent laryngeal nerve neuropathy, myositis, and laryngeal nodules, all of which may cause hoarseness of voice.
Mucous membrane pemphigoid:
This is a rare chronic autoimmune vesiculobullous disease that manifests as blisters or bullae of the ocular and oral mucous membranes, with involvement of the aero-digestive tract. Laryngeal involvement is a rare but life-threatening complication, affecting 12% of patients; this condition is managed with cyclophosphamide and prednisolone.
Granulomatous cause:
Sarcoidosis:
Laryngeal sarcoidosis is present in 0.5-5% of patients with sarcoidosis. They commonly present with non-specific laryngeal symptoms like laryngitis. Dysphonia may be present due to recurrent laryngeal nerve palsy from mediastinal lymphadenopathy. A laryngoscopic examination may reveal oedematous laryngeal mucosa, with the supra-glottis being the most commonly involved site. The vocal folds are rarely involved. A biopsy is required to confirm the diagnosis and treated with systemic corticosteroids.
Q: What to expect when you consult your ENT Doctor?
When you see us in the clinic, we will take a comprehensive history of your symptoms and the duration you have experienced difficulties.
We will inspect and palpate your neck around your larynx (voice box) and perform a Naso-endoscopy to look at the larynx internally and inspect your vocal cords.
In addition, some of us will perform a VIDEO STROBOSCOPY whereby we examine and record the vibrations of your vocal cords as you phonate and sing a note. This is useful not just to ENT but also to the Speech Therapist who may work with you to restore your voice eg in the management of vocal cord nodules or Muscle Tension Dysphonia (MTD) etc.
We usually work closely with a speech therapist to provide a holistic approach to restoring normal functions eg: voice and swallowing.
Once we have established the cause of your Laryngitis, we will discuss a plan of treatment with you and usually a referral to the Speech Therapist. Most Speech therapists will see you for between 4 to 6 sessions to help teach you certain vocal exercises to help restore your voice to normal.
Sometimes, we need to take a closer look inside your Larynx, and may discuss doing another procedure under General Anaesthesia (GA); this is called an Endo-Laryngeal Micro-Surgery (ELMS) where we inspect and take close up photos and even biopsies of the various sites in the larynx to send off for more definitive testing (histo-pathology) and even culture tests to identify any possible microbes eg Mycobacterium Tuberculosis which causes TB.
Endoscopic photo showing a normal larynx
Endoscopic photo of larynx showing Gastroesophageal Reflux (GERD) with swollen mucosal lining
Endoscopic photo of larynx showing soft nodules on the vocal cords
So dear friends, there are many possible causes for Laryngitis. So it is important to get an accurate diagnosis and institute the correct treatment.
If you or your loved one is experiencing any such symptoms, do consult your GP or ENT Specialist for a check-up.
For more information, do check out some of these useful references listed below; have a GREAT weekend.
REFERENCES:
Gupta G, Mahajan K. Acute Laryngitis. StatPearls. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Postma GN, Koufman JA. Laryngitis. Bailey BJ, ed. Head and Neck Surgery-Otolaryngology. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998. 731-739.
Modlin IM, Moss SF, Kidd M, et al. Gastroesophageal reflux disease: then and now. J Clin Gastroenterol. 2004 May-Jun. 38(5):390-402. [QxMD MEDLINE Link].
Antunes C, Aleem A, Curtis SA. Gastroesophageal Reflux Disease. StatPearls. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Bhattacharyya N. The prevalence of pediatric voice and swallowing problems in the United States. Laryngoscope. 2015 Mar. 125 (3):746-50. [QxMD MEDLINE Link].
Roy N, Kim J, Courey M, Cohen SM. Voice disorders in the elderly: a national database study. Laryngoscope. 2016 Feb. 126 (2):421-8. [QxMD MEDLINE Link].
Benninger MS, Holy CE, Bryson PC, Milstein CF. Prevalence and Occupation of Patients Presenting With Dysphonia in the United States. J Voice. 2017 Sep. 31 (5):594-600. [QxMD MEDLINE Link].
Ng ML, Gilbert HR, Lerman JW. Some aerodynamic and acoustic characteristics of acute laryngitis. J Voice. 1997 Sep. 11(3):356-63. [QxMD MEDLINE Link].
Vaughan CW. Current concepts in otolaryngology: diagnosis and treatment of organic voice disorders. N Engl J Med. 1982 Sep 30. 307(14):863-6. [QxMD MEDLINE Link].
Cohen SM, Kim J, Roy N, Asche C, Courey M. Direct health care costs of laryngeal diseases and disorders. Laryngoscope. 2012 Jul. 122(7):1582-8. [QxMD MEDLINE Link].
Jaworek AJ, Earasi K, Lyons KM, Daggumati S, Hu A, Sataloff RT. Acute infectious laryngitis: a case series. Ear Nose Throat J. 2018 Sep. 97 (9):306-13. [QxMD MEDLINE Link].
Park JM, Kim SE, Yang HC. Clinical characteristics of herpes zoster laryngitis. Eur Arch Otorhinolaryngol. 2020 Jun 6. [QxMD MEDLINE Link].
Thompson L. Herpes simplex virus laryngitis. Ear Nose Throat J. 2006 May. 85(5):304. [QxMD MEDLINE Link].
Turley R, Cohen SM, Becker A, Ebert CS Jr. Role of rhinitis in laryngitis: another dimension of the unified airway. Ann Otol Rhinol Laryngol. 2011 Aug. 120(8):505-10. [QxMD MEDLINE Link].
Bhattacharyya N. The prevalence of voice problems among adults in the United States. Laryngoscope. 2014 Apr 29. [QxMD MEDLINE Link].
Schalén L. Acute laryngitis in adults: diagnosis, etiology, treatment. Acta Otolaryngol Suppl. 1988. 449:31. [QxMD MEDLINE Link].
Muller D, Lindemann T, Shah-Hosseini K, et al. Efficacy and tolerability of an ectoine mouth and throat spray compared with those of saline lozenges in the treatment of acute pharyngitis and/or laryngitis: a prospective, controlled, observational clinical trial. Eur Arch Otorhinolaryngol. 2016 Sep. 273 (9):2591-7. [QxMD MEDLINE Link]. [Full Text].
Schalen L, Christensen P, Eliasson I, et al. Inefficacy of penicillin V in acute laryngitis in adults. Evaluation from results of double-blind study. Ann Otol Rhinol Laryngol. 1985 Jan-Feb. 94(1 Pt 1):14-7. [QxMD MEDLINE Link].
Reveiz L, Cardona AF. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev. 2015 May 23. 5:CD004783. [QxMD MEDLINE Link].
Silverman M, Povitz M, Sontrop JM, et al. Antibiotic Prescribing for Nonbacterial Acute Upper Respiratory Infections in Elderly Persons. Ann Intern Med. 2017 Jun 6. 166 (11):765-74. [QxMD MEDLINE Link].
Katz PO. Gastroesophageal reflux disease--state of the art. Rev Gastroenterol Disord. 2001. 1(3):128-38. [QxMD MEDLINE Link].
Reveiz L, Cardona AF, Ospina EG. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev. 2007 Apr 18. CD004783. [QxMD MEDLINE Link]. [Full Text].
