Laryngitis

 

What is it?

The larynx is the voice-box in the front of the neck. It houses the vocal cords, which are two flaps of thin, moist skin running half-way across the windpipe from front to back. The vocal cords can be stretched or slackened, and their position adjusted by special controlling muscles anchoring minute cartilages (arytenoid cartilages) which support the cords. An easy way to visualise this is to imagine a ship's sail being controlled by ropes attached to the boom and mast.

The voice is produced by the vibration of the cords as air passes between them. The tautness and separation of the cords determines the pitch and quality of the voice. If the cords become inflamed and swollen (laryngitis), they cannot vibrate properly, and a husky sound results. This is hoarseness, and laryngitis is only one of many causes

Who gets it?

Anyone can get laryngitis or hoarseness. There are many causes of both, but they are more common in smokers and people who use their voices professionally, like teachers and singers.

What are the causes?

Laryngitis may start suddenly and last a few days (acute), or develop gradually, and last for weeks or months (chronic). Chronic laryngitis is defined as hoarseness that has lasted more than three weeks.

Causes of acute laryngitis

  • Commonly caused by a virus infection (often a cold virus), but occasionally by bacterial infection. Fever, general malaise and a sore throat would be likely as well.
  • Sudden excessive misuse of the voice, such as screaming and shouting at a rock concert or football match.

Causes of chronic laryngitis

The list of causes of hoarseness is long. In summary these include:

  • Hoarseness due to chronic laryngitis is seen in people with chronic infections, like sinusitis or chest infections.
  • Recurrent flowing back of acid up the oesophagus from the stomach (acid reflux) can cause a chronic laryngitis and hoarseness. This can happen when a hiatus hernia is present.
  • Growths on the vocal cords. These are usually benign (eg polyps and singer's nodes), but some are cancerous. These are much commoner in smokers than non-smokers.
  • Interference with the movement of the cords, for example by arthritis of the cartilage joints, or damage to a nerve controlling the muscles (recurrent laryngeal nerve).
  • An underactive thyroid gland (myxoedema).
  • Stress itself can cause hoarseness and emotional crises can even cause total loss of voice.
 

What are the symptoms?

Below are listed the main symptoms. You may experience some or all of them to varying degrees.

  • Hoarse voice.
  • Difficulty in speaking with the voice becoming gruff, high pitched, weak or even absent.
  • Mild fever.
  • General feeling of being unwell.
  • Sore throat.
  • Swelling of the lymph glands in the neck, below the ears or under the angle of the jaw.
  • Irritating cough with excessive clearing of the throat.

However it is quite common for laryngitis to be completely painless and for the patient to feel quite well.

What are the risks?

Acute laryngitis rarely causes any serious problems in adults. The main risk is of permanent damage to the voice if it is not rested during recovery.

In children, because the larynx is very small, swelling causes greater interference with airflow than in an adult. Breathing is often noisy and a cough sounds like a seal's bark. This is called stridor. Stridor is alarming to hear, but not dangerous itself. However, if it is especially severe, combined with a rapid onset, marked difficulty in breathing and excessive drooling, it could mark the onset of epiglottitis, an altogether different and dangerous condition requiring emergency hospital treatment. Fortunately it is rare.

What are the tests?

In general, hoarseness which persists for more than three weeks must be investigated to rule out serious causes and point the way to the correct treatment.

Blood tests

A full blood count (FBC) might be useful in chronic laryngitis to rule out iron-deficiency anaemia, a cause of some oesophagus problems which in turn could lead to acid reflux and laryngitis.
Thyroid function tests (TFT) can detect an underactive thyroid gland.

Bacteriology

A throat swab might be useful in severe acute laryngitis to tell what the infection is caused by. As this test takes three days to get a result, treatment would normally be started beforehand, and the test would confirm (or not) the choice of antibiotic.

Indirect laryngoscopy

An angled mirror on a stalk and a light allows an indirect view of the vocal cords for an examination. An ENT (Ear, Nose and Throat or Otorhinolaryngology) specialist or a GP with special skills would use this technique.

Direct laryngoscopy

This can be done whilst awake through a very fine fibre-optic probe introduced through a nostril, allowing a close-up direct view, or whilst under a general anaesthetic if the view is not clear enough.

 

What is the treatment?

An important part of treatment is a good explanation of the disorder and how symptoms are produced, and what to expect from the investigation and treatment options.

Drug treatments

  • Antibiotics may be used to treat laryngitis, though usually they are not of much help.
  • An underactive thyroid gland is treated with thyroid hormone (thyroxine) tablets.
  • Acid reflux has a variety of medical treatments, from simple antacids through to sophisticated acid-reducing drugs and even surgery for severe cases.
  • Stress is best tackled through sensitive conversation to uncover the root causes. Drug treatment may be helpful, but a sensible practical plan of action, counselling or even just a chat may be sufficient.

Surgery

Growths are removed by surgery. The type of operation varies depending on the exact problem, and can be best explained by the specialist undertaking the treatment. Examples include:

  • Simple polyp removal (polypectomy). This may be done using an endoscope.
  • Laser treatment for nodes or warty growths on the vocal cords.
  • Removal of the whole larynx itself (laryngectomy) in cases of cancer of the larynx. This may be extended to remove the nearby lymph glands if the cancer has spread (radical laryngectomy).

Other treatments

  • Steam inhalations may be helpful in relieving discomfort and breathing difficulty in children and adults alike, in acute laryngitis. This is best achieved in children through sitting them in a closed bathroom with a favourite toy or book and the hot taps running.
  • Radiotherapy: growths are also treated with powerful, targeted x-ray treatment to destroy the cancerous cells. This may be used alone or in conjunction with surgery.
 

What are the treatment side effects?

All drug treatment can cause allergic rashes and reactions, though these are rare. A careful assessment of their likelihood and whether the risk is worth taking will be made by the prescribing doctor.

For surgery or direct laryngoscopy, the anaesthetic has its own particular side effects. These can be quite different between individuals, and they should be discussed with the anaesthetist beforehand. All forms of surgery carry a small but recognised risk of excess bleeding and infection, even with the best possible technique. The particular side-effects of the actual operation being done can be explained by the surgeon performing the operation.

Radiotherapy can result in local scarring of tissues which may interfere with neighbouring structures. The exact way this could happen can vary between individuals.

What self-help strategies are there?

  • Avoid cigarette smoking.
  • Wear a dust mask if working in a dusty or smoky atmosphere.
  • Avoid prolonged shouting.
  • If hoarse for whatever reason, rest the voice as much as possible.
  • If hoarseness persists for more than three weeks, it is essential to see a doctor for examination and investigation. It is unlikely to be caused by acute laryngitis.