Diagnosis and Management of Pure Hoarseness (Acute Laryngitis) เสียงแหบ
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🧠 Overview
Acute laryngitis is the most common cause of hoarseness (dysphonia).It is usually viral, self-limited, and involves inflammation of the laryngeal mucosa and vocal cords.
When hoarseness occurs without other major airway symptoms, it is called “pure hoarseness” — meaning the patient has voice change without dyspnea, stridor, dysphagia, or systemic toxicity.
🧩 Pathophysiology
Normally, the vocal cords vibrate symmetrically to produce sound.In laryngitis:
- Viral infection or voice overuse causes edema of the vocal cords, leading to irregular vibration and hoarseness.
- Common viruses: parainfluenza, rhinovirus, influenza, adenovirus.
- Rare bacterial cause: Haemophilus influenzae, Streptococcus pneumoniae (usually in children or immunocompromised).
🔬 Mechanism:
Inflammation → Capillary leakage → Edema of mucosa → Impaired vibration → Voice change. If prolonged, mucosal trauma may cause vocal cord nodules.
🔍 Diagnosis
1️⃣ History Taking
Chief complaint: Hoarseness (voice change, roughness, or loss of voice).Duration: < 2 weeks (acute).Associated symptoms:
- May have mild sore throat, cough, low-grade fever.
- No stridor, no dyspnea, no dysphagia (otherwise suspect serious causes).
- History of voice overuse (teachers, singers, yelling).
- Smoking, alcohol, or GERD history increases chronicity risk.
🧠 Mnemonic: L-O-D-C-R-A-F-T-S for pain (if sore throat coexists) — but hoarseness alone usually has minimal pain.
2️⃣ Physical Examination
General:
- Mild fever may be present; otherwise well-appearing.Voice: Hoarse, raspy, breathy, or weak.HEENT:
- Mild pharyngeal erythema.
- No tonsillar exudate (if present → think pharyngitis or tonsillitis).
- No neck mass or lymphadenopathy (if present → consider malignancy).Respiratory:
- No stridor, wheezing, or distress.Laryngoscopy (if done):
- Diffuse erythema, edema of true vocal cords.
- No nodules, ulceration, or suspicious mass.
3️⃣ Investigations (usually unnecessary)
Diagnosis is clinical.But if hoarseness lasts > 2–3 weeks, or if red flags appear → investigate:
| Test | Indication |
| Flexible laryngoscopy | Persistent hoarseness, mass, or suspected malignancy |
| CBC | If systemic infection suspected |
| Throat culture | If bacterial cause suspected |
| Neck CT/MRI | If mass or malignancy suspected |
🧠 Remember: Hoarseness > 2 weeks without URI → always refer to ENT.
⚠️ Red Flags (require urgent ENT referral)
- Hoarseness > 2 weeks
- Dyspnea, stridor, or airway obstruction
- Dysphagia, odynophagia, or hemoptysis
- Neck mass or unexplained weight loss
- History of smoking/alcohol use (risk of laryngeal cancer)
🧮 Differential Diagnosis
| Category | Common Causes |
| Inflammatory | Acute laryngitis (viral), bacterial laryngitis |
| Functional | Voice overuse, psychogenic |
| Structural | Vocal cord nodule/polyp, cyst |
| Neoplastic | Laryngeal carcinoma |
| Systemic | Hypothyroidism, GERD, postnasal drip, allergy |
💊 Management of Acute (Pure) Laryngitis
🏥 Setting:
Outpatient Department (OPD)(As long as no airway compromise)
1️⃣ Definitive Treatment
✅ Voice rest — most important treatment.
- Avoid talking, singing, shouting, or whispering (whispering increases strain).
- Usually improves in 3–7 days.
✅ Steam inhalation — 15 minutes, 2–3 times/day.Moist heat reduces inflammation and soothes mucosa.
✅ Hydration — 2–3 L/day warm fluids.Keeps vocal cords moist and reduces irritation.
✅ Avoid irritants — smoking, alcohol, spicy food, caffeine.
✅ Medications:
- Paracetamol (500 mg) 1×3 po pc for 3–5 days for pain or low-grade fever.
- Antihistamine (Cetirizine 10 mg po od pc) if allergic component suspected.
- Proton pump inhibitor (Omeprazole 20 mg 1×2 po ac) if reflux suspected.
❌ Antibiotics: Not recommended unless evidence of bacterial infection. ❌ Systemic steroids: Avoid unless urgent voice recovery (e.g., singer, public speaker).
- If used: Prednisolone 10 mg/day × 3 days (short course, no taper needed).
2️⃣ Supportive Treatment
- Warm saline gargles (½ teaspoon salt in 1 cup warm water, 2–3×/day).
- Humidified environment (use humidifier or steam inhalation).
- Avoid whispering and frequent throat clearing.
- Use lozenges to maintain throat moisture.
3️⃣ Follow-Up
- Follow up in 7 days.
- If symptoms persist > 2 weeks → refer for ENT laryngoscopy.
- Reevaluate for chronic causes (GERD, nodules, malignancy).
🧬 Complications (if neglected)
- Chronic laryngitis
- Vocal cord nodules/polyps
- Permanent voice change
- Laryngeal malignancy (especially with smoking/alcohol use)
🗣️ Patient Education
✅ Voice hygiene: speak softly, avoid shouting, whispering, or clearing throat. ✅ Stay hydrated and humidify air. ✅ Avoid irritants (smoke, alcohol, spicy food). ✅ Manage GERD and allergies if present. ✅ Return if symptoms persist or if breathing difficulty occurs.
🧾 Prescription Example
| Drug | Dose | Frequency | Route | Duration | Note |
| Paracetamol | 500 mg | 1×3 | po pc | 3–5 days | For pain/fever |
| Cetirizine | 10 mg | 1×1 | po pc | 5 days | For allergy |
| Omeprazole | 20 mg | 1×2 | po ac | 2 weeks | If reflux suspected |
| Prednisolone (optional)** | 10 mg | 1×1 | po pc | 3 - 5 days | Only for professionals needing urgent voice recovery |
📚 References
- American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS). Clinical Practice Guideline: Hoarseness (Dysphonia). 2021.
- Thai Clinical Practice Guideline: Acute Laryngitis (เสียงแหบเฉียบพลัน), Department of Medical Services, MOPH 2023.
- UpToDate. Evaluation and management of hoarseness in adults. (updated 2024).
- Robbins Basic Pathology, 11th ed. — Chapter on Upper Airway Inflammation.
🩺 Key Takeaway
Pure hoarseness = acute laryngitis until proven otherwise.Treat conservatively (voice rest, steam, hydration).No antibiotics or steroids unless specific indication.Always re-evaluate if hoarseness lasts > 2 weeks.