Diagnosis and Management of Pure Hoarseness (Acute Laryngitis) เสียงแหบ

Mayta
11 hours ago
3 min read

🧠 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.