Acute Inflammations of Larynx

Acute laryngitis is a sudden inflammation of the glottis and supraglottis., often causing hoarseness or loss of voice. It can be infectious (caused by viruses or bacteria) or non-infectious (due to voice strain, allergies, or chemical irritation).

Causes of Acute Laryngitis

Infectious Causes (more common)

1. 1. It usually starts as a viral infection (common cold, flu) of the upper respiratory tract but can also be due to lower respiratory tract such as tonsillitis or chest infections.
   2. Later, bacteria like Streptococcus pneumoniae, Haemophilus influenzae and haemolytic Streptococci or Staphylococcus aureus.
   3. Fungal infections (candida or aspergillus) in immunocompromised patients.
   4. Childhood infections (measles, chickenpox, whooping cough) can also trigger laryngitis.

Non-infectious Causes

1. 1. Voice overuse (shouting, singing).
   2. Allergies (pollen, smoke).
   3. Chemical or thermal burns (inhaling fumes, hot liquids).
   4. Trauma (endotracheal intubation).

Clinical Features. The onset of symptoms is typically acute and includes:

1. Hoarseness (may progress to complete voice loss).
2. Throat pain, especially after speaking.
3. Dry, irritating cough (worse at night).
4. Cold-like symptoms (fever, fatigue) if caused by infection.

How the Larynx Looks During Infection

• Early stage: Redness and swelling in the epiglottis, aryepiglottic folds, arytenoids and ventricular bands. Vocal cords appear normal but hoarseness is present.
• Later stage: Vocal cords turn red and swollen and may involve subglottis. Sticky mucus builds up, and vocal cord haemorrhages may occur if strained.

Treatment

1. Most cases are self-limiting and resolved within a couple of weeks.
2. Voice rest, analgesics, anti-inflammatory medications, and steroids help reduce inflammation and promote healing, especially in severe cases.
3. Avoid smoking and alcohol as they irritate the throat, and use steam inhalation (Tr. Benzoin Co, Eucalyptus oil or Pine oil can be added) and cough suppressants for relief.
4. Antibiotics– Indicated in the presence of secondary bacterial infection, evidenced by fever, toxaemia, or purulent sputum. The choice of antibiotics is macrolides (e.g. erythromycin or clarithromycin).
5. For fungal infections – Systemic antifungal therapy (Fluconazole – Candida, Itraconazole – Aspergillus, Ketoconazole – Histoplasmosis and blastomycosis, Amphotericin B – Mucor and invasive fungal infections)
6. For patients with stridor – Antibiotics, nebulization with adrenaline and steroids should be considered. Tracheostomy is rarely indicated.
7. Speech therapy – If hoarseness persists for more than a few weeks.

Acute Membranous Laryngitis

A rare, severe form where a pus-filled membrane forms on the larynx resembles acute membranous tonsillitis and is attributed to nonspecific pyogenic organisms. It may originate in the larynx or extend from the pharynx, necessitating differentiation from laryngeal diphtheria.

 

2. Acute Epiglottitis (Synonym: Supraglottic Laryngitis)

Acute epiglottitis is an inflammatory condition localized to the supraglottic structures—namely, the epiglottis, aryepiglottic folds, and arytenoids—characterized by significant oedema. It should be considered an emergency condition due to the potential rapid and life-threatening airway obstruction.

Aetiology. Earlier, Haemophilus influenzae type b (Hib) was the predominant causative agent; however, widespread Haemophilus influenza type b vaccination under universal immunization programs has reduced its incidence. Currently, Group A β-hemolytic Streptococcus (GABHS) is the most frequent aetiology. Other pathogens, including H. influenzae (in unvaccinated populations), Streptococcus pneumoniae, and Staphylococcus aureus, are less commonly seen. Candida albicans is an important cause in immuno-compromised patients.

Clinical Features

1. Most common in children (2–7 years old), though adults may also be afflicted.
2. Presents with high fever (up to 40°C) secondary to septicaemia.
3. Inspiratory stridor with rapid progression; The child often adopts an upright sitting posture with both hands taking support of bed (e.g., tripod position) to maintain airway patency, as the supine position exacerbates obstruction due to the oedematous epiglottis.
4. There is a triad of odynophagia, salivary drooling and distress.
5. Notably, the glottis (vocal cords) remains uninvolved, preserving normal phonation and cry, with stridor confined to the inspiratory phase.
6. In adults, pain in the throat and odynophagia predominate. Stridor is not commonly seen in adults as there is denser submucosal tissue that limits gross oedema as compared to the looser, more edematous tissue in pediatric patients.

Examination

1. Tongue depression or indirect laryngoscopy may reveal a red, swollen epiglottis (termed the “rising beam” appearance) and congested supraglottic structures; however, such examination risks laryngospasm and is preferably conducted in a controlled setting with intubation facilities.
2. Lateral soft-tissue neck radiography demonstrates a thickened epiglottis resembling a thumb (the “thumb sign”).

Treatment

1. Hospitalization: Mandatory due to the potential for respiratory compromise.
2. Antibiotics: Parenteral ampicillin or third-generation cephalosporins are administered promptly, targeting H. influenzae and other pathogens, pending culture results. Rifampicin prophylaxis is advised for unvaccinated family members for 04 days.
3. Corticosteroids: A short course of hydrocortisone or dexamethasone reduces oedema, potentially averting the need for tracheostomy.
4. Hydration: Intravenous fluids may be required.
5. Humidification and Oxygenation: Delivered via mist tent or croupette.
6. Airway Management: Intubation (preferred) or tracheostomy is indicated if respiratory distress persists despite medical therapy, as untreated obstruction may prove fatal.

 

3. Acute Laryngo-Tracheo-Bronchitis (Croup)

Acute laryngo-tracheo-bronchitis, commonly termed croup, represents the most frequent inflammatory condition affecting the larynx, trachea, and bronchi, surpassing acute epiglottitis in incidence. It is the most common cause of stridor in children.

Aetiology. Primarily viral in origin (parainfluenza virus, adenovirus, RSV), it is often complicated by secondary bacterial infection with Gram-positive cocci.

Pathology. Oedema of the loose areolar tissue in the subglottic region precipitates respiratory obstruction and stridor, with progression to the trachea and bronchi. Thick, tenacious secretions and crusting may exacerbate airway occlusion.

Clinical Features

1. Typically affects children aged 6 months to 3 years, with a male predominance.
2. Initiates as an upper respiratory infection, with hoarseness and a distinctive “croupy” barking seal-like cough.
3. Accompanied by fever (39–40°C).
4. Progresses to dyspnea and biphasic stridor, with signs of upper airway obstruction (e.g., suprasternal and intercostal retractions).

Diagnosis. Anteroposterior neck radiography reveals subglottic and upper tracheal narrowing, forming an inverted “V” or “steeple sign,” alongside hypopharyngeal dilatation and a normal epiglottis. It should be differentiated from diphtheria, epiglottitis, peritonsillar abscess and inhalational injuries.

Treatment

1. Hospitalization: Frequently required due to progressive respiratory difficulty.
2. Bronchodilators: Racemic epinephrine via nebulization may alleviate dyspnea and preclude tracheostomy.
3. Decongestants: Support symptomatic relief.
4. Antibiotics: Ampicillin (50 mg/kg/day) targets secondary Gram-positive coccal infections and H. influenzae.
5. Humidification: Softens crusts and secretions obstructing the tracheobronchial tree.
6. Hydration and cool humified air: Parenteral fluids address dehydration.
7. Corticosteroids: Intravenous hydrocortisone (100 mg) mitigates oedema.
8. Airway Intervention: Intubation or tracheostomy is performed if obstruction persists, with tracheostomy favoured for prolonged intubation beyond 72 hours; assisted ventilation may be necessary.

 

4. Pertussis (Whooping Cough)

Pertussis, caused by Bordetella pertussis, is a contagious respiratory infection spread through coughing/sneezing. It triggers severe coughing fits, often ending with a “whoop” in children, while adults may only have a prolonged cough. Infants are most vulnerable. Diagnosis involves PCR testing of nasopharyngeal samples.

Treatment includes erythromycin (or alternatives like azithromycin), which reduces transmission but doesn’t shorten illness. Cough suppressants help symptoms, but other medications lack proven benefits. Vaccination remains the best prevention, as antibiotics offer limited protection compared to immunization. Early diagnosis and household prophylaxis are key to controlling outbreaks.

 

5. Diphtheria

Diphtheria is an acute infectious disease caused by Corynebacterium diphtheriae, a Gram-positive bacillus transmitted via respiratory droplets. It usually occurs as a secondary complication of faucial diphtheria, more commonly in children under 10 years of age. The disease primarily affects the pharynx, larynx, and nasal cavity, with severity ranging from asymptomatic carriage to life-threatening systemic illness. The severity depends on the immunity of the host and the virulence of the causative organism. While global immunization programs have reduced incidence, outbreaks persist in under-vaccinated populations.

Pathogenesis involves two key mechanisms:

1. Formation of a thick pseudomembrane that can obstruct airways, and
2. Release of a potent exotoxin causing myocarditis and neurological complications.

Clinical Features

1. General Symptoms: Low-grade fever (100–101°F), Sore throat and difficulty swallowing, Malaise and fatigue, Toxaemia, Tachycardia, Thready pulse (weak pulse due to circulatory strain)
2. Laryngeal Symptoms: Hoarseness, Croupy cough, Inspiratory stridor, Progressive dyspnoea, Severe upper airway obstruction (life-threatening without intervention).
3. Characteristic Membrane: Greyish-white pseudo membrane covering tonsils, pharynx, and soft palate, It is firmly adherent and its removal causes bleeding, It can extend to the larynx and trachea, worsening obstruction
4. “Bull-Neck” Appearance: Bilateral tender and enlarged cervical lymph nodes creating a thick neck appearance
5. Systemic Complications: Toxic myocarditis leads to circulatory failure and risk of sudden death (peaks at 10–14 days). Neurological effects (late complication) can cause palatal paralysis →nasal regurgitation or Laryngeal/pharyngeal paralysis → aspiration risk.

Diagnosis relies on clinical suspicion confirmed by Albert’s/Neisser’s staining of membrane specimens.

Treatment

1. Immediate Hospitalization. Urgent referral to an infectious disease facility with oxygen support without waiting for lab confirmation.
2. Diphtheria Antitoxin (DAT). The dosage ranges from 20,000–100,000 units IV (based on site, severity and duration following a test dose). It is Diluted in saline (1:20) and infused at 1 mL/min. It neutralizes circulating toxin (ineffective on bound toxin)
3. Antibiotic Therapy. Crystalline penicillin (1–1.5 lakh units/kg/day IV in 4 divided doses for 14 days) or Procaine penicillin (3 lakh units IM for children <10 kg; 6 lakh units IM for >10 kg, once daily for 14 days). Syrup Erythromycin (40 mg/kg/day oral for 7–10 days) for penicillin-hypersensitive patients and Rifampicin/ Clindamycin for penicillin-allergic patients.
4. Airway Management. Tracheostomy may prove necessary in severe cases. Direct laryngoscopy, removal of the diphtheritic membrane, and intubation facilitate airway patency, simplifying subsequent tracheostomy if required.
5. Supportive Care. Strict bed rest for 2–4 weeks to prevent myocarditis exacerbation. Cardiac monitoring for arrhythmias/heart failure. IV fluids to maintain circulation.
6. Prophylaxis for Contacts. Benzathine penicillin(6 lakh units IM for children <6 years; 12 lakh units IM for ≥6 years) or Oral erythromycin(40 mg/kg/day for 7–10 days)

Complications

Diphtheria may lead to several serious sequelae:

1. Asphyxia and mortality resulting from airway obstruction.
2. Palatal paralysis, associated with nasal regurgitation.
3. Paralysis affecting the larynx and pharynx.

 

6. Mycotic Laryngitis

Fungal infections of the larynx occur due to fungal inhalation in immunosuppressed patients (e.g., hematologic malignancy, diabetes, steroid use). It is rare in immunocompetent individuals.

Causative organisms: Candida and Aspergillus

Symptoms: It usually presents as a white pseudomembrane (mimicking leukoplakia). It can also present as erythema, oedema, and ulceration in severe conditions.

Diagnosis: Chest X-ray (to exclude pulmonary fungal involvement), laryngoscopy, biopsy, and fungal staining (e.g., PAS, methenamine silver).

Treatment: Systemic antifungal therapy (Fluconazole – Candida, Itraconazole – Aspergillus, Ketoconazole – Histoplasmosis and blastomycosis, Amphotericin B – Mucor and invasive fungal infections). Recurrence is likely if predisposing factors (e.g., immunosuppression, steroid use) persist.

 

7. Laryngocoele/ Laryngopyocoele

A laryngocoele is an abnormal dilation of the larynx’s ventricle lined by respiratory epithelium. It is more commonly seen in men (5:1) in the age group 50-60 years and it is mostly unilateral. Risk factors include increased glottic pressure (e.g., glass blowing, trumpet playing, weight lifting). It contains air or mucus and it is classified into

• Internal laryngocoele (20%) – It is confined in the larynx.
• External laryngocoele (30%) – It extends laterally beyond the thyrohyoid membrane and presents as a neck lump.
• Mixed laryngocoele (50%) – has both internal and external components.

Infection of the laryngocoele contents, due to blockage of the neck of the sac leads to laryngopyocoele (pus-filled sac).

Symptoms:

• External laryngocoele: It presents as a lump in the neck and inflates with Valsalva or maybe emptied with external pressure producing a gurgling or hissing sound (Bryce’s sign).
• Internal laryngocoele: The patient presents with hoarseness, dysphagia, false vocal cord swelling and occasionally with stridor.
• Laryngopyocoele: Fever, dysphagia, airway obstruction.

Diagnosis:

• Laryngoscopy shows an enlarged and smooth swelling in the region of the false vocal cord and aryepiglottic fold.
• X-ray Neck with or without Valsalva shows an air-filled cavity in the neck communicating with the larynx.
• CT/MRI to assess the extent.

Management:

• Acute laryngopyocoele: Presents as an airway emergency and may require tracheostomy or intubation. IV antibiotics, steroids (dexamethasone), needle aspiration of external lump if present, or airway intervention (tracheostomy if obstructed).
• Definitive treatment: Surgical excision (uncapping or marsupialization) via external approach or endoscopic CO₂ laser, after the infection resolves.

———— End of the chapter ————

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Acute Inflammations of the Larynx Best Lecture Notes Dr Rahul Bagla ENT Textbook

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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Keywords: Acute laryngitis, Acute epiglottitis, Acute laryngotracheobronchitis, Pertussis, Diphtheria, Mycotic Laryngitis, Laryngopyocoele