Infectious or Allergic Chronic Laryngitis Clinical Presentation

Signs and symptoms derive from anatomic functional alterations of the larynx and from involvement of contiguous structures. When chronic laryngitis is a manifestation of a systemic disease, then the stigmata of the main pathologic process predominate.

• Hoarse voice and dysphonia are frequently described. Voice quality and quantity may fluctuate, although complete recovery never occurs.

• Chronic cough is reportedly most marked at night. If gastroesophageal reflux disease (GERD) is the causative factor, the cough can be described as either dry or productive of small amounts of mucus, depending on the degree of involvement of the posterior wall of the larynx. Belching can occur.

• Stridor due to laryngospasm may occur if mucus strands cross the vocal cords.

• Dysphagia and otalgia are identified when the pharynx is involved because of the shared innervation between the throat and the pharynx.

• Personal history

  • Time of symptom onset and symptom quality and variation, along with precipitating or relieving factors

  • General state of health, symptoms and signs of thyroid disease or lung cancer, and any medical conditions that could elicit or mimic chronic laryngitis

  • Occupational history, including contact with toxic substances, fumes, dusts, and/or rapid temperature changes

  • Vocal abuse, professionally related or otherwise

  • Heartburn, regurgitation, dysphagia, cough, wheezing, hoarseness, chest pain, or otalgia, which raise suspicion for GERD. According to a recently published survey, ENT physicians who diagnosed GERD-related laryngitis often relied on the presence of globus and throat clearing. ^[1]

  • Presence of asthma, which should alert physicians to the possibility of vocal cord dysfunction (ie, history of throat but not chest tightness, difficult phonation, laryngeal stridor and wheezing that is worse on inspiration), allergies, GERD, or processes involving the tracheobronchial tree

  • Prescriptions or over-the-counter medications (eg, diuretics, antihypertensives, psychotropic drugs, antihistamines, decongestants) that may cause predisposition to or determine the onset of chronic laryngitis

    • These agents may cause local drying, mucosal injury, or both.

    • If a patient provides a history of immunosuppressant or inhaled steroid use, then candidal laryngitis must be suspected.

  • Medications (eg, calcium channel blockers, nitrates, beta-blockers, progesterone) that may cause predisposition to GERD by decreasing the tone of the lower esophageal sphincter (LES) (Fuchs and Bucheler described a case of chronic hyperplastic laryngitis following the prolonged use of Cibacen 10, an angiotensin converting enzyme inhibitor. ^[2] )

  • Inhalation treatments, such as those in thermal baths

  • Surgical history, especially if intubation occurred

    • Thoracic and abdominal surgery point to the possibility of iatrogenic damage to the recurrent laryngeal nerve and resultant dysphonia.

    • These surgeries may cause consequent anatomic alterations that may predispose patients to GERD.

  • History of neck trauma

  • Ingestion of caustic substances

  • Travel history (for the possibility of parasitic infections)

• Family history

  • Family history is important when autoimmune diseases (eg, amyloidosis, systemic lupus erythematosus, Wegener granulomatosis, rheumatoid arthritis) are suspected.

  • Similar symptoms in other family members could help identify possible environmental pollutants responsible for chronic laryngitis.

  • Family members should be checked for infectious diseases with a propensity to spread (eg, tuberculosis).

• Social history

  • Cigarette smoking, recreational drugs, and alcohol abuse

  • Any practices that may pose a risk for infectious diseases (eg, promiscuity, risk factors for HIV/AIDS, syphilis)

  • Eating habits, with special attention to the consumption of chocolate and caffeine that may determine relaxation of the LES and eventually cause irritative laryngitis and GERD

General appearance and vital signs may provide useful clues.

• Accessory muscle use during respiration must be detected, if present. Auscultation of the airways and pulse oximetry measurement can be performed, if indicated.

• In case of infection, fever or parameters indicating toxicity may be present. Findings that point to a systemic condition as the etiologic factor can be detected.

• A thorough head and neck examination is a fundamental initial tool. Special attention to masses and lymphadenopathies may help localize malignancies.

• The thyroid gland and the laryngeal and tracheal cartilages must be evaluated.

• Indirect laryngoscopy can be performed during a routine physical examination. Direct techniques allow a more thorough examination of the larynx, using a flexible endoscope in patients who are awake or a rigid laryngoscope in patients under general anesthesia.

• Rarely, the inflammatory process is localized to the larynx. The surrounding structures may be involved. According to recent literature, some ENT physicians most often relied on the nonspecific findings of laryngeal erythema and edema to diagnose and treat GERD-related laryngitis. ^[1]

  • Particular attention must be paid to the base of the tongue, tonsil, nasopharynx, and sinuses to find an eventual primary source of infection.

  • The tracheobronchial tree and lungs must be considered as potential sources of infection.

  • Mucus (especially in the posterior wall of the larynx), erythema, and swelling are the most common findings in the nonspecific form of laryngitis. Pus may be present in cases of bacterial infection.

• Many conditions may look similar, such as histoplasmosis and blastomycosis, which are 2 fungal infections that may mimic tuberculosis or squamous cell cancer of the larynx.

• The epiglottis and vocal cords must be examined. The latter must be assessed during phonation.

• Stroboscopic examination helps determine if the mucosal stiffness is secondary to epithelial hyperplasia or chronic inflammation.

Cigarette smoke is chronically irritating to the laryngeal mucosa. At the extreme, it can provoke cancer.

Ethanol contains many impurities, such as mycotoxins, tannins, aldehydes, and pesticides, which may cause cancer, either by direct contact with the mucosa or through a systemic effect, or may act as an irritant.

Gastroesophageal reflux disease

Chronic laryngitis associated with GERD is particularly important. The irritant is the gastric content, and the most significant part of the injury occurs at night when patients lie down.

The posterior wall of the larynx is mainly involved in the common and mild forms of GERD, although the process can involve any part of the upper respiratory tract epithelium. Diagnosis can be made after excluding other causes and after confirming the condition with appropriate pH studies. Reflux from any cause can elicit chronic laryngitis.

Infections

The bacterium most commonly isolated in chronic infectious laryngitis is Staphylococcus aureus. Haemophilus influenzae and pneumococcal species may complicate the course of viral laryngitis.

In a retrospective study of 15 patients with infectious laryngitis, by Thomas et al, cultures revealed the presence of methicillin-sensitive Staphylococcus aureus, methicillin-resistant S aureus, Pseudomonas aeruginosa, and Serratia marcescens, along with normal respiratory flora. ^[3]  A study by Carpenter and Kendall reported that of 23 patients with chronic bacterial laryngitis, seven (30.4%) were found to be infected with methicillin-resistant Staphylococcus aureus. ^[4]

Tuberculosis, caused by infection with the tubercle bacillus Mycobacterium tuberculosis hominis, was a common disease of the larynx. Overall incidence has declined. The hematogenous route and the infected sputum from pulmonary tuberculosis are the most likely sources of infection.

Leprosy, caused by infection with Mycobacterium leprae (also known as Hansen bacillus): This acid-fast bacilli has a propensity to invade nerves and to affect the larynx, primarily the epiglottis. The portal of entry is thought to be the nasal mucosa; hence, nasal perforation is common. The larynx is the second most commonly affected part.

Syphilis, caused by the spiral bacterium Treponema pallidum: Syphilis has 3 stages of disease, as follows: primary, in which the chancre is the main clinical finding; secondary, in which systemic and cutaneous involvement predominate; and tertiary, in which destructive noninfectious processes are prevalent. The larynx is involved in the secondary and tertiary stages. Laryngeal involvement in congenital syphilis is similar to that seen in secondary syphilis.

Rhinoscleroma is caused by the gram-negative rod Klebsiella rhinoscleromatis.

Actinomycosis, a granulomatous disease caused by the anaerobic gram-positive bacteria Actinomyces israelii, is part of the normal oropharyngeal flora and may manifest as an abscess.

Viruses, although most important in determining viral laryngitis, play a minor role in the etiology of chronic laryngitis.

Fungal infections are very common. Patients who are immunocompromised, either naturally or as a consequence of a pharmacologic treatment, are mainly affected. Fungi can be found on the mucosal surface of the larynx, or they can invade it. Immunosuppression can be congenital or acquired and can be derived from AIDS. Immunosuppression can be drug induced (eg, antibiotics, steroids, chemotherapeutic agents) or secondary to radiation therapy.

A case study and literature review by Worrall et al found that out of 29 cases of laryngeal cryptococcosis, each of which involved persistent or progressive hoarseness, 28% of patients were immunocompromised, while, prior to infection, 67% of the immunocompetent patients had used nebulized or inhaled corticosteroids. ^[5]

Candidal laryngitis almost invariably manifests with pharyngitis due to superficial colonization of the mucosa; the oral cavity is often involved. When a patient takes inhaled steroids, the larynx can be the only site involved.

Invasive infections can occur as with blastomycosis and histoplasmosis, which are endemic conditions in certain areas of the world. In the United States, Histoplasma capsulatum and Blastomyces dermatitis are prevalent in the Ohio River area (histoplasmosis) and in the southwestern United States (blastomycosis).

Paracoccidioidomycosis, coccidiosis, aspergillosis, and rhinosporidiosis represent other fungal organisms that are less frequently involved in the development of chronic fungal laryngitis.

Although no endemic laryngeal parasitic infections exist in the United States, sporadic cases may affect foreign travelers with local organisms and with leishmaniasis and sporotrichosis.

Kania et al reported of a primary MALT lymphoma of the larynx associated with extraesophageal reflux, chronic laryngitis, and gastric Helicobacter pylori infection. ^[6]

Other

Voice abuse can be pertinent to professional singers and to occasional shouters. Lesions can range from simple edema, in the occasional abuser, to hyperplastic reactions if the stimuli persist over time.

Allergic responses of immediate or delayed hypersensitivity types can cause chronic laryngitis. ^[7] Although the authors found no data quantifying the exact number of people affected, current thought seems to indicate an increasing prevalence.

Environmental factors, such as dust, fumes, chemicals, and toxins, can cause this condition.

Chronic laryngitis has been diagnosed in many people who 20 years earlier inhaled sulfur mustard, an alkylating warfare agent used in the Iran-Iraq war (1983-88). ^[8]

Systemic diseases

Systemic diseases, mostly autoimmune, may cause chronic laryngitis. They include the following:

• Wegener granulomatosis: Inflammation and granulomas may affect the larynx. It can be localized, involving only the upper airways. Clinically, patients may present with hemoptysis and stridor and upper airway stenosis of unexplained etiology, depending on the degree of involvement. Biopsy is not always diagnostic.

• Amyloidosis: Amyloid deposition can involve the larynx and the upper aerodigestive tract. Patients may present with symptoms of upper airway obstruction, dyspnea, and hoarseness. The amyloid can cause vascular fragility and consequent bleeding.

• Relapsing polychondritis: Adults in the fifth decade are mostly affected. They may present with hoarseness, airway obstruction, and pain. Clinically, the larynx can be tender. Symptoms and signs are secondary to inflammation and swelling of the glottic and subglottic areas. Repeated inflammation may result in tracheomalacia.

Cutaneous diseases

The larynx and the skin share similar microcharacteristics and macrocharacteristics. Pemphigus, Stevens-Johnson syndrome, systemic lupus erythematous, and epidermolysis bullosa are among the most important conditions.

Systemic lupus erythematous may manifest with laryngeal ulceration, erythema, and edema. Rheumatoid type nodules and necrotizing vasculitis can be seen.

With rheumatoid arthritis, the joints and the mucosa of the larynx can be affected to the same extent that other parts of the body are affected.

Neurologic causes

Neurologic causes may contribute to chronic laryngitis. Two branches of the vagus nerve supply the larynx, the superior laryngeal nerve and the recurrent laryngeal nerve (RLN). Alterations of the nerve supply and the larynx muscles determine abnormal motility of the various components of the larynx with resultant irritation.

Possible outcomes include the following:

• Unilateral paralysis of the vagus nerve or the RLN

• Bilateral abductor paralysis, in almost all cases caused by extensive thyroid surgery, with injury to the RLN

• Superior laryngeal nerve paralysis, most often secondary to thyroidectomy or supraglottic laryngectomy

Additional causes

Spastic dysphonia is a discrete vocal disorder characterized by strained, choked vocal attacks (laryngeal stuttering). The onset usually follows a stressful period in middle life. This condition is probably a vocal expression of psychoneurotic behavior or a CNS and/or proprioceptive disorder of the larynx.

Vocal folds atrophy and lose tension with age, causing changes in phonation. Loss of thyroarytenoid ligament elasticity results in breathiness and loss of breath support because of bowed vocal folds.

Muscular disorders may contribute to chronic laryngitis. Weakness of the larynx and the pharynx is present in one third of patients with myasthenia gravis.

Laryngitis can be secondary to pellagra. ^[9]