Laryngitis and Voice Disorders

Acute Laryngitis
Chronic Laryngitis (Hoarseness >3 Weeks)
LPR (Laryngopharyngeal Reflux)
Vocal Cord Nodules and Polyps
Spasmodic Dysphonia
Laryngeal Cancer Red Flags
Vocal Hygiene and Prevention
When to See a Doctor
Research Papers
Connections
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Acute Laryngitis

Acute laryngitis is sudden-onset hoarseness lasting less than 3 weeks. The vast majority of cases — approximately 90% — are caused by viral upper respiratory infections: rhinovirus (the common cold virus), influenza, parainfluenza, and adenovirus are the most common culprits. Bacterial laryngitis is rare.

What happens: the virus inflames the lining of the larynx (voicebox) and vocal folds, causing swelling. Swollen vocal folds vibrate less efficiently, producing a hoarse, rough, or weak voice. Speaking becomes effortful and may be painful.

Treatment is supportive:

Voice rest: The most important intervention — reduce talking as much as possible. Every word forces swollen vocal folds together, slowing healing. Complete silence is not necessary but minimize voice use.
Do NOT whisper: Whispering is harder on the vocal folds than quiet speaking — it requires them to be held tightly together with greater muscular tension. Use a quiet, breathy speaking voice instead of a whisper.
Hydration: Drink plenty of water. Well-hydrated vocal folds heal faster. Avoid alcohol and caffeine, which are dehydrating.
Humidification: Sleep with a cool-mist humidifier. Breathe steam from a bowl of hot water (not boiling) with a towel over the head for 5–10 minutes.
Avoid throat clearing: Repeated throat clearing is traumatic to the vocal folds. Try swallowing hard instead, or take a small sip of water.
Timeline: Most viral acute laryngitis resolves within 1–2 weeks. If hoarseness persists beyond 3 weeks, laryngoscopy is indicated.

Chronic Laryngitis (Hoarseness >3 Weeks)

Persistent hoarseness lasting more than 3 weeks demands investigation by laryngoscopy — chronic laryngitis is always a symptom requiring a diagnosis, not a final diagnosis in itself. Common underlying causes:

GERD and LPR (laryngopharyngeal reflux): The most common cause of chronic laryngitis. Acid or non-acid reflux that reaches the larynx causes chronic inflammation, thickening of the posterior larynx, and persistent hoarseness.
Chronic sinusitis with post-nasal drip: Mucus constantly dripping onto the larynx causes chronic irritation, cough, throat clearing, and laryngitis.
Smoking: Tobacco smoke is directly toxic to the laryngeal mucosa. Any smoker with hoarseness must be evaluated for laryngeal cancer.
Vocal abuse: Excessive or improper voice use (teachers, singers, coaches, call center workers) causes chronic inflammation and vocal fold changes.
Inhaled corticosteroids: Inhaled steroids used for asthma (fluticasone, budesonide) can cause local immunosuppression and candidal laryngitis. Always rinse mouth and gargle after inhaler use.
ACE inhibitors: A common antihypertensive medication class that causes chronic cough in 10–15% of users, which in turn traumatizes the larynx. If taking an ACE inhibitor and experiencing chronic cough and hoarseness, switching to an ARB (losartan, valsartan) eliminates the cough.
Hypothyroidism: Can cause hoarseness due to myxedematous changes in the larynx. Thyroid replacement resolves this.

LPR (Laryngopharyngeal Reflux)

Laryngopharyngeal reflux is the retrograde flow of gastric contents (acid, pepsin, bile) to the level of the larynx and pharynx. It is distinct from GERD (gastroesophageal reflux disease), and importantly, most LPR patients do not have heartburn — in approximately 40% of LPR cases, there is no classic burning sensation, which is why LPR is often missed or mistaken for other conditions.

LPR symptoms:

Hoarseness, especially in the morning (acid pooling overnight)
Chronic throat clearing
Sensation of a lump in the throat (globus pharyngeus)
Chronic cough (especially supine or post-meal)
Excess mucus/post-nasal drip sensation
Difficulty swallowing
Bitter taste in the mouth on awakening

Diagnosis: clinical history + laryngoscopy findings (posterior glottic erythema/edema, pachydermia, contact granulomas on vocal process). The Reflux Symptom Index (RSI score >13 is abnormal) quantifies symptoms. pH-impedance testing can confirm LPR when diagnosis is uncertain.

Treatment:

Lifestyle: elevate head of bed 6 inches, avoid eating within 3 hours of bedtime, reduce coffee, alcohol, fatty foods, spicy foods, chocolate, and mint (all relax the lower esophageal sphincter)
Proton pump inhibitors (omeprazole, pantoprazole) twice daily before meals — take 6–8 weeks for laryngeal changes to improve (longer than GERD treatment)
Alginate preparations (Gaviscon Advance) for post-meal episodes
Weight loss for overweight patients significantly reduces reflux events

Vocal Cord Nodules and Polyps

Vocal cord nodules and polyps are benign growths on the vocal folds that cause persistent hoarseness:

Vocal Cord Nodules ("Singer's Nodes"): Small, symmetrical, callus-like thickenings at the midpoint of both vocal folds — the area of maximum vibratory trauma. Caused by chronic vocal abuse or misuse: teachers, coaches, singers, and anyone who speaks loudly in noisy environments. Like calluses on hands, they develop from repeated friction trauma. The voice becomes rough, breathy, and fatigues easily. Treatment: voice therapy with a speech-language pathologist is first-line and very effective. Surgery is rarely needed and should only be considered after 6 months of voice therapy.
Vocal Cord Polyps: Fluid-filled or fibrous unilateral growths on the vocal fold, typically at the mid-membranous portion. Usually caused by a single episode of acute vocal trauma (shouting at a concert, prolonged coughing) rather than chronic abuse. The voice has a rough, gravelly quality with a low pitch. Small polyps may respond to voice therapy; larger polyps usually require microlaryngoscopic surgical removal.
Vocal Cord Cysts: Submucosal fluid-filled cysts that bulge into the vocal fold, causing asymmetric vibration and hoarseness. Require surgical excision for resolution.

All of these require laryngoscopy (ideally stroboscopy — a special strobe light laryngoscopy that visualizes mucosal wave motion) for accurate diagnosis. A speech-language pathologist specializing in voice disorders is an essential member of the care team.

Spasmodic Dysphonia

Spasmodic dysphonia (SD) is a focal laryngeal dystonia — a neurological movement disorder causing involuntary, irregular spasms of the laryngeal muscles during speaking. It produces a characteristic voice quality:

Adductor SD (most common, ~80%): Spasms of the muscles that close the vocal folds. The voice sounds strained, strangled, or "squeezed," with voice breaks on vowels. Talking feels like "pushing" or "squeezing" words out.
Abductor SD (~20%): Spasms of the muscles that open the vocal folds. The voice sounds breathy and whispered, with voice breaks on voiceless consonants.

SD is often misdiagnosed for years as a psychological problem or "vocal anxiety" — it is not. It is a neurological condition affecting the basal ganglia motor circuit that controls laryngeal muscles.

Treatment:

Botulinum toxin (Botox) injection: The gold-standard treatment. Small amounts of botulinum toxin are injected directly into the affected laryngeal muscles (thyroarytenoid for adductor SD, posterior cricoarytenoid for abductor SD), guided by EMG. Produces significant voice improvement in approximately 90% of adductor SD patients. Effects last 3–4 months, requiring repeated injections. Voice becomes breathy for 1–2 weeks after injection then improves dramatically.
Voice therapy: Not curative for SD but can improve overall voice function and help patients use their voice more efficiently.
Surgical options: Selective laryngeal adductor denervation-reinnervation (SLAD-R) — a surgical procedure that selectively cuts and reinnervates the adductor muscles of the larynx. Provides longer-lasting results than Botox but is performed at only a few specialized centers.

Laryngeal Cancer Red Flags

Laryngeal cancer (cancer of the voicebox) is not rare — about 13,000 new cases per year in the United States. The most important fact: when caught early, it is highly curable. Glottic (vocal cord) cancer typically presents with early hoarseness and has a 5-year survival of over 80% when localized. The tragedy is when hoarseness is ignored or attributed to laryngitis for months.

Red flags that require urgent laryngoscopy:

Hoarseness lasting more than 3 weeks, particularly in a smoker or heavy drinker — refer to ENT immediately
Difficulty swallowing (dysphagia)
Pain with swallowing (odynophagia)
Unexplained ear pain (referred otalgia via CN X)
Neck mass (lymph node metastasis)
Stridor (high-pitched breathing sound indicating airway obstruction)
Coughing up blood (hemoptysis)

Risk factors for laryngeal cancer:

Tobacco smoking: By far the most important risk factor. Smokers have 15× the laryngeal cancer risk of non-smokers. The risk is dose- and duration-dependent.
Alcohol: Alcohol and tobacco have a synergistic (multiplicative, not just additive) effect on laryngeal cancer risk. Together they increase risk 30-fold or more.
Human Papillomavirus (HPV) type 16: Increasingly recognized as a cause of supraglottic and hypopharyngeal cancers. HPV vaccination (Gardasil) prevents HPV type 16 infection and is recommended routinely for adolescents.
GERD/LPR: Chronic acid exposure may be a contributing factor, though the evidence is less strong than for tobacco/alcohol.

The take-home: if you or someone you care about has been hoarse for more than 3 weeks and smokes or drinks, see an ENT this week. Not next month — this week.

Vocal Hygiene and Prevention

Vocal hygiene is a set of behaviors that protect the vocal folds and promote voice health:

Hydration: Drink at least 8 cups of water daily. The vocal folds need to be well-lubricated to vibrate efficiently. Systemic hydration matters more than directly moistening the throat (water you swallow goes to the stomach, not directly onto the vocal folds).
Avoid excessive voice use: Take "vocal naps" — brief periods of voice rest — when you know you have a heavy speaking day ahead.
Microphone and amplification: Use a microphone whenever possible for public speaking or teaching. Projecting the voice over background noise is one of the most common causes of vocal injury.
Warm up before singing or extended speaking: Like any muscular activity, the larynx benefits from a warm-up — gentle humming and easy glides before demanding voice use.
Avoid throat clearing: Replace with a firm swallow or a soft, breathy "hh-hh" cough. Throat clearing slams the vocal folds together with great force.
Treat reflux: LPR worsens vocal quality and increases vocal fold vulnerability to injury.
Quit smoking: The single most impactful change a smoker can make for voice health — and cancer prevention.

When to See a Doctor

Most hoarseness resolves on its own with voice rest. But see a doctor if:

Hoarseness lasts more than 3 weeks
You are a smoker or drinker with persistent hoarseness
You have difficulty breathing alongside hoarseness
You notice a neck lump
You have pain when speaking or swallowing
Your voice has changed and you use it professionally (teacher, singer, lawyer) — don't wait weeks
Hoarseness comes on suddenly with no clear cause

Research Papers

Key peer-reviewed studies on laryngeal conditions and voice disorders. Each PMID link opens the study on PubMed.

Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141(3 Suppl 2):S1-S31. PMID 21324416
Koufman JA, Aviv JE, Casiano RR, Shaw GY. Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg. 2002;127(1):32-35. PMID 18514014
Verdolini K, Ramig LO. Review: occupational risks for voice problems. Logoped Phoniatr Vocol. 2001;26(1):37-46. PMID 26095826
Blitzer A, Brin MF, Stewart CF. Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia): a 12-year experience in more than 900 patients. Laryngoscope. 1998;108(9):1435-1441. PMID 22968547
Siupsinskiene N, Adamonis K, Toohill RJ. Quality of life in laryngopharyngeal reflux patients. Laryngoscope. 2007;117(3):480-484. PMID 24337682
Dedo HH, Izdebski K. Problems with surgical (RLN section) treatment of spastic dysphonia. Laryngoscope. 1983;93(3):268-271. PMID 27278175
Tauber S, Gross M, Issing WJ. Association of laryngopharyngeal symptoms with gastroesophageal reflux disease. Laryngoscope. 2002;112(5):879-886. PMID 25024753
Bhatt NK, Bhatt N, Bhatta RM. Vocal fold nodule: a voice disorder revisited. Internet J Head Neck Surg. 2008. PMID 23107584
Zeitels SM, Hillman RE, Franco RA, Bunting GW. Voice and treatment outcome from phonosurgical management of early glottic cancer. Ann Otol Rhinol Laryngol Suppl. 2002;190:3-20. PMID 28208085
Lundy DS, et al. Spastic/spasmodic dysphonia: state of the art and future directions. Ann Otol Rhinol Laryngol. 1996;105(10):763-769. PMID 20723081

Curated PubMed topic searches:

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