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Chronic laryngitis in detail according to standard ENT textbook

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Chronic Laryngitis - A Detailed Account

Based primarily on Scott-Brown's Otorhinolaryngology Head & Neck Surgery and Cummings Otolaryngology Head and Neck Surgery

Definition and Overview

Chronic laryngitis is a persistent inflammatory condition of the laryngeal mucosa lasting more than three weeks, presenting with unrelenting dysphonia. It is not a single entity but a heterogeneous group of conditions unified by the common end point of chronic laryngeal inflammation. The distinction between acute and chronic laryngitis is not always strict - many acute processes may contribute to or evolve into chronic dysfunction.

Classification

Chronic laryngitis can be broadly divided into:

1. Non-Specific (Non-Infectious) Chronic Laryngitis

The most common type in clinical practice. Includes:
  • Simple chronic laryngitis
  • Laryngopharyngeal reflux (LPR) / Reflux laryngitis
  • Reinke's oedema (polypoid degeneration)

2. Specific Chronic Infectious Laryngitis

  • Bacterial: S. aureus superinfection, rarely specific organisms
  • Fungal (Mycotic): Candida, Aspergillus, Blastomyces, Histoplasma, Coccidioides, Cryptococcus
  • Mycobacterial: Laryngeal tuberculosis
  • Other: Syphilis, Scleroma

3. Autoimmune / Systemic Disease

  • Pemphigus / Pemphigoid
  • Granulomatosis with Polyangiitis (Wegener's)
  • Relapsing polychondritis
  • Sarcoidosis / Amyloidosis

4. Radiation-Induced Chronic Laryngitis

5. Chronic Laryngitis in the Immunocompromised Host

Aetiology

The aetiology is generally multifactorial. The main factors are:
1. Smoking - The single most commonly implicated aetiological factor. The type, frequency, and duration of smoking should be documented. Smoking causes both direct mucosal irritation and carcinogenic risk. It also causes the confounding scenario of a background of chronic laryngitis that may mask underlying dysplasia or malignancy.
2. Voice Misuse and Abuse - Prolonged voice use in irritating or noisy environments, without adequate rest periods, generates secondary inflammatory changes that can become chronic if the pattern repeats. This is especially relevant in professional voice users (teachers, singers, lawyers).
3. Laryngopharyngeal Reflux (LPR) / Gastro-Oesophageal Reflux Disease (GORD) - The third major aetiological factor. Two pathophysiological mechanisms operate:
  • Direct contact: Acidic refluxate (including pepsin, bile) from the stomach crossing the upper oesophageal sphincter causes direct inflammatory injury to the laryngeal mucosa. Pepsin maintains damaging activity even at pH above 4 and can be reactivated after a period in a neutral pH environment - challenging the strategy of simply neutralizing gastric acid.
  • Vagal reflex: Acidification of the distal oesophagus triggers a vagally mediated reflex causing chronic coughing and throat clearing, which in turn traumatizes the larynx indirectly.
  • El-Serag and Sonnenberg demonstrated in a large controlled series (n = 101,366 patients with erosive oesophagitis) a statistically significantly higher odds ratio for laryngitis (OR 2.1; 95% CI 1.53-2.63).
4. Environmental factors - Industrial fumes, dust (asbestos, cement), air pollution, allergens, and atmospheric conditions.
5. Bacterial biofilm - The role of bacteria remains debated. H. pylori has been identified in patients with chronic laryngitis and laryngeal cancer, raising questions about whether eradication strategies should be employed.
6. Alcohol - Works synergistically with smoking as a direct mucosal irritant and carcinogen.

Clinical Presentation

Symptoms

The key symptom is dysphonia - alteration in voice quality, typically:
  • Rough or coarse voice
  • Gradual, insidious onset over months to years
  • Overall reduction in pitch
  • Persistent - the voice is seldom, if ever, completely normal
  • True aphonia is rare
Associated symptoms may include:
  • Dysphagia (difficulty swallowing)
  • Globus pharyngeus - a sensation of something in the throat
  • Throat discomfort or ache
  • Persistent throat clearing or non-productive cough
  • Halitosis
  • Unusual or bitter taste
  • Otalgia (referred pain)
  • Water brash or indigestion (suggesting reflux)
  • Excess catarrh

Impact on Quality of Life

The chronicity of the condition and its relationship to habitual factors (e.g., smoking) creates a substantial burden. Dysphonia significantly impairs the quality of life across professional and social spheres - this is measurable using tools like the Voice Handicap Index (VHI).

History Taking - Key Elements

Beyond the presenting complaint, a structured history must address:
  • Smoking: Type (cigarettes, cigars, pipe), quantity, duration
  • Reflux history: Heartburn, upper GI investigations (gastroscopy, pH monitoring, manometry), prior GI surgery
  • Occupation: Working environment, fumes, noise levels requiring raised voice
  • Social habits: Alcohol, dust exposure, social environments
  • Allergies: Upper and lower airway
  • Co-morbidities: Radiation therapy to head and neck; immunosuppression; diabetes; systemic diseases (tuberculosis, sarcoid, GPA/Wegener's)
  • Professional voice use: Teachers, singers, barristers - whose livelihood depends on their voice

Diagnosis and Examination

Outpatient Assessment

The majority of diagnoses are made in the outpatient setting using flexible fibreoptic nasendoscopy or video-stroboscopy.
Laryngoscopic findings in non-specific chronic laryngitis:
  • Diffuse inflammatory picture
  • Widespread irregular mucosa
  • Variable oedema, erythema, and exudate
  • Distortion of normal anatomical features in a diffusely irregular and swollen manner
  • In severe cases, the mucosal surface may be obscured by dried, crusted exudate
A key clinical decision in every patient is whether cancerous or pre-cancerous elements are present, particularly in smokers. If the appearances cannot be stated unequivocally as benign, operative assessment is required.

Assessment Tools for Reflux

  • Reflux Symptom Index (RSI): A validated 9-item self-administered outcome instrument for LPR, described by Belafsky et al. Scores above 13 indicate LPR
  • Reflux Finding Score (RFS): Scored endoscopic tool for assessment of laryngopharyngeal changes
  • 24-hour oesophageal pH monitoring / impedance studies

Operative Assessment (Microlaryngoscopy Under GA)

Indicated in the following situations:
  • Any area suspicious for dysplastic change or malignancy
  • Co-existent discrete pathology (vocal cord polyp) requiring surgery
  • Inability to adequately examine the larynx in the outpatient (poor compliance, crusting obscuring the view)
  • Failure to respond to medical treatment
Technique: Patient examined with 0, 30, and 70-degree rod lens endoscopes. For ventilation, options include:
  • Microlaryngeal tube (size 5/5.5) - secure but partially obstructs view
  • Supraglottic jet ventilation - unobstructed view but CO2 monitoring is difficult
  • Subglottic jet ventilation (Hunsacker Mon-jet system) - compromise with better view and more controlled ventilation; end-tidal CO2 can be monitored
If a discrete lesion is present, excision biopsy is preferred using cold instrumentation. For diffuse changes, a representative biopsy should be taken from an area unlikely to affect the voice - the superior superolateral aspect of the true vocal cord or the supraglottis. In severe cases, laryngeal irrigation with saline may be necessary before biopsy.

Histological Features

(Scott-Brown's Otorhinolaryngology)
Microscopy reveals:
  • Benign mucosa usually covered by squamous epithelium of variable thickness with a tendency to keratinization
  • Active changes in the epithelium without convincing epithelial dysplasia
  • Lamina propria: Oedematous, containing a chronic inflammatory infiltrate of variable intensity (lymphocytes, macrophages)
  • A light scattering of acute inflammatory cells
  • Patchy permeation of the surface epithelium by inflammatory cells
  • Variable degree of fibrosis of the lamina propria
  • Prominent small vascular channels

Grading of Dysplasia

Two principal classification systems exist:
  1. WHO grading system: Mild, moderate, and severe dysplasia - widely used but prone to low inter-rater agreement.
  2. Ljubljana classification system: Hyperplastic laryngeal lesions graded as:
    • Simple hyperplasia
    • Abnormal hyperplasia
    • Atypical hyperplasia ("risky epithelium")
    • Carcinoma in situ
    In a retrospective study of 4,574 lesions by Gale et al., malignant transformation in atypical hyperplasia was 11.6% vs. only 0.3% in the simple/abnormal group.
  3. Current terminology (updated): Low-grade squamous intraepithelial neoplasia (SIL), high-grade SIL, carcinoma-in-situ.

Specific Types of Chronic Laryngitis

Chronic Bacterial Laryngitis

  • Most bacterial laryngitis is acute, but chronic disease can arise - particularly as superinfection complicating intubation injuries or larynges damaged by relapsing polychondritis
  • Presents with prolonged hoarseness and stridor lasting >1 month, with purulent chondritis
  • S. aureus is the most common pathogen
  • Lipopolysaccharide of bacterial origin induces IL-8 expression and alters mucin gene expression in laryngeal goblet cells
  • Management: Culture, surgical drainage of abscess spaces; hyperbaric oxygen for chondroradionecrosis should be considered

Chronic Fungal (Mycotic) Laryngitis

The larynx may become chronically infected with pathogenic fungi. Up to 15% of patients with chronic laryngitis have mycotic lesions on examination.
Organisms (in order of prevalence):
  • Candida albicans - Most common; characteristic finding is a white pseudomembrane or adherent white plaque that can be mistaken for leukoplakia. Also appears as diffuse erythema with oedema in severe infection.
  • Aspergillus - Opportunistic; occurs mainly in immunocompromised patients with haematological malignancies
  • Blastomyces (blastomycosis) - Endemic in the southern US; enters via inhalation, spreads haematogenously; laryngeal involvement in <5% of cases; shows broad-based budding yeast on fungal stains
  • Histoplasma - Treated with ketoconazole
  • Coccidioides, Cryptococcus, Paracoccidioides, Sporothrix
Predisposing factors in immunocompetent patients: Recent antibiotics, inhaled corticosteroids, diabetes, chemotherapy, radiation, smoking, acid reflux, inhalational or thermal trauma.
Investigation:
  • Chest radiograph (to exclude pulmonary fungal disease)
  • Direct laryngoscopy and biopsy in severe presentations / non-responders
  • Special fungal stains: Methenamine silver (GMS) and Periodic acid-Schiff (PAS) to identify hyphae
  • Histology identifies fungus but not species - cultures are needed for speciation
Treatment:
  • Fluconazole (3-4 weeks) - preferred for Candida
  • Itraconazole (100-400 mg/day) - for Aspergillus; levels monitored by blood tests
  • Ketoconazole - agent of choice for Histoplasma and Blastomyces
  • Amphotericin B - IV; reserved for severe cases; significant nephrotoxic, hepatotoxic, and cardiotoxic adverse effects
  • Address and correct underlying predisposing factors; recurrence is likely otherwise

Autoimmune and Systemic Disease

Pemphigus / Pemphigoid:
  • Up to 80% of patients with pemphigus have otolaryngologic signs; 40% are laryngeal
  • Intraepithelial (pemphigus vulgaris) or subepithelial (pemphigoid) autoantibodies cause severe epithelial loss
  • 35% of pemphigoid patients have head and neck involvement; half have laryngeal lesions
  • Laryngeal pemphigus responds well to high-dose corticosteroids combined with immunosuppressives
Granulomatosis with Polyangiitis (GPA, formerly Wegener's granulomatosis):
  • Small- and medium-vessel vasculitis; autoantibodies against proteinase 3 (c-ANCA) or myeloperoxidase (p-ANCA)
  • 90% of patients have head and neck manifestations
  • Most common laryngeal manifestation: Subglottic stenosis (in 20% of cases)
  • 95% of systemic disease patients are ANCA-positive; 75% of localized head and neck disease
  • Treatment: Endoscopic airway dilation or open resection; systemic immunosuppression has not been shown to prevent restenosis
Relapsing Polychondritis (RP):
  • Episodic autoimmune inflammation of glycosaminoglycan-rich cartilage
  • Anti-type II collagen antibodies
  • 25-50% of patients demonstrate laryngeal dysfunction ranging from hoarseness, pain, and cough to lethal airway obstruction
  • Treatment: Medical and surgical combination; bacterial superinfection (often S. aureus) may complicate the picture
Sarcoidosis:
  • Noncaseating granulomas throughout the body; laryngeal involvement in <1% of patients
  • Supraglottic involvement is most common
  • The laryngeal appearances can be confused with squamous cell carcinoma
Amyloidosis:
  • Included in the differential diagnosis for unexplained laryngeal dysfunction

Reinke's Oedema (Polypoid Degeneration)

A distinct form of chronic laryngeal inflammation. Pathologically, there is a chronic state of oedema in Reinke's space (the potential space between the vocal ligament and the overlying mucosa) along the membranous portion of both vocal cords from the anterior commissure to the vocal process.
  • Predilection for females in middle age
  • Co-aetiological factors: Smoking and voice abuse
  • Presents with dysphonia and overall reduction in pitch (characteristically low, deep voice)
  • Obstructive symptoms are rare
  • Laryngoscopy: Uniformly, diffusely swollen cords with a bulbous appearance, normal mobility
Treatment:
  • Address predisposing factors (smoking cessation, voice therapy)
  • Surgical: Incision in the superior mucosa of the true vocal cord in its long axis; Reinke's space entered, submucosal fluid aspirated, and excess mucosa trimmed - originally described by Hirano
  • Can be done with cold instruments or CO2 laser; bilateral surgery should not be done simultaneously

Treatment

Non-Surgical (Mainstay)

1. Smoking cessation - The single most important intervention. Crucial both to reduce mucosal irritation and to reduce the risk of malignant transformation.
2. Voice therapy - Carried out by speech and language therapists. Targets voice misuse/abuse patterns and teaches appropriate vocal hygiene. Referral prior to any surgical option is considered good practice. Evidence in support of voice therapy for chronic laryngitis itself is limited, though it is widely used.
3. Anti-reflux therapy:
  • Empirical treatment with PPIs (e.g. Lansoprazole 30 mg twice daily) is widely practised
  • In the pivotal RCT by El Serag et al. (2001), lansoprazole vs. placebo in patients with confirmed chronic laryngitis and GORD: complete resolution of symptoms in 6/11 (lansoprazole group) vs. 1/10 (placebo group, 10%), p<0.05
  • The empirical approach is controversial as most large placebo-controlled trials have not consistently shown benefit for unselected patients; patient selection remains important
  • Alginates (e.g. sodium alginate) can be used as an adjunct, providing a physical barrier
  • Lifestyle modifications: dietary changes, weight loss, head of bed elevation, avoiding large meals before sleeping
4. Lifestyle modification - Alcohol reduction, dietary changes, weight reduction.

Surgical

Surgery is reserved for:
  • Excision of discrete lesions (for histopathological diagnosis)
  • Tissue sampling (where malignancy or dysplasia is suspected)
  • Management of co-existent pathology (polyps, Reinke's oedema)
  • Cases unresponsive to medical management
Surgery should not be used as the primary treatment for diffuse inflammatory change.

Chronic Laryngitis and Malignancy

The relationship between chronic laryngitis and malignancy is a clinical imperative. (Scott-Brown's)
  • A high proportion of patients with chronic laryngitis are smokers, and will therefore be exposed to the carcinogenic effects of tobacco
  • A proportion of these patients will progress to invasive squamous cell carcinoma, likely through a co-existent pathway (dysplastic change co-existing with laryngitis, rather than direct malignant transformation from chronic laryngitis)
  • This co-existence does not reduce the clinical urgency - the level of suspicion and treatment need to be the same
  • Any patient with persistent hoarseness >6 weeks, especially in the context of smoking/alcohol use, must be assessed with laryngoscopy
  • "Red flag" symptoms warranting urgent investigation: persistent unilateral otalgia in a normal ear, intractable throat pain, progressive dysphagia
  • A patient who smokes and drinks with intractable otalgia and evidence of laryngitis cannot be managed with a 3-month wait period - rebiopsy, PET scanning, or CT should be strongly considered even before MDT discussion if a previous biopsy is negative

Radiation-Induced Chronic Laryngitis

One of the commonest causes of chronic laryngitis in a head and neck oncology practice. (Scott-Brown's)
  • Arises as an incremental acute inflammatory reaction during radical radiotherapy that evolves into chronic laryngitis
  • The reaction is dose-dependent but with considerable individual variation
  • Modern radiation delivery techniques (IMRT, etc.) can reduce the dose to the larynx
  • Treatment is based on the same principles as non-specific laryngitis
  • Smoking cessation is especially important - to increase the efficacy of radiotherapy and decrease the severity of chronic laryngitis
  • Acid suppression is appropriate given the debated but plausible role of GORD in laryngeal carcinogenesis

Chronic Laryngitis in the Immunocompromised Host

  • Colonization and infection with Candida albicans is the most common cause
  • Occurs secondary to AIDS, chemotherapy, or long-term corticosteroid use (systemic or inhaled)
  • Appearance: White patches on a friable erythematous mucosa
  • Diagnosis: Culture of laryngeal plaques and secretions
  • Treatment: Nystatin, amphotericin B, or fluconazole

Best Clinical Practice Summary

(Scott-Brown's key points)
  • Chronic laryngitis frequently has a multifactorial aetiology
  • The main aetiological factors are smoking, voice abuse, and reflux disease (LPR and GORD)
  • Following clinical diagnosis, treat with voice therapy, smoking cessation, and anti-reflux treatment
  • Surgery should be used for excision of discrete lesions and tissue sampling only
  • Any intervention must be assessed by some form of outcome measure, preferably patient-centred (e.g., VHI)
  • Chronic infectious processes of the larynx are rare and frequently mimic squamous cell carcinoma - biopsy is required
Sources:
  • Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol. 2 (Chapters on Non-Specific Laryngitis, Histological Features, Chronic Laryngitis and Malignancy, Radiation-Induced Chronic Laryngitis, Immunocompromised Host)
  • Cummings Otolaryngology Head and Neck Surgery (Chapter 61 - Chronic Laryngopharyngitis, Chronic Bacterial/Fungal/Mycobacterial Laryngitis, Autoimmune and Systemic Disease, Reflux Laryngitis)
  • Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol. 1 (Chronic Laryngitis - Medicolegal Context)
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