This document discusses various causes of laryngeal inflammation including infections of the vocal cords caused by viruses, bacteria, fungi, and other irritants. It describes the clinical features of different laryngeal infections such as laryngitis, epiglottitis, croup and infectious mononucleosis. The management of these conditions involves treatments such as antibiotics, steroids, intubation and vocal rest. Fungal laryngitis is also discussed and diagnosed by laryngoscopy and biopsy.

1. Acute infections of the larynx
Larynx is lying just anterior to the upper end of the digestive tract. It is there vernable to various
causes of inflammation, not all of which are infective. Gastro-oesophageal disease is now a well-defined
clinical entity that is associated with posterior glottic & arytenoids inflammation.
Inflammation affecting the vocal cords can be induced by vocal misuse/abuse, exposure to irritants
& allergies. General clinical features includes:
1. Change or loss of voice;
2. Difficulty in breathing/stridor;
3. Sore throat &otalgia;
4. Difficult orpainful swallowing;
5. Tender larynx with or without cervical lymadenopathy.
Stridor occurs if there is significant airway narrowing & therefore much more likely to present in
children. Inspiratory stridor occurs with narrowing of the supraglottis or glottis. Expiratory stridor
implies narrowing of the subglottis.
Acute laryngitis
Acute laryngitis is a common inflammatory condition that affects the vocal cords & supraglottis. The
usual cause is a virus associated with an upper respiratory tract infection but laryngitis may also be
secondary to infection of the tonsils or the chest. Inhalations of dusts & fumes or underlying allergy
can induce laryngeal inflammation & may facilitate the development of acute laryngeal infection.
Pathophysiology
Why acute laryngitis occurs only in some & not all patients with a common cold is not fully
understood. It has been suggested that moraxella catarrhalis is involved in association with common
cold .
Clinical feature
Acute viral laryngitis is normally a self-limiting infection that resolves after a few days. Voice changes
are preceded by the symptoms of a common cold & sore throat. Voice will have a rough & deep
voice.
Examination will show erythema & oedema of the vocal cords & there may be excess secretions.
Management
Acute laryngitis usually resolves completely over one to two weeks & investigation is unnecessary.
Basic therapy includes,vocal rest, avoidance of irritant & steam. & maintain good hydration.
Penicillin has no effect, but erythromycin which is active against Moraxella catarrhalis.
Speech therapy is indicated if the problem persists.

2. Adult epiglottitis
Epiglottitis or supraglottitis is an acute infection of the supraglottis that affect primarily the epiglottis
but also lingual tonsil, aryepiglottic folds & false cords.
Epiglottitis affects all age groups. The main difference in children compared to adults is that acute
epiglottitis progresses very rapidly & compromises the airway.
There have been marked decrease in paediatric epiglottitis since the introduction of vaccination
against Haemophilus infleuenzae type B(Hib vaccine) to prevent childhood meningitis.
Microbiology
Prior to vaccination, haemophilus influenza type B was the commonest pathogen especially in
children.
Group A Streptococccus, Streptococus pneumonia, staphylococcus aureus & Klelbsiella pneumonia.
Recently neisseria meningitides has been recognized as a cause of fulminant life-threatening
suptraglottitis.
Clinical features
The patients often complain of an acute painful sore throat, dysphagia, & odynophagia.
Examination usually reveals a red swollen epiglottis & larynx is extremely tender. Cervical
lymphadenopathy is common. Drooling , respiratory distress, hoarseness of voice, oedema of
palatine arches & uvula may also been seen. Stridor is uncommon but tachycardia that is
disproportionate to the pyrexia is an important sign that precedes airway obstruction.
Investigations
The white cells count is important & significant elevation is likely to occur in patients with impending
airway obstruction.
Blood culture & throat swab culture are often negative.
Plain x-ray soft tissue lateral view shows thickening of epiglottis( thumb sign) & absence of deep
vallecula(valeculla sign).
Management
Once suspected or diagnosed, the patient should be admitted & observed. Airway obstruction is
potentially life threatening & intubation should be considered before the airway becomes seriously
compromised.or tracheostomy.
Intravenous antibiotic & 100% humidified oxygen. Choice of antibiotics are 2nd or 3rd generation
cephalosporins.
Complications
Death due to acute airway obstruction. Epiglottic abscess, pulmonary oedema & thrombosis of the
internal jugular vein(Lemierre’s syndrome).

3. Best clinical practice
Adults with suspected acute epiglottitis should be admitted & airway closely monitored.
Patients should be treated with intravenous second or third generation cephalosporin & 100&
humidified oxygen.
Airway obstruction should be treated early, ideally by intubation.
Laryngotracheobronchitis or croup
Croup is an Scottish word for sore throat with harsh breathing . it is an acute illness with hoarseness,
a barking cough, stridor & varing degree of airway distress.
Croup affects mainly young children, aged six months to three years in which subglottic oedema
leads to early respiratory distress & biphasic stridor.
Laryngotracheobronchitis is usually caused by a viral infection. The paramyxoviruses, parainfluenza
virus type I & II are commomly implicated but in adult infection may alsooccur from herpes simplex,
cytomegalovirus, inflenzae virus.
The characteristic feature of this specific form of laryngitis is subglottic oedema. The inflammatory
response & migration of dendritic cells, neutrophils, lymphocytes is much greater in the subglottis
compared to glottis.
Clinical features
The illness usually present with a cough , sore throat, malaise & mild fever for 2 to 4 days.
Endoscopic appearance of the larynx will show a normal epiglottis, inflamed vocal cords& subglottis
extending into the trachea.
Investigation
Direct viral antigen detected by sampling mucus from the nasopharynx may be helpful in identifying
the viral pathogen.
A plain neck radiography may show narrowing of the subglottis.
Management
Oxygen , steroids & nebulized epidrine should be administered. Intubation considered if airway is
impaired. Broad spectrum antibiotics are advisable to cover secondary infection.
Best clinical practice
Adult croup is rare but can be rapidly progressive & cause significant airway obstruction. Once
suspected, patients should be admitted & closely monitored.
The larynx & subglottis should be inspected by a flexible endoscope or bronchoscope.
Broad spectrum antibiotic are advisable to prevent bacterial infection.
If the airway deteriorates, the patient should be intubated & ventilated.

4. Infectious mononucleosis
Infectious mononucleuosis is a common disease that is often subclinical or mild. It is caused by the
Epstein-Barr virus that has a special affinity for B lymphocytes. Spread is usually by transfer of
infected saliva during kiss & the condition is therefore most likely seen in adolescents & young
adults.
Clinical features
The characteristic features include an acute sore throat with large red infected tonsils, cervical
lymphadenopathy with grossly enlarge bilateral lymph nodes, pyrexia, general malaise. There may
be palatal petechiae, ulceration, splenomegaly & hepatomegaly.
Investigation
A full blood count
The heterophil antibody test is highly specific. If negative should be repeated. If still negative,
specific EBV serology should be requested together with serology for HIV, cytomegalovirus, rubella,
toxoplasma.
Management
Intravenous fluids & analgesia.
If severe infection, antibiotic/ steroids/acyclovir should be considered. Ampicillin& amoxicillin should
be avoided for fear of inducing maculopapular rash.
Mycotic laryngitis
Most fungal infections of the larynx are caused by inhalation of the fungus associated with a
breakdown in normal tissue defence mechanism.
Most laryngitis with the exception of candida infection usually causes ulceration. Infections from
candida & aspergillus are widespread but coccidioidomycosis, blastomycosis & histoplasmosis are
endemic to specific geographical area.
The characteristic finding in the larynx is a white pseudomembrane or adherent white plaque that
looks like the same as leukoplakia. It can also appear as diffuse erythema, with oedema, & ulceration
in severe cases.
Invasive aspergillosis is an opportunistic infection that occurs mainly in immunocompromised
patients with haematological malignancies.
Investigation
Direct laryngoscopy & biopsy may be necessary to confirm diagnosis. Tissue sample should be sent
for special fungal stains such as methenamine silver & periodic acid-schiff to identify the fungal
hyphae.
Treatment
Itraconazole particularly effective for aspergillus infection.

5. Fluconazole for candida infections.
Ketaconazole for histoplasmosis & blastomycosis.
Amphotericin B for mucormycosis.(it has significant adverse effects on the kidney, heart, liver).

6. Fluconazole for candida infections.
Ketaconazole for histoplasmosis & blastomycosis.
Amphotericin B for mucormycosis.(it has significant adverse effects on the kidney, heart, liver).