Progress in Chronic Laryngitis: Improvement in diagnosis but continuing debate

Nonetheless, “chronic laryngitis is inflammation of the larynx; it is not commonly misdiagnosed,” Dr. Sataloff said. But, “its causes commonly are not recognized or are misdiagnosed because of lack of familiarity with some of the etiologies and suboptimal physical examination.” He added that most common mistakes are the results of an incomplete history and inadequate physical exam.

“Practitioners often attach the label of chronic laryngitis when they are unable to identify another cause,” Dr. Klein said. “Some people might be diagnosed with reflux when it is actually allergies, a vocal cord lesion or something worse. Therefore, it is important for patients to undergo a proper voice workup when their cause of hoarseness or laryngitis cannot be identified.”

Dr. Akst said many causes of chronic laryngitis relate to lifestyle rather than infection. “It’s often related to smoking, alcohol use, reflux disease, overuse of the voice [or] exposure to irritants like dust or chemicals or inhalers,” he said. “A lot of the treatment is in counseling patients how to take care of their voices and reduce inflammation.”

He added that another problem is looking only at structure and not function, such as muscle tension dysphonia. “In the absence of stroboscopy, the cords may look normal, with no lesions or paralysis, and the assumption is made that inflammation must be causing the voice complaints,” he said, noting that one role of fellowship- or subspecialty-trained laryngologists is to take that next step and look at vocal cord function.

And then there are the limitations of the sensory system. “As otolaryngologists, we are perpetually frustrated because of the sensory feedback from the esophagus and pharynx to the brain. If you have some sort of noxious stimulus in your throat, you might feel it in your ear,” Dr. Dailey said. “In addition to poor spatial resolution, temporal resolution is poor. The stimulus may have come and gone, but the patient still feels it.”

If misdiagnoses are occurring, Dr. Dailey said, it’s often due to the “general paucity of good diagnostic tools. In an ideal world, we could take biopsies and send them out for genetic analysis. Or maybe we could put stains on the pharynx so that we can see if there are pepsin molecules there. Until then, we’ll continue to have a best guess scenario.”

Differential Diagnosis

• Glottic and subglottic stenosis
• Contact granulomas
• Sulcus vocalis
• Vascular lesions of the vocal fold
• Latrogenic vocal fold scar
• Vocal fold nodules, polyps or cysts
• Functional dysphonia (such as muscle tension)
• Vocal cord paralysis
• Tumors
• Infection
• Lifestyle: smoking, allergies, vocal abuse/misuse, exposure to environmental pollutants or toxins
• Medication side effects
• Chondronecrosis of the larynx

Sources: Drs. Robert Sataloff, MD; Seth Dailey, MD; Kenneth Altman, MD, PhD; Adam Klein, MD; Dale Ekbom, MD; Lee Akst, MD; Jamie Koufman, MD; and Linda Brodsky, MD

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