Acute Laryngitis: Clinical Guidelines

List of Abbreviations

AL – acute laryngitis

ARVI – acute respiratory viral infection

ESR – erythrocyte sedimentation rate

CT – computed tomography

MRI – magnetic resonance imaging

RCTs – Randomized Controlled Trials

Terms and Definitions

Acute laryngitis (AL) – acute inflammation of the laryngeal mucosa lasting up to 3 weeks [1, 2].

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Acute laryngitis (AL) – acute inflammation of the laryngeal mucosa lasting up to 3 weeks [1, 2]. If the disease duration exceeds 3 weeks, an autoimmune etiology of the disease must be ruled out.

Abscess-forming or phlegmonous laryngitis – acute laryngitis with abscess formation, most commonly on the lingual surface of the epiglottis or on the aryepiglottic folds; manifested by sharp pains on swallowing and phonation radiating to the ear, fever, and presence of a dense infiltrate in the laryngeal tissues.

Acute chondroperichondritis of the larynx is an acute inflammation of the laryngeal cartilages, i.e., chondritis, in which the inflammatory process involves the perichondrium and surrounding tissues.

Acute subglottic laryngitis (croup) is an inflammatory process with a specific clinical presentation, localized in the subglottic region with subchordal mucosal edema, breathing difficulty, and dyspnea, which occurs in children aged 6 months to 6 years [1, 3, 4].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Acute inflammation of the laryngeal mucosa may be a continuation of catarrhal inflammation of the nasal or pharyngeal mucosa or occur during an acute upper respiratory tract catarrh, viral respiratory infection, or influenza. Usually, acute laryngitis constitutes a symptom complex of acute respiratory viral infection (ARVI) (influenza, parainfluenza, adenoviral infection), in which the mucous membrane of the nose and pharynx, and sometimes of the lower respiratory tract (bronchi, lungs), is also involved in the inflammatory process. It is known that the microflora colonizing the non-sterile parts of the respiratory tract, including the larynx, is represented by saprophytic microorganisms that practically never cause disease in humans, and opportunistic bacteria capable of causing purulent inflammation under conditions unfavorable to the microorganism.

Microorganisms that are the main causative agents of acute forms of bacterial laryngitis include S. pneumoniae (20-43%) and H. influenzae (22-35%). In addition, Moraxella catarrhalis (2-10%), various species of streptococci and staphylococci are quite frequently isolated, and representatives of the genera Neisseria, Corynebacterium, etc., are much less common [1, 5]. It is also necessary to take into account the fact that, both in acute and chronic forms of ENT infections, microorganisms can be isolated as a monoculture or in various associations.

In the pathogenesis of acute laryngeal edema, anatomical features of the laryngeal mucosa structure play an important role. Impaired lymphatic drainage and local water metabolism are of great importance. Mucosal edema can occur in any part of the larynx and rapidly spread to others, causing acute laryngeal stenosis and threatening the patient's life. The causes of acute inflammation of the laryngeal mucosa are diverse: infectious factors, external and internal trauma to the neck and larynx, including inhalation injuries, foreign body aspiration, allergies, and gastroesophageal reflux disease. Significant vocal load is also important. The development of inflammatory laryngeal pathology is facilitated by chronic diseases of the bronchopulmonary system, nose, paranasal sinuses, metabolic disorders in diabetes mellitus, hypothyroidism or gastrointestinal diseases, chronic renal failure, pathology of the laryngeal protective function, alcohol and tobacco abuse, and history of radiation therapy [4, 6, 7].

1.3 Epidemiology of the Disease or Condition

The highest incidence of acute laryngitis is noted in children aged 6 months to 2-3 years, most often occurring as stenosing laryngotracheitis [49]. At this age, it is observed in 34% of children with acute respiratory disease [1, 3, 8]. Among the adult population, individuals aged 18 to 40 years are most frequently affected, although the disease can occur at any age.

1.4 Features of Coding the Disease or Condition

J04.0 – Acute laryngitis.

J04.2 – Acute laryngotracheitis.

1.5 Classification of the disease or condition

By form of acute laryngitis:

• catarrhal;

• edematous;

• phlegmonous (infiltrative-purulent):

- infiltrative,

- abscessing;

• acute subglottic laryngitis.

By type of pathogen [1]:

• viral;

• bacterial;

• fungal;

• specific.

1.6 Clinical presentation of the disease or condition

The main symptoms of acute laryngitis are impaired vocal function – dysphonia of varying severity, up to aphonia, acute sore throat, cough, and possible breathing difficulty, and deterioration of general well-being. Acute forms are characterized by a sudden onset of the disease against a generally satisfactory condition or against the background of mild malaise. Body temperature remains normal or rises to subfebrile levels in acute catarrhal laryngitis. Febrile temperature generally reflects the involvement of the lower respiratory tract or the transition of catarrhal laryngeal inflammation into phlegmonous.

Infiltrative and abscessing forms of acute laryngitis are characterized by severe sore throat, swallowing disorders including liquids, hypersalivation, forced head position, pronounced intoxication, and escalating symptoms of laryngeal stenosis. The severity of clinical manifestations correlates directly with the severity of inflammatory changes. The patient's general condition becomes severe. In the absence of adequate therapy, the development of neck phlegmon, mediastinitis, sepsis, abscessing pneumonia, and laryngeal stenosis is possible. In these cases, regardless of the cause of acute laryngeal stenosis, its clinical picture is uniform and determined by the degree of airway narrowing. Sharply expressed negative pressure in the mediastinum during forced inspiration and increasing oxygen deprivation cause a symptom complex consisting of noisy breathing, changes in respiratory rhythm, retraction of the supraclavicular fossae and intercostal spaces, a forced posture of the patient with a thrown-back head, and downward displacement of the larynx during inspiration and upward during expiration [1, 2, 7].

With incomplete laryngeal obstruction, noisy breathing (stridor) occurs, caused by vibrations of the epiglottis, arytenoid cartilages, and partially the vocal cords during intense turbulent airflow through the narrowed airways according to Bernoulli's principle. When laryngeal tissue edema dominates, a whistling sound is observed; with increasing hypersecretion, there is wheezing, gargling, noisy breathing. In the terminal stage of stenosis, breathing becomes less noisy due to a decrease in tidal volume [1, 2].

In patients with laryngeal obstruction caused by an inflammatory infiltrate during an epiglottic abscess against the background of acute pain, the first complaints are the inability to swallow, associated with limited mobility of the epiglottis and edema of the posterior laryngeal wall, followed by difficulty breathing as the disease progresses. Glottic obstruction can occur very rapidly, requiring emergency measures by the physician to save the patient's life [2, 3].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition:

The criteria for diagnosing acute laryngitis are:

1. Anamnestic data (sudden onset against a background of mild malaise), with severe forms showing deterioration of general condition

2. Complaints of voice changes (dysphonia), pain on swallowing, cough, fever. In severe forms, complaints of severe pain on swallowing even liquids, fever up to febrile levels, hypersalivation, breathing disorders.

3. Physical examination findings in severe forms of acute laryngitis indicate painful palpation of the neck and larynx, impaired mobility of laryngeal cartilages, and a forced position of the head and neck.

4. Instrumental examination – performance of laryngoscopy. Acute catarrhal laryngitis is characterized by hyperemia, edema, and enhanced vascular pattern of the laryngeal mucosa. The vocal folds may be bright pink, bright red, or thickened. The glottis during phonation is oval or linear, with marked hyperemia and edema of the laryngeal mucosa, and fibrinous deposits [1, 2, 5].

2.1 Complaints and Anamnesis

See section "1.6 Clinical picture of the disease or condition (groups of diseases or conditions)".

2.2 Physical Examination

• During the physical examination of patients with suspected acute laryngitis, an appointment (examination, consultation) with anotorhinolaryngologist, general practitioner (family physician), or pediatrician is recommended in order to establish and clarify the diagnosis [6, 10, 53].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

When conducting a physical examination, attention should be paid to the presence/absence of symptoms of respiratory failure.

The main symptom of acute respiratory failure is dyspnea. Depending on the severity of dyspnea, the following degrees are distinguished: Grade I respiratory failure – dyspnea occurs upon physical exertion; Grade II – dyspnea occurs with minor physical exertion (slow walking, washing, dressing); Grade III – dyspnea at rest.

According to the clinical course and the size of the airway lumen, four stages of laryngeal stenosis are distinguished:

1. Compensation stage, characterized by the absence of dyspnea at rest, with dyspnea appearing upon walking. Characterized by narrowing of the laryngeal lumen by 1/3.

2. Subcompensation stage – characterized by inspiratory dyspnea involving accessory muscles of respiration upon physical exertion, retraction of the intercostal spaces, soft tissues of the jugular and supraclavicular fossae, stridorous (noisy) breathing, pallor of the skin, normal or elevated blood pressure, and laryngeal lumen narrowed by 1/2 or more.

3. Decompensation stage. Breathing is shallow, frequent, and stridor is pronounced. Forced sitting position. The larynx makes maximum excursions. The face becomes pale-cyanotic, sweating is increased, acrocyanosis is present, the pulse is accelerated and thready, blood pressure is lowered, and the laryngeal lumen is slit-like.

4. Asphyxia – breathing is intermittent or stops altogether. The vocal cords are sharply narrowed. Marked depression of cardiac activity. The pulse is frequent, thready, often not palpable. The skin is pale-gray due to spasm of small arteries. Loss of consciousness, exophthalmos, involuntary urination, defecation, and cardiac arrest are noted [1, 2, 5, 8].

The acute onset of the disease with rapid progression of stenosis symptoms exacerbates the severity of the patient's condition, as compensatory mechanisms do not have time to develop in a short period. This must be taken into account when determining indications for emergency surgical treatment [1, 2, 5].

2.3 Laboratory Diagnostics

Comments: Upon admission for inpatient treatment, a standard laboratory examination is performed [3, 5, 10].

2.4 Instrumental Diagnostics

Comments: performing indirect laryngoscopy using a laryngeal mirror is a mandatory diagnostic procedure when examining patients aged 12 years and older by an otorhinolaryngologist at both the outpatient and inpatient stages of diagnosis. When examining preschool and early school-age children at the outpatient stage by an otorhinolaryngologist and pediatrician, performing indirect laryngoscopy using a laryngeal mirror is often not feasible due to the patient's emotional lability and pronounced gag reflex.

If it is impossible to examine the larynx via indirect laryngoscopy, video fibrhinopharyngolaryngoscopy is indicated. During laryngoscopy, it is necessary to determine the nature of the pathological process, its localization, level, extent, and degree of airway narrowing [13-15].

The picture of acute laryngitis is characterized by hyperemia, edema of the laryngeal mucosa, and enhanced vascular pattern. The vocal cords are typically pink or bright red, thickened, and the glottis during phonation is oval or linear with an accumulation of mucus. In acute laryngitis, the mucous membrane of the subglottic region of the larynx may be involved in the inflammatory process. In subglottic laryngitis, a ridge-like thickening of the mucous membrane of the subglottic region of the larynx is diagnosed.

In the catarrhal form of acute laryngitis, changes are observed mainly on the vocal cords, in the interarytenoid or subglottic space. Against the background of the hyperemic laryngeal mucosa and vocal cords, dilated superficial blood vessels and mucous or mucopurulent secretions are visible, which increases hoarseness

In the edematous form of acute laryngitis, diffuse hyperemia and edema of the entire laryngeal mucosa of varying severity are determined. During phonation, incomplete closure of the vocal cords is observed, while the glottis has a linear or oval shape.

In acute laryngitis developing against the background of influenza or acute respiratory viral infection (ARVI), laryngoscopy reveals hemorrhages in the laryngeal mucosa: from petechial to small-sized hematomas (so-called hemorrhagic laryngitis) [11, 13].

The appearance of a white and yellowish-white fibrinous coating in the larynx is a sign of the transition of the disease to a more severe form – fibrinous laryngitis, and a gray or brown coating may be a sign of diphtheria.

If the process is not associated with intubation trauma, its detection in adults requires urgent differential diagnosis with systemic diseases and tuberculosis. In infiltrative laryngitis, significant infiltration, hyperemia, enlargement, and impaired mobility of the affected part of the larynx are determined. Fibrinous deposits are often visible, and purulent contents shine through at the site of abscess formation. In severe forms of laryngitis and chondroperichondritis of the larynx, tenderness upon palpation, impaired mobility of the laryngeal cartilages are characteristic, and infiltration and hyperemia of the skin over the larynx are possible, against the background of pain syndrome and clinical signs of general purulent infection. An epiglottic abscess looks like a spherical formation on its lingual surface with translucent purulent contents accompanied by pronounced pain syndrome and swallowing disorders.

2.5 Other Procedures

Comments: considering the issue of performing CT of the larynx with intravenous bolus contrast enhancement is advisable for patients with acute laryngitis at the inpatient stage of treatment if purulent complications of acute laryngitis are suspected and in case of difficulty in differential diagnosis with other laryngeal diseases.

If CT is not feasible in the presence of signs of laryngeal stenosis in questionable situations in children, plain radiography of the neck in anteroposterior and lateral projections may be performed [13, 1].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

Comments: it is advisable for this purpose to prescribe paracetamol** up to 60 mg/kg/day and/or ibuprofen** up to 30 mg/kg/day. In children with a body temperature increase > 39-39.5°C, it is recommended to use physical cooling methods (undress the child, wipe with water at a temperature of 25-30ºC) and administer antipyretic therapy (drugs of the non-steroidal anti-inflammatory and antirheumatic drugs group (ibuprofen** at a dose of 7.5 mg/kg every 6-8 hours (maximum 30 mg/kg/day) or drugs of the other analgesics and antipyretics group (paracetamol** at a dose of 10-15 mg/kg every 6 hours (maximum 60 mg/kg/day) [22].

Comments: The benefit of abundant fluid intake is questionable, while the increased secretion of antidiuretic hormone during the illness, on the contrary, contributes to fluid retention.

Comments: before prescribing antitussive drugs, one should ensure the absence of conditions requiring appropriate treatment and in which the prescription of therapy aimed at suppressing cough may be dangerous, for example, symptoms of bronchial obstruction, and in children – additionally – symptoms of acute obstructive laryngitis (croup).

Comments: A special place in the treatment of AL is occupied by local anti-inflammatory therapy: instillation of medicinal substances into the larynx, inhalation therapy. Among medicinal products for laryngeal instillation, antiseptics from the quinoline derivative groups (ATC D08AH) and quaternary ammonium compounds (ATC D08AJ) are most frequently used [37]; The temperature of the instilled medications should correspond to normal body temperature, instilled drop by drop in a volume of up to 2 ml. Due to the risk of laryngospasm, endolaryngeal instillations into the larynx should not be performed in children [34].

Comments: it is advisable to prescribe systemic antibacterial therapy to adult patients with protracted acute laryngitis lasting 10 days or more, as well as in cases of pronounced vocal fold infiltration and exudation.

Antibacterial therapy is prescribed empirically for adults using oral medications: Amoxicillin** (ATX code J01CA04) orally 500¹-1000² mg 3 times a day for adults for 5-10 days; *Amoxicillin+[Clavulanic acid]³ (ATX J01CR02) 875 mg+125 mg 2 times a day for adults for 5-10 days; cephalosporins – Cefixime (ATX J01DD08) 400 mg 1 time a day for 5-10 days, Cefditoren (ATX J01DD16 400 mg 1 time a day) for 10 days; Clarithromycin** 250-500 mg 2 times a day for 6 days, Josamycin** (ATX J01FA09) 1000 mg 2 times a day for adults for 5-10 days.

Table 1. Recommended systemic antibacterial drugs (ABDs) (ATX J01) and treatment regimens for acute laryngitis in adults

¹ – in the absence of risk factors for pneumococcal resistance to beta-lactams (use of antibiotics in the previous 3 months, presence of preschool-aged children in the family attending childcare facilities, adults living in "closed" institutions).

² – in the presence of risk factors for pneumococcal resistance to beta-lactams (use of antibiotics in the previous 3 months, presence of preschool-aged children in the family attending childcare facilities, adults living in "closed" institutions).

³ – risk factors for the presence of a beta-lactamase-producing pathogen strain (H. influenzae, S. aureus, M. catarrhalis), presence of concomitant diseases (bronchial asthma, diabetes mellitus, chronic bronchitis), immunosuppressive states, age over 65 years; previous unsuccessful antibacterial therapy with amoxicillin**.

For children: Amoxicillin** (ATX code J01CA04) orally 40-60 or 80-90 mg/kg/day for 5-7 days; Amoxicillin/clavulanate** Amoxicillin+[Clavulanic acid]** (ATX J01CR02) up to 3 months – 30 mg/kg/day in 2 doses; 3 months and older – 25 mg/kg/day in 2 doses or 20 mg/kg/day in 3 doses for 5-10 days.

Cefixime (ATX code: J01DD08) suspension 8 mg/kg/day in 1-2 doses for 5-10 days; ceftriaxone** (ATX J01DD04) is prescribed to children from 15 days to 12 years of age at 20-80 mg/kg of body weight 1 time a day. Children with a body weight of more than 50 kg are prescribed doses intended for adults for 6 days.

Clarithromycin** (ATX J01FA09) for children over 12 years of age, a single dose is 7.5-15 mg/kg/day in 2 doses for no more than 14 days; Josamycin** (ATX J01FA07) 50 mg/kg/day in 2-3 doses for 5-10 days.

Thiamphenicol glycinate acetylcysteinate⁴ (ATX code J01BA02) i.m. For children under 2 years of age, a single dose is 125 mg – 2 times/day; from 3 to 6 years – 250 mg 2 times/day; from 7 to 12 years – 250 mg 3 times/day. For adults, a single dose is 500 mg 2-3 times/day for 10 days.

Table 2. Recommended ABDs and treatment regimens for acute laryngitis in children

¹ – in the absence of risk factors for pneumococcal resistance to beta-lactams (use of antibiotics in the previous 3 months, presence of preschool-aged children in the family attending childcare facilities, children living in "closed" institutions).

² – in the presence of risk factors for pneumococcal resistance to beta-lactams (use of antibiotics in the previous 3 months, presence of preschool-aged children in the family attending childcare facilities, children living in "closed" institutions).

³ – risk factors for the presence of a beta-lactamase-producing pathogen strain (H. influenzae, S. aureus, M. catarrhalis), presence of concomitant diseases (comorbid pathology), immunosuppressive states, previous unsuccessful antibacterial therapy with amoxicillin**.

⁴ – when beta-lactams and macrolides cannot be prescribed

Comments: The choice of therapy algorithm for acute laryngitis depends on the form and severity of the inflammatory process.

Comments: it is advisable to prescribe Fluconazole** (ATX J02AC01) 100 mg per day or Itraconazole (ATX J02AC02) 100 mg 1 time a day for 15 days to adult patients only after verification of candidiasis [25, 26].

Comments: it is advisable to prescribe antihistamines to patients with a history of allergies. Children from 3 to 12 years old with a body weight of more than 30 kg: Loratadine**/Cetirizine** 10 mg 1 time a day; with a body weight of less than 30 kg: Loratadine**/Cetirizine** 5 mg 1 time a day: Levocetirizine (ATX R06AX13) for children aged 2-6 years, 1.25 mg – 2 times a day, older than 6 years and adults – 5 mg – 1 time a day. Desloratadine from 6 to 12 months, 1 mg of the drug 1 time a day, from 1 to 5 years, 1.25 mg 1 time a day, from 6-11 years, 2.5 mg – 1 time a day. For adults and children over 12 years old: Loratadine** (ATX R06AX13), Cetirizine** (ATX R06AE07) 10 mg 1 time a day, Desloratadine (ATX R06AX27) 5 mg 1 time a day.

Comments: It should also be borne in mind that for any inflammatory disease of the larynx, it is necessary to create a protective regimen (voice rest regimen), recommend complete voice rest to the patient in case of dysphonia for a period of 1-2 days, followed by restriction of any voice load. It is also necessary to stop taking spicy, salty, hot, cold food, alcoholic beverages, and smoking.

Comments: Hospitalization is indicated for patients with a complicated course of acute laryngitis in a medical facility equipped with an intensive care unit and the capability for tracheal intubation.

Antibacterial therapy in inpatient settings is prescribed empirically to adults and children taking into account data on regional resistance of key pathogens.

Prescribed for children: Amoxicillin + [Clavulanic acid]** (ATC J01CR02) for children from 3 months of age, the intravenous dosage is 25 mg/5 mg per kg of body weight every 6-8 hours for 5-10 days, or Cefotaxime** (ATC J01DD01) i.m., i.v. 150 mg/kg/day in 4 injections, or Ceftriaxone** (ATC J01DD04) i.m., i.v. for children (from 15 days to 12 years): 20-80 mg/kg of body weight once daily for 5-10 days [24, 25].

In children with severe phlegmonous laryngitis and complications, it is advisable in the ICU to prescribe 4th generation cephalosporins – Cefepime** (ATC J01DE01) 2.0 g every 12 hours for weight over 40 kg, up to 40 kg – 50 mg/kg every 12 hours for 7-10 days, Meropenem** (ATC J01DH02): after 3 months to 12 years 10-20 mg/kg – 3 times a day, over 50 kg – adult dose is used) for 5-10 days [24, 25]. (The Vidal reference book indicates its use "for soft tissue infections")

It is advisable to prescribe antibacterial therapy for adults with complicated forms of phlegmonous laryngitis: Amoxicillin + [Clavulanic acid]** (ATC J01CR02) i.v. 1.2 g 3 times/day for 7-10 days; Cefotaxime** (ATC J01DD01) i.v. 2 g 3 times/day for 7-10 days; Ceftriaxone** (ATC J01DD04) i.m., i.v. 2 g 1 time/day for 7-10 days; Thiamphenicol glycinate acetylcysteinate (ATC code: J01BA02)

For children under 2 years of age, a single dose is 125 mg – 2 times/day; from 3 to 6 years – 250 mg 2 times/day; from 7 to 12 years – 250 mg 3 times/day; 125-250 mg 2-3 times a day depending on age. For adults, a single dose is 500 mg 2-3 times/day for 10 days.

After clinical improvement, switching to oral antibiotic administration (step-down therapy) is possible [27].

In the treatment of acute abscessing and phlegmonous laryngitis, all patients undergo irrigation of the abscess cavity with antiseptic solutions of benzyldimethyl[3-(myristoylamino)propyl]ammonium chloride monohydrate 0.01% (ATC D08AJ), hydroxymethylquinoxalinedioxide (ATC J01XX) [44].

Comments: for destenosing therapy, parenteral administration of glucocorticoids at 60-120 mg is advisable

Comments: The duration of inhalation is usually 10 minutes, and the break between inhalations with drugs of different actions is about 30 minutes.

In the presence of crusts, therapy begins with the inhalation of mucolytic drugs. Acetylcysteine** (form: solution for intravenous administration and inhalation) is used by inhalation, 1 ampoule (3 ml) 1-2 times a day for 5-7 days (ATC R05CB01) [37, 38].

Prescription of corticosteroid inhalation (ATC R03BA) is possible: #Budesonide** (ATC R03BA02) 1000 mcg 1-2 times a day, course of 5-8 procedures [31, 35].

Ready-made pharmacy herbal mixtures may be used in the absence of contraindications, taking into account age restrictions for essential oils

Eucalyptus globulus leaf oil (ATC R07AX Other drugs for obstructive airway diseases), as well as 5-10% decoctions of Matricaria chamomilla flowers, Salvia officinalis leaves, Thymus serpyllum herb (wild thyme), Calendula officinalis flowers, Plantago major leaves are used. Inhalations can be warm or cold. The duration of the first inhalation is 1-2 minutes, followed by 5-10 minutes [32, 34].

3.2 Surgical Treatment

Not required in uncomplicated cases of acute laryngitis.

• In decompensated laryngeal stenosis in children, emergency intubation is recommended to ensure respiratory function [51].

GDR CLE 5Grade of recommendation C (level of evidence – 5)

3.3 Other Treatment

Comments: The complex homeopathic preparation Homeovox (Active ingredients: Aconitum napellus, Arum triphyllum, Ferrum phosphoricum, Calendula officinalis, Spongia tosta, Belladonna, Mercurius solubilis, Hepar sulfur, Kalium bichromicum, Populus candicans, Bryonia) is registered in the Russian Federation for the following indications: laryngitis of various etiologies, including loss of voice, hoarseness, vocal cord fatigue. It is prescribed to adults and children over 6 years of age from the first days of the disease for a period of 6 days [34].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• For patients with voice-dependent professions after acute laryngitis, an initial examination (consultation) by an otorhinolaryngologist is recommended until full recovery of voice function [7, 9, 10, 43, 44].

GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)

Comments: In patients with voice-dependent professions, the period of temporary disability is extended until the full recovery of voice function. Uncomplicated acute laryngitis resolves within 7–14 days; infiltrative forms last for more than 14 days.

5. Prevention and Dispensary Observation

Prevention of the chronic progression of laryngeal inflammation consists of the timely treatment of acute laryngitis, increasing the body's resistance, treatment of gastroesophageal reflux disease, upper and lower respiratory tract infections, smoking cessation, and adherence to vocal rest.

6. Organization of Medical Care

Patients with acute laryngitis without laryngeal stenosis associated with acute viral respiratory infection do not require hospitalization. All patients with complicated acute laryngitis are subject to hospitalization.

Indications for emergency inpatient hospitalization: acute respiratory failure (greater than grade I).

Indications for patient discharge from the medical organization: positive dynamics of the inflammatory process, absence of respiratory failure, absence of complications of the inflammatory process.

7. Additional Information

When acute laryngitis develops, voice rest is necessary. Hot, cold, and spicy foods, alcohol, smoking, and steam inhalations are contraindicated. Continuous indoor air humidification using special humidifiers and the administration of antiviral drugs as part of combination therapy are indicated.

The prognosis is favorable for uncomplicated forms of laryngitis, whereas in complicated forms with the development of laryngeal stenosis, timely specialized care and surgical treatment help save the patient's life.

Criteria for Evaluating the Quality of Medical Care

Quality assessment criteria for primary health care in adults and children with acute laryngitis (ICD-10 codes J04.0, J04.2)

Quality assessment criteria for specialized medical care in adults and children with acute laryngitis (ICD-10 codes J04.0, J04.2)

References

Appendix A1. Working Group Composition

1. Krivopalov A.A., MD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

2. Karneeva O.V., MD, Associate Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

3. Kim I.A., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

4. Tkachuk I.V., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

5. Romanenko S.G., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

6. Osipenko E.V., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

7. Zyabkin I.V., PhD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

8. Polunin M.M., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

9. Garashchenko T.I., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

10. Nikiforova G.N., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

11. Gurov A.V., MD, Professor, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

12. Alekseenko S.I., MD, Member of the National Medical Association of Otorhinolaryngologists, no conflict of interest;

13. Namazova-Baranova L.S., MD, Professor, Academician of the Russian Academy of Sciences, no conflict of interest;

14. Geppe N.A., MD, Professor, no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Otolaryngologists.

2. General practitioners.

3. Pediatricians.

4. Allergists-immunologists.

5. General practitioners (family physicians).

6. Infectious disease physicians.

7. Medical students.

8. Residents in training.

Table 1. Level of Reliable Evidence (LRE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Level of Reliable Evidence (LRE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Level of Clinical Recommendation (LCR) grading scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The update mechanism for clinical guidelines provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific conditions, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Russian Ministry of Health No. 905n of November 12, 2012, "On Approval of the Procedure for Providing Medical Care to the Population in the Profile 'Otorhinolaryngology'."

2. Order of the Russian Ministry of Health No. 1654n of December 28, 2012, "On Approval of the Standard of Primary Health Care for Acute Nasopharyngitis, Laryngitis, Tracheitis, and Mild Acute Upper Respiratory Infections."

3. Order of the Russian Ministry of Health No. 798n of November 9, 2012, "On Approval of the Standard of Specialized Medical Care for Children with Moderate Acute Respiratory Diseases."

4. Order of the Ministry of Health and Social Development of the Russian Federation No. 366n of April 16, 2012, "On Approval of the Procedure for Providing Pediatric Care";

5. Order of the Ministry of Health and Social Development of the Russian Federation No. 521n of May 5, 2012, "On Approval of the Procedure for Providing Medical Care to Children with Infectious Diseases."

6. State Register of Medicinal Products: https://grls.rosminzdrav.ru

7. Order of the Ministry of Health of the Russian Federation No. 1183n dated December 20, 2012 "On approval of the nomenclature of positions of medical and pharmaceutical workers".

8. Order of the Ministry of Health of the Russian Federation No. 541n dated July 23, 2010. "Unified Qualification Handbook of Positions of Managers, Specialists, and Employees, Section: Qualification Characteristics of Positions of Healthcare Workers."

9. Federal Law No. 489-FZ dated December 25, 2018, "On Amendments to Article 40 of the Federal Law 'On Compulsory Medical Insurance in the Russian Federation' and the Federal Law 'On the Fundamentals of Public Health Protection in the Russian Federation' regarding Clinical Guidelines".

10. Order of the Russian Ministry of Health No. 103n dated February 28, 2019, "On approval of the procedure and timelines for the development of clinical guidelines, their revision, the standard template of clinical guidelines, and requirements for their structure, composition, and scientific validity of the information included in the clinical guidelines."

11. Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017 "On approval of the nomenclature of medical services".

12. Order of the Ministry of Health of the Russian Federation No. 4n dated January 14, 2019, "On Approval of the Procedure for Prescribing Medicinal Products, Prescription Forms for Medicinal Products, the Procedure for Issuing Said Forms, Their Accounting, and Storage"

13. Order of the Ministry of Health of the Russian Federation No. 335 dated 29.11.95. On the use of homeopathy in practical healthcare.

Appendix A3.1 Explanation of Notes

** – a medicinal product included in the List of Vital and Essential Drugs for medical use for 2020 (Decree of the Government of the Russian Federation No. 2406-r dated October 12, 2019)

# – off-label use outside the indications registered in the medicine's instructions is carried out by decision of the medical commission, with the permission of the Local Ethics Committee of the medical organization (if any), subject to the signed informed consent of the parents (legal representative) and the patient over 15 years of age.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

When acute laryngitis develops, voice rest is necessary. Hot, cold, and spicy foods, alcoholic beverages, smoking, and steam inhalations are prohibited. Continuous indoor air humidification using special humidifiers and the intake of antiviral drugs are indicated.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Absent