Laryngitis
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Direct answer
Hoarseness persisting beyond three weeks is never "just laryngitis" — it mandates laryngoscopy to exclude malignancy. Acute laryngitis, mostly viral, settles in a week with voice rest, steam and treatment of reflux; chronic laryngitis traces to smoking, acid reflux, voice abuse or tuberculosis. The benign vocal fold lesions follow a pattern worth memorising: bilateral singer's nodules at the junction of the anterior and middle thirds, a unilateral polyp in a smoker, and Reinke oedema giving both cords a baggy, low-pitched swelling in heavy-smoking women.
What you must remember
- The three-week rule: hoarseness lasting more than three weeks needs visualisation of the larynx; in a smoker or drinker over forty, it is laryngeal carcinoma until proven otherwise.
- Acute laryngitis is viral and self-limiting: strict voice rest, humidification, hydration and analgesia; antibiotics are not routine, and corticosteroids are reserved for professional voice users under supervision.
- Voice rest does not mean whispering — whispering strains adductor muscles harder than soft phonation, a classic viva correction.
- Reflux laryngitis (laryngopharyngeal reflux): morning hoarseness, globus, chronic throat clearing and cough, with laryngeal erythema and interarytenoid oedema; treated with proton pump inhibitors, weight reduction and dietary timing.
- Vocal nodules (singer's or screamer's nodules): bilateral, symmetrical, at the junction of the anterior and middle third of the membranous cord; first-line treatment is voice therapy, surgery only for failure.
- Vocal polyp: unilateral, pedunculated or sessile, often haemorrhagic, in smokers and heavy voice users; removed by microlaryngoscopy, often with the CO2 laser.
- Reinke oedema: bilateral polypoid degeneration of the superficial lamina propria (Reinke space) in middle-aged female heavy smokers, producing a deep, husky voice; smoking cessation comes before surgery.
- Tuberculous laryngitis, still seen in India: painful hoarseness out of proportion, granular or pale granulating mucosa, commonly posterior glottis; biopsy shows caseating granulomas — it heals with antitubercular therapy, and mistaking it for cancer is the published trap.
Reasoned comparison: the four benign cord lesions
Compare where the injury lands. Nodules are the calluses of voice abuse: at each phonatory stroke, the junction of the anterior and middle thirds of the membranous cord takes maximal collision, so a teacher or singer develops paired, symmetrical thickenings — and because the mechanism is behavioural, the cure is behavioural: voice therapy, hydration and amplified speaking correct most early nodules, with microlaryngeal excision reserved for mature fibrotic ones. The polyp is a single event — a haemorrhage or oedematous prolapse after one shouting match or intubation — so it is unilateral, focal and mechanical; it does not regress with therapy and needs precise microlaryngeal removal. Reinke oedema is diffuse and bilateral because the whole superficial lamina propria of both cords is waterlogged by chronic smoke and sometimes hypothyroidism; the voice drops in pitch rather than breaking, and the definitive step is smoking cessation, with mucosal strip or laser reduction only in selected, abstinent patients. Contact granuloma or intubation granuloma completes the set: a raw nodule over the vocal process of the arytenoid from reflux or tube trauma, painful, and treated by reflux control rather than excision, since surgical removal alone regrows it.
Against this benign background sits the rule that overrides everything: the unilateral, progressive, painless hoarseness of a smoker over forty does not fit any of the above — the nodules are bilateral, the polyp fluctuates little but is rare, Reinke oedema spares the voice's usefulness — and that description belongs to a tumour until laryngoscopy and biopsy say otherwise.
How the exam frames it
Stems match lesion to population: bilateral nodules in a teacher answer voice abuse and voice therapy; a unilateral polyp in a smoker answers microlaryngeal excision; a husky-voiced heavy-smoking woman answers Reinke oedema; morning hoarseness with throat clearing answers reflux laryngitis and proton pump inhibitors; and excruciatingly painful hoarseness with weight loss in a young Indian patient answers tuberculosis, biopsy first, antitubercular therapy next. The two most repeated one-liners are the three-week rule and the whispering correction.
Frequently asked questions
What is the significance of hoarseness lasting more than three weeks?
It requires laryngoscopy to exclude malignancy, particularly in smokers and alcohol users above forty years.
Where do vocal nodules form and how are they treated?
At the junction of the anterior and middle thirds of both membranous vocal folds; voice therapy is first-line, with surgical excision reserved for refractory fibrotic nodules.
What is Reinke oedema?
Bilateral diffuse oedema of the superficial lamina propria (Reinke space), classically in middle-aged female heavy smokers, producing a deep husky voice.
How does laryngopharyngeal reflux present?
Morning hoarseness, globus sensation, chronic throat clearing and cough with interarytenoid oedema on laryngoscopy; treated with proton pump inhibitors and lifestyle measures.
How does tuberculous laryngitis differ from tumour clinically?
Severe local pain out of proportion to findings, granular pale mucosa often posteriorly, with pulmonary tuberculosis in the background; biopsy confirms caseation and antitubercular therapy resolves it.