Ulcerative Laryngitis

Ulcerative laryngitis is a distinctive but uncommon form of laryngitis. Even in a very busy laryngology-only practice staffed by four clinicians, only a few cases are seen each year. By comparison, both viral and bacterial laryngitis are far more common.

Symptoms

Patients may have an associated upper respiratory illness, cough, or other infectious symptoms, although this is not always the case. Severe dysphonia—or even complete aphonia—can develop rapidly. Many patients, however, do not present until several to many weeks after symptom onset, when healing has already begun. For this reason, it is important to recognize ulcerative laryngitis in both its acute and healing phases, as illustrated in the case series below.

Etiology

The underlying cause remains uncertain. An as-yet unidentified pathogen or other inflammatory process appears to produce focal ulceration of the vocal fold mucosa. On laryngoscopic examination, the lesion may appear as though the mucosal covering has sloughed away, all the way down to the vocal ligament, leaving a striking depression in the surface of the vocal fold. The initial impression can be alarming, leading the examiner to wonder whether the patient’s voice can ever recover fully.

Prognosis

Fortunately, the clinical course is often much more favorable than the appearance suggests. Although the laryngitis is unusually prolonged—typically lasting about two months and sometimes more—healing generally occurs, and many patients recover an excellent or even normal voice. This favorable outcome is not guaranteed. Some authors have reported permanent vocal fold scarring, although we have not observed this in our own experience. Whether scarring occurs primarily in patients who have undergone biopsy is unknown, but the possibility reinforces the need for caution.

Ulcerative laryngitis is the longest-lasting form of laryngitis that we encounter in clinical practice.

Treatment

The responsible pathogen has not been identified. Various investigators have proposed viral, bacterial, fungal, and immune-mediated mechanisms, but no single etiology has been established. Based on our own clinical impression, we have suspected Mycoplasma infection in at least some cases and therefore commonly treat empirically with either doxycycline or azithromycin, recognizing that this approach is based on clinical judgment rather than definitive evidence.

Perhaps the most important management principles are as follows;

1. To help the patient understand the concept of ulcerative laryngitis, and to provide cautious optimism but no guarantees;
2. To resist the temptation to biopsy these lesions simply because of their dramatic appearance.

In our opinion, biopsy should generally be avoided because it may convert a reversible mucosal injury into permanent scarring. Observation with serial examinations is usually appropriate. Only when there is no convincing evidence of healing after approximately three months—or when other clinical features raise concern for an alternative diagnosis—should biopsy be considered, and then only on a highly individualized basis.