Viral Upper Respiratory Tract Infection (Acute Laryngitis)
Pediatric Patient
5 y/o pt with no h/o reactive airway disease, immunocompromised state presents with acute onset hoarseness. Parent reports 2-3 days of malaise, nasal congestion, rhinorrhea, cough, and pain with swallowing. Denies significant, abrupt worsening of symptoms since onset. Denies headache, sinus pressure. Sick contacts include siblings, classmates. Immunizations are up to date. Low grade fever with no purulent exudate in the oropharynx. Normal tympanic membranes. No increased work of breathing, retractions, wheezing, egophony, cyanosis on exam.
Treatment
Recommend adequate PO intake, ingestion of warmed liquids, and nasal suction PRN
Administer acetaminophen and ibuprofen PRN for fever, malaise
Nasal congestion
Intranasal ipratropium 0.06% (42 mcg/spray), two sprays per nostril BID (< 5 y/o) or TID
> 12 y/o: Consider decongestants (see adults)
Cough symptoms
> 1 y/o: Administer 1 teaspoon honey q6h PRN
> 4 y/o: Consider dextromethorphan for cough suppression (see directions for dosing instructions)
Hoarseness: Complete vocal rest advised for 48 hours; avoid whispering and throat clearing as they can cause laryngeal trauma
Parent counseled that
Symptoms peak at 2-3 days and last 1-2 weeks
Cough may last up to 4 weeks
Good hand hygiene with hand washing/sanitizer should be emphasized to prevent transmission to others
Encouraged to return for repeat evaluation if
Patient develops difficulty breathing or decreased oral intake
Symptoms, especially cough, continue to worsen during the next 4 to 5 days
Symptoms last longer than 10-14 days
Additional Treatment for Adults
Malaise and myalgia: Ibuprofen 600 mg q6h
Malaise and nasal congestion: Acetaminophen 500 mg q6h
Nasal decongestants (select one) and no h/o cardiovascular disease, thyroid disease, DM, BPH/urinary obstruction
Intranasal oxymetazoline 0.05% two sprays in each nostril BID for up to 3 days
Additionally, no h/o glaucoma, renal disease, seizures: Pseudoephedrine 60 mg q6h
Congestion and cough
Loratadine 10 mg qd
Intranasal ipratropium (0.06%) two sprays in each nostril TID for up to 3 weeks
Zinc
Zinc acetate 50 mg TID: Reduces symptom duration if started within 72 hours of symptom onset
Zinc acetate lozenges 75 mg BID: Reduces cough
Ineffective treatments
OTC remedies: Saltwater gargles, vitamin C, vitamin D, probiotics, ginseng, and echinacea do not improve symptoms
Patient counseled that codeine is not effective in treating cough
Patient counseled that smoking may increase duration of viral illness
Notes
Acute laryngitis/viral URI is also known as the common cold and “man flu”
Diluted apple juice (half water and half juice) is as effective as Pedialyte for oral rehydration
Differential diagnosis
Rule out allergic rhinitis, bacterial sinusitis, isolated pharyngitis, acute bronchitis, pertussis, and influenza
Progressively worsening cough may indicate pneumonia or pertussis