Evidencia y recomendación: ¿cuándo es necesario descartar una laringitis herpética?

Abstract

Introduction and objective: Herpes simplex virus laryngitis is a rare but potentially serious clinical entity presenting with nonspecific symptoms, leading to diagnostic delays and significant morbidity. The objective of this systematic review is to establish evidence-based clinical criteria to guide clinicians on when to suspect and actively rule out herpetic laryngitis, identifying risk factors, distinctive clinical features, and laryngoscopic findings that warrant confirmatory testing to enable timely antiviral treatment. Methods: A systematic review on herpetic laryngitis was conducted to establish clinical criteria guiding when to rule out this rare but serious condition. The review identified that clinical presentation varies by age (stridor in children, dysphonia/dysphagia in adults), is associated with significant morbidity (prolonged hospitalizations, need for tracheotomy), and requires a high index of suspicion in immunocompromised patients, those with prolonged intubation, or with atypical laryngeal lesions unresponsive to conventional treatment. Variables included: demographic variables: age (pediatric vs. adult), sex, immune status (immunocompetent vs. immunocompromised); clinical variables: main symptoms (stridor, dysphonia, dysphagia, odynophagia), symptom duration, airway compromise severity, risk factors (HIV, transplant, corticosteroid therapy, intubation >7 days, mechanical ventilation); diagnostic variables: laryngoscopic findings (whitish exudate, ulceration, proliferative lesions), diagnostic method used (PCR/NAAT, viral culture, histopathology, immunohistochemistry), time to diagnosis; outcome variables: hospital length of stay, need for tracheotomy, ICU admission, antiviral treatment used (acyclovir, cidofovir), treatment response, complications (cartilage destruction, need for laryngectomy), mortality. Results: The systematic review identified 31 studies with 36 patients (17 pediatric, 19 adults) with confirmed HSV laryngitis. Results show that stridor is significantly more frequent in children (p<0,01), while adults predominantly present with dysphonia (p<0,01) and dysphagia (p=0,03). Adults required tracheotomy more frequently than children (p=0,047), with prolonged hospital stays in both groups (21,2 days in children, 15,8 days in adults). Level of evidence: 4 (very low) according to GRADE classification. Evidence derives exclusively from case series and individual case reports, without controlled clinical trials or comparative cohort studies. The scarcity of cases (36 patients in the world literature), heterogeneity in diagnostic methods, and absence of control groups significantly limit evidence quality and the possibility of establishing strong recommendations. Conclusions: HSV laryngitis is an underdiagnosed entity with nonspecific clinical presentation varying by age: predominant stridor in pediatric population and dysphonia/dysphagia in adults. Diagnostic delay leads to significant morbidity, including prolonged hospitalizations (2-3 weeks) and need for tracheotomy, especially in adults. A high clinical index of suspicion is required to enable early diagnosis and timely initiation of antiviral treatment.