Seasonal Variations in Public Inquiries into Laryngitis:

An Infodemiology Study
David Tianxiang Liu, Gerold Besser, Matthias Leonhard, Tina Josefin Bartosik, Thomas Parzefall, Faris F. Brkic,
Christian Albert Mueller, and Dominik Riss, Vienna, Austria

Summary: Objectives. Acute laryngitis is a common disease with self-limiting nature. Since the leading cause
is attributed to viral infections and thus self-limiting, many affected individuals do not seek professional medical
help. However, because the major symptom of hoarseness imposes a substantial burden in everyday life, it might
be speculated that web-based search interest on this condition follows incidence rates, with highest peaks during
winter months. The aim of this study was to evaluate global public health-information seeking behaviour on
laryngitis-related search terms.
Methods. We utilized Google Trends to assess country-specific, representative laryngitis-related search terms
for English and non-English speaking countries of both hemispheres. Extracted time series data from Australia,
Brazil, Canada, Germany, the United Kingdom, and the United States of America, covering a timeframe between
2004 and 2019 were first assessed for reliability, followed by seasonality analysis using the cosinor model.
Results. Direct comparisons revealed different, representative laryngitis-related search terms for English- and
non-English speaking countries. Extracted data showed a trend of higher reliability in countries with more inhabi-
tants. Subsequent graphical analysis revealed winter peaks in all countries from both hemispheres. Cosinor analysis
confirmed these seasonal variations to be significant (all P < 0.001).
Conclusion. Public interest in laryngitis-related, online health information displayed seasonal variations in
countries from both hemispheres, with highest interest during winter months. These findings emphasize the
importance to optimize the distribution of reliable, web-based health education in order to prevent the spread of
misinformation and to improve health literacy among general populations.
Key Words: Laryngitis−Seasonality−Google Trends−Cosinor−Infodemiology−Google.

INTRODUCTION behavior. Consequently, there is a need for assessment and

Acute laryngitis is a common disease and can be defined as
an inflammation of the larynx and vocal cords.1−3 The most
frequent type of acute laryngitis is caused by viral infections,
which are generally linked to a common cold and winterly
weather conditions.4−7 Hoarseness represents the hallmark
symptom of vocal cord inflammations and can not only
have a profound effect on social life, but also imposes a risk
of mental distress in affected individuals.8−12 It was specu-
lated that only a minority of patients with acute laryngitis
seek professional medical help. This might be explained by
the self-limiting course of this disease, which usually subsides
within three weeks without further medical treatment.3,13
Considering that more than two in three adults have already
used the Internet to learn more about health-related issues,14
it seems plausible that web-based interest on laryngitis-
related search terms might follow annual incidence rates of
acute laryngitis, with peaks during winter months.4 Although
significant advances have already been made in improving
quality of care for patients with dysphonia,13 there is cur-
rently no evidence on related online information-seeking
Accepted for publication April 21, 2020.
From the Department of Otorhinolaryngology, Head and Neck Surgery, Medical
University of Vienna, Vienna, Austria.
Address correspondence and reprint requests to David Tianxiang Liu, Department
of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna,
W€ahringer G€ urtel 18-20, 1090 Vienna, Austria. E-mail: david.liu@meduniwien.ac.at
Journal of Voice, Vol. 36, No. 1, pp. 98−105
0892-1997
© 2020 The Authors. Published by Elsevier Inc. on behalf of The Voice Founda-
tion. This is an open access article under the CC BY-NC-ND license.
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
https://doi.org/10.1016/j.jvoice.2020.04.018
monitoring of the general interest for this topic in order to
optimize online information distribution.
Infodemiology is an emerging research area which involves
the analysis methods of web-based inquiry attitude to gain
more insight into human behavior and to provide informa-
tion to health-professionals and policy makers.15,16 Assessing
the role of seasonal variations and awareness of public inqui-
ries into specific diseases can be useful to understand the
mechanism of public attention triggering. Given the promi-
nent role of Google web search as the most frequently used
search engine worldwide,17 it is not surprising that search
query analysis tools, such as Google Trends (GT) have
emerged as powerful instruments to gain more insight into
public interest in health-related issues. The wide range of pos-
sible applications for the healthcare sector is also mirrored by
the considerable number of publications in recent years.18,19
For example, GT was used to track the outbreak of the sea-
sonal flu20 and to complement traditional data sources by
assessing seasonal variations in public interest for various
medical conditions.21−24
Over the last two-decades, progress has been made in
understanding more about the epidemiology of laryngitis. A
nationwide study in Greece on laryngitis epidemiology
revealed an association of higher incidence rates in winterly
weather conditions.4 Conversely, global patterns of acute
laryngitis incidence have not been reported yet, possibly due
to the self-limiting nature of the disease, keeping patients
from seeking professional medical help. However, there is at
least preliminary evidence that individuals affected by
David Tianxiang Liu, et al Seasonal Variations in Public Inquiries into Laryngitis
laryngitis or their interested relatives searched for disease-
related information online, given the fact that more than 70%
of adults from the United States already have used the Internet
for health-related issues.25 Therefore, we hypothesized that
incidence peaks might also be reflected in public interest in
laryngitis-related search terms.
The aim of this study was to apply GT to test our hypoth-
esis that public interest in laryngitis-related search terms fol-
lows annual incidence-cycles, with highest search volume
during winter months and lowest interest during summer
months in countries from both hemispheres. GT was there-
fore used to (i) evaluate representative, laryngitis-related
search terms for English, and non-English speaking coun-
tries worldwide, (ii) evaluate the reliability of extracted
data, (iii) perform seasonality analysis, and (iv) compare
interest-peaks with geographical seasons. The results are
discussed in terms of validity for web-based instruments to
predict seasonal variations in information demand and
strategies to improve current health literacy.
MATERIAL AND METHODS
Ethical consideration
As this study utilized nonpersonally identifiable, publicly
accessible data, an ethical approval was not required in
accordance with the guidelines of the Ethics Committee
of the Medical University of Vienna.
Google Trends
GT (Google Inc26) is an online analysis tool, which allows
studies of search-query frequency (volume) on various
search terms entered on Google web search. Inquiries on
search terms using GT are specified for: (1) timeframe (real
time or customized timeframe, dating back to 2004), (2)
geographical location (country, state, or worldwide), (3) cat-
egory (eg, travel or health), and (4) content (eg, web search
or image search). GT displays search volumes as normalized
“ratios,” namely relative search volume (RSV), with higher
scores indicating more volume. GT therefore computes the
number of inquiries for the requested term and divides it by
all searches to account for countries with higher search vol-
ume. Following, this value is then rescaled as an integer
ranging from 0 to 100 based on the share of a topic com-
pared to all searches on all topics. This normalized ratio
then allows comparisons between up to five different search
terms simultaneously. In order to eliminate the potential
bias of repeated searches from the same person within a
short time, GT filters out these duplicate searches. Another
feature of GT is “Related queries,” which displays search
terms that users entered on Google Web search following
the specified one. Results of this feature can either be dis-
played in the “Top” category, presenting the most popular
search queries or “Rising,” which displays search terms
with the biggest increase since the last time period.
As already noted in previous works, search queries using
fixed filters done at different timepoints lead to (marginally)
99
different results for each new query. It was assumed that
GT uses a nondisclosed algorithm to select representative
data-samples for calculation of RSV, since the analysis of
Google’s entire amount of collected data is not feasible
in a short timeframe. Notably, there was evidence for an
association between population size and reliability of
retrieved datasets. 23,27
Search strategy
Previous reviews on GT-related research objectives pro-
vided a framework for online-based studies, which this
investigation followed.18,19 This study included countries
from both hemispheres, in order to assess seasonal varia-
tions globally.21,24,27,28 We therefore selected four major
English-speaking countries (Australia, Canada, United
Kingdom, and the United States) and two non-English
speaking countries from both hemispheres (Germany and
Brazil). First, we entered [laryngitis] as primary search
term in all countries selected and used GT function
“Related queries” and “Top” category to note all [laryn-
gitis] related search terms (Supplementary Table 1). Sec-
ond, we compared all relevant search terms with each
other using the comparison function, in order to pick up
the most representative search term with the highest RSV
for each country separately. The country specific search
term with the highest RSV (Table 1) was then used for
subsequent queries.
As mentioned above, searches done on different days
showed (slightly) different results. Therefore, the country-
specific, most representative search term was entered on
seven consecutive days (starting from November 1, 2019).
Subsequently, monthly RSV’s were extracted on a daily
base as comma-separated value files (CSV) from November
1, 2019 until November 8, 2019 in order to assess the reli-
ability of GT-data. This resulted in 189 data points (15 years
x 12 + 9 months) for each country, term, and day. We
selected the following two fixed factors for all queries: Time-
frame beginning from January 1, 2004 until September 30,
2019 and the “health” category. For purposes of compari-
son, winter months were defined as December through
March and summer months as June through September for
the northern hemisphere. Summer and winter months were
TABLE 1.
Search Terms that Were Selected Based on The Highest
Relative Search Volume for Each Country and Used for
Further Data Retrieval
Country Highest Relative Search Volume
Australia [laryngitis]
Brazil [laringite]
Canada [laryngitis]
Germany [kehlkopfentzu € ndung]
United Kingdom [laryngitis]
United States [laryngitis]
100 Journal of Voice, Vol. 36, No. 1, 2022

defined vice versa for countries from the southern
hemisphere.21,24,28 Finally, the number of inhabitants (in
million29) from included countries were also assessed on
November 8, 2019: Australia, 25; Brazil, 211; Canada, 37;
Germany, 83; United Kingdom, 67; United States, 329. All
datasets generated during the current study are available
from the corresponding author upon request.
Statistical analysis
Reliability of daily-retrieved GT data was assessed using the
intraclass correlation coefficient (ICC; two-way random
model) according to Shrout and Fleiss.30 We interpreted ICC
values as follows: ICC < 0.5 was considered poor, 0.5 ≤ ICC
< 0.75 moderate, 0.75 ≤ ICC < 0.9 good, and 0.9 ≤ ICC excel-
lent reliability.31 Bivariate correlation between reliability of
single time series data and number of inhabitants was per-
formed using Spearman rank sign correlation. We interpreted
correlation coefficients as follows: r(s) > 0.4 was considered
weak, 0.4 ≤ r(s) < 0.7 moderate, 0.7 ≤ r(s) < 0.9 strong, and r
(s) ≥ 0.9 perfect correlation.32 Subsequently, cosinor analysis
was used to determine annual seasonal variations in RSV for
single and averaged time series data.33 Single time series repre-
sented all data queried on the first day of data retrieval
(November 1, 2019) and averaged time series data were calcu-
lated as mean of single time series data extracted from seven
consecutive days (November 1, 2019 until November 8, 2019).
The cosinor model is a parametric seasonal model that fits a
sine wave based on linear regression using only a sine and
cosine parameter. Those two parameters are used to determine
the Amplitude A (Size) and Phase P (Peak) of the sinusoid.
Since we evaluated annual seasonal variations and the cosinor
model assumes the seasonal pattern to be symmetric and sta-
tionary, a peak and low point (peak § 6 months) was defined
once a year. Detailed descriptions of this method are available
elsewhere.33 Statistical significance can be tested as part of the
generalized linear model. The P value was set at 0.025 to
control for the Type I error rate. Data were analyzed and visu-
alized using the “season” and “ICC” package in R 3.5.1 (R
Development Core Team, 2008; R Foundation for Statistical
Computing, Vienna, Austria).
RESULTS
Reliability of GT data
The reliability of GT was assessed using the ICC for single
time series data queried over seven consecutive days, as speci-
fied above.30 We then performed a correlation analysis to
determine the association between the reliability of single time
series data and the number of inhabitants for each country.
The results showed moderate to good reliability for single
time series data of Australia, Brazil, and Canada. Excellent
reliability was found for single time series data of Germany,
the United Kingdom, and the United States. Averaged time
series data demonstrated higher reliability than single
time series data, showing excellent reliability for all coun-
tries (Table 2). Correlation analysis revealed a strong
correlation between single time series data and popula-
tion size (r (5) = 0.81, P = 0.07).
Winter peaks in search volume using single time
series data
To determine possible seasonal patterns in GT search vol-
ume for laryngitis related search terms in countries from
both hemispheres, we performed our analysis using single
time series data queried on the first day of data retrieval,
November 1, 2019.
Seasonality analysis revealed significant patterns and win-
ter peaks in countries from the northern hemisphere: Can-
ada (A = 13.95, P = 1.4, P < 0.001), Germany (A = 14.56,
P = 1.6, P < 0.001), United Kingdom (A = 14.38, P = 1.2,
P < 0.001), and the United States (A = 18.45, P = 1.3, P <
0.001). Similarly, significant winter peaks were found in

TABLE 2.
Reliability of Single and Averaged Time Series Data on Laryngitis Related Search Terms
Country Measure Intraclass Correlation Lower Bound Upper Bound F Df1 Df2 P value
Australia Single 0.72 0.60 0.80 30.1 188 1128 <0.001
Average 0.94 0.93 0.97 30.1 188 1128 <0.001
Canada Single 0.72 0.60 0.80 30.1 188 1128 <0.001
Average 0.95 0.91 0.97 30.1 188 1128 <0.001
Germany Single 0.96 0.96 0.97 205.1 188 1128 <0.001
Average 0.99 0.99 1.00 205.1 188 1128 <0.001
Brazil Single 0.79 0.75 0.83 30.8 188 1128 <0.001
Average 0.96 0.96 0.97 30.8 188 1128 <0.001
United Kingdom Single 0.95 0.93 0.96 145.9 188 1128 <0.001
Average 0.99 0.99 0.99 145.9 188 1128 <0.001
United States Single 0.97 0.96 0.98 264.4 188 1128 <0.001
Average 1.00 0.99 1.00 264.4 188 1128 <0.001
Abbreviations: Average, Averaged time series data; Df1, numerator degrees of freedom; Df2, denominator degrees of freedom; F, F-test for significance of the
correlation coefficient; Intraclass Correlation, Intraclass correlation coefficient; Lower and upper bound, 95% Confidence interval of the intraclass correlation
coefficient; Single, Single time series data.
David Tianxiang Liu, et al Seasonal Variations in Public Inquiries into Laryngitis 101

TABLE 3.
Cosinor Analysis on Seasonality of Laryngitis Related Search Terms
Country Measure Amplitude Peak* Nadir* Standard error P value
Australia Single 21.06 7.4 1.4 0.016 <0.001
Average 18.6 7.5 1.5 0.016 <0.001
Brazil Single 8.43 6.1 12.1 0.015 <0.001
Average 10.73 6.2 12.2 0.015 <0.001
Canada Single 13.95 1.4 7.4 0.016 <0.001
Average 13.95 1.4 7.4 0.016 <0.001
Germany Single 14.56 1.6 7.6 0.016 <0.001
Average 14.61 1.7 7.7 0.016 <0.001
United Kingdom Single 14.38 1.2 7.2 0.017 <0.001
Average 13.09 1.2 7.2 0.017 <0.001
United States Single 18.45 1.3 7.3 0.015 <0.001
Average 17.84 1.3 7.3 0.015 <0.001
* Number corresponds to the respective month (ie, 1, January; 2, February).
Abbreviations: Average, averaged time series data; Single, single time series data.

countries from the southern hemisphere: Brazil (A = 8.43,
P = 6.1, P < 0.001; Table 3) and Australia (A = 21.06,
P = 7.4, P < 0.001).
Hence it would seem that single time series data
showed winter peaks for laryngitis-related search terms
in countries from both hemispheres (Figure 1), which
was in line with our primary hypothesis. We were then
interested to determine whether averaged time series
data, extracted on seven consecutive days might also
pick up winter peaks.
Winter peaks in search volume using averaged time
series data
The results of cosinor analysis revealed significant seasonal
patterns with peaks during winter months in all countries
included, confirming the results of single time series analysis:
Australia (A = 18.6, P = 7.5, P < 0.001; Figure 2A), Brazil
(A = 10.73, P = 6.2, P < 0.001; Table 3; Figure 2B), Canada
(A = 13.95, P = 1.4, P < 0.001; Figure 2C), Germany
(A = 14.61, P = 1.7, P < 0.001; Figure 2D), the United King-
dom (A = 13.09, P = 1.2, P < 0.001; Figure 2E), and the
United States (A = 17.84, P = 1.3, P < 0.001; Figure 2F).
DISCUSSION
The identification of seasonal variations in web-based public
inquiries for laryngitis-related search terms is described
herein. To the best of our knowledge, this was the first dem-
onstration of annual cycles with winter peaks in Google
search query frequency for laryngitis-related search terms
across different countries from both hemispheres. Additional
important results include the reliability analysis of GT data,
also considering the number of inhabitants of each country.
These variations were also demonstrated for non-English
speaking countries as a proof-of-concept.
The role of meteorological factors and incidence of acute
laryngitis have been described previously based on a nation-
wide study.4 The authors showed that winterly weather
conditions, such as decreasing temperature and humidity
were strongly associated with an increasing incidence in
acute laryngitis. Since most cases of acute laryngitis are
attributed to self-limiting viral infections,2,7 our findings of
a single annual interest-cycle, with highest search volume
during winter months and lowest interest during summer
months were anticipated. Moreover, considering the associ-
ation between the presence of allergy and concurrent laryn-
geal symptoms,34 it is thus not surprising that web-based
search interest also displayed higher search volume in winter
transition months (at the beginning of the main pollination
period) compared to summer months.35−37 Based on these
findings, we speculate that an association between seasonal
variations of laryngitis related search volume and the
incidence of acute laryngitis exists.
A plausible explanation for the considerable interest in
laryngitis-related search terms may be related to the high
burden of hoarseness, which is the most common symptom
in patients affected by an acute laryngitis.9,13,38 Voice disor-
ders not only impact social life and daily activities, but also
have a negative effect on quality of life.11,12 This may well
result in a higher disease-specific search query frequency,
given the abundance of health information online.
Noteworthy, although acute laryngitis represents a self-
limiting symptom in the majority of cases, the financial bur-
den of laryngeal diseases on the health care system are
comparably high.13,39 This might also be attributed to addi-
tional disease entities, including neoplastic disease, involv-
ing repeated and costly interventions such as surgical or
radiation therapy.13
Regarding the antimicrobial treatment strategies for
acute laryngitis, clinical guidelines still lack high level evi-
dence in regards to possible benefits.40 Hence, the first-line
treatment of uncomplicated acute laryngitis is limited to
symptom control including vocal hygiene, air humidifier,
and analgesic therapy if needed.40,41 The fact that treatment
of this disease does not necessarily involve a physician office
visit, highlights the importance of easily accessible, reliable,
102
FIGURE 1. Time series plot of Google based relative search volume for laryngitis related terms in Australia (A), Brazil (B), Canada (C),
Germany (D), United Kingdom (E), and United States (F) from January 1, 2004 until September 30, 2019. Points represent monthly means.
and plain information on the World Wide Web from reli-
able sources. Such information will not only improve health
literacy among the general population but also allows the
public to recognize potential red flags (eg, stridor, prolonged
hoarseness with history of smoking).
The reliability of GT has been addressed in a previous
work on behavioral forecasting of suicide rates.23 The
authors found evidence that GT-data from larger countries
display higher reliability compared to smaller countries and
recommended the use of averaged time series data, retrieved
on different days for research objectives. An association
between the number of inhabitants and reliability of single
time series data were also apparent during our study as
revealed by the correlation coefficient. Hence, we also sup-
port the aforementioned recommendation on averaged time
series data and would like to highlight the importance of
reliability analysis when using GT data.
The importance of voice in everyday life and efforts to
increase awareness for the human larynx and its pathologies
among the general population have culminated in a “world
voice day,” which now takes place every year on April 16.
Interestingly, the first voice awareness day was promoted by
the Brazilian Society of Laryngology and Voice in 1999.42
Journal of Voice, Vol. 36, No. 1, 2022
In view of the laryngitis-related search interest peak for Bra-
zil, which was determined as June during our analysis, the
fact that the world voice day was optimally timed at the
beginning of winter may just be coincidence, but might also
have an additional positive impact on public awareness.
Although seasonal variations were consistent in all coun-
tries evaluated, this study also has limitations. First, GT
data does not reflect real-world incidence rates, but rather
the variations in public inquiry into specific search terms. It
is well known that news coverage and media reports on
different topics generate significant public interest and
response.43 Therefore, timeseries data should always be
assessed for unexpected incidence peaks prior to analyses.
However, since we covered a timeframe of more than
15 years and found no outliers during initial data visualiza-
tion, small variations in search volume should not have
affected our results to a large extend. Second, inherent to
the comparison of web-based interest peaks with winter
months is the assumption, that weather conditions vary
only slightly across individual countries. We also included
larger countries such as Brazil or the United States in our
analysis, and thus our results may only represent regions
with more inhabitants (and therefore higher search volume).
David Tianxiang Liu, et al Seasonal Variations in Public Inquiries into Laryngitis 103

FIGURE 2. Average seasonal variation for Google based relative search volume for laryngitis related terms in Australia (A), Brazil (B),
Canada (C), Germany (D), United Kingdom (E), and United States (F) from January 1, 2004 until September 30, 2019. The curve represents
the adjusted cosinor analysis model. Points represent monthly means and the two horizontal lines mark the standard error. Abbreviations: 1,
January; 2, February; 3=March; 4, April; 5=May; 6, June; 7, July; 8, August; 9, September; 10, October; 11, November; 12, December.
104
Although it might be expected that weather conditions vary
more within the United States compared to Canada,44 web-
based interest peaks showed little to no relevant differences
between these countries. Nevertheless, future studies will
reveal whether regional differences in climate conditions
have influences on web-based search frequency of different
medical conditions. Third, since GT-data neither include
demographic information nor account for inter-individual dif-
ferences such as socioeconomic status or age distribution, the
generalization must be made very cautiously. One possibility
to partly account for these factors might be to consider the
share of internet users by age groups for each country sepa-
rately during data interpretation.
Concerning the relevance of this work, we emphasize
these results to be important for current online-health edu-
cation strategies. With the constant pursuit of technological
and mobile network advances, web-based information can
be accessed nearly everywhere at any time. Simultaneously,
the rise of social media and its growing influence on “Gener-
ation Google” must also be considered.45 Particularly, the
danger of rapidly spreading, health-related misinformation
have become a major issue, which can be potentially fatal at
the individual level.46 Hence, there is an urgent need to iden-
tify future efforts on strategies guiding health-information
seeking individuals to reliable and easily understandable
directives. One way to do so would be to consider state-of-
the-art marketing strategies, such as quality-controlled, inter-
net-based advertising methods. Applying these approaches to
current online-health education strategies could possibly
open a new door to personalized medicine. This might not
only reduce the risk of being misinformed, but also reduce
the spread of false information. Either way, further coopera-
tion efforts between traditional online health-information
providers such as governments, health insurances, or medical
professionals are certainly warranted.
CONCLUSION
Public interest in laryngitis-related, online health informa-
tion displayed seasonal variations in countries from both
hemispheres, with highest interest during winter months.
Our results were concurrent with previous findings on win-
ter-weather conditions and occurrence of acute laryngitis
and may provide further evidence for this incidence peak.
These findings may also be valuable regarding optimal
timing of web-based health education and emphasize the
importance of reliable, accurate, and high-quality online
information sources.
Acknowledgments
The authors greatly thank David Lumenta (Medical Uni-
versity of Graz) for his valuable advices.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found
online at https://doi.org/10.1016/j.jvoice.2020.04.018.
Journal of Voice, Vol. 36, No. 1, 2022
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