“There’s a frog in my throat, Dr” Mr Richard Harris. ENT SpR Royal Devon & Exeter NHS Foundation Trust

Rationale ENT poorly taught in the UK Throat symptoms common in GP Symptoms are often vague Patients are often anxious GPs may be daunted/uninterested/naïve Many conditions treatable Cancer prognosis dependent on stage Nimita asked me to!

My favourite subject

Background Birmingham graduate Currently on Peninsula SpR rotation Work at RD&E Fellow in Head & Neck Surgery at Royal Melbourne Hospital.

Stupid questions

Specialists’ bugbears Missed red flags Lack of information on 2ww referrals Longstanding misdiagnosis Poor descriptions of anatomy

Who’s the Daddy?

Aim to answer: “what should I not refer?” “what should I definitely refer?” “how should I manage X in the community?” “when should I be worried about….?” “how should I describe this?” “who can help me with this?”

Is it this…..

……..or this

Common pathology LPR Vocal cord dysfunction Reinke’s oedema Laryngeal SCC Vocal cord nodules Catarrh/postnasal drip/phlegm/sinusitis

History Absolutely key Endoscopic predictor GP advantage of knowing the pt- use it!

What should you ask?

What should you ask? Duration Constant/intermittent Pain Dysphagia Try to avoid the pt naming a condition Voice change Voice fluctuation Social history Symptoms through the day

Case 1 81 years old Male non smoker Wife has trouble hearing him Voice feels weaker Has got worse over last 12 months

Presbyphonia Harmless Due to VC atrophy Rule out neoplasia Sympathy Speech therapy VC augmentation

Case 2 63 year old male smoker 3 months constant hoarseness Cough Husky voice No weight loss Neck normal

Laryngeal SCC Strong link with tobacco Alcohol synergistic Glottic most common Voice symptoms common -hoarseness -hot potato Distant Sx may present first Beware otalgia in the normal ear!

Case 3 23 years old newly qualified teacher Non smoker 8 weeks of constantly altered voice Pretty quick onset over a few days Getting worse Husky and breathy.

Vocal cord nodules Due to “voice abuse” More common in women Cause a husky, breathy voice Most respond to SALT Some need surgery ~6% of adult voice disorders

Case 4 57 year old female Ex smoker Intermittent voice change Sometimes has to strain to speak Can feel a lump in her throat No dysphagia Examination NAD

Vocal cord dysfunction Common! Due to loss of synergy in laryngeal muscles Often globus Sx accompany Often psychological component SALT/ENT collaboration to treat Response to PPI usually placebo

Case 5 48 year old company director Voice gruff in the morning Throat dry and sore first thing Things get a bit better in the day Needs to clear throat a lot but can’t No weight loss

LPR Reflux of acid and pepsin Often silent Symptoms often fluctuate Lifestyle change PPI twice daily (pre-prandial) Gaviscon advance nocte

Case 6 54 year old female bank manager Heavy smoker for 30 years Upset as voice gruff and low pitched- has been mistaken for a man on the phone! No weight loss No heartburn

Reinke’s oedema Chronic vocal cord oedema Almost exclusive to smokers 50-60 common age at onset Deeper pitch Gruff voice Effortful speaking Stop smoking Vocal hygiene Surgery

Examination ?need to do it Absolutely! Helps get a good idea of “normal”

Examination Airway! Oral cavity Oropharynx Neck General appearance -cachexia -nicotine stains

Key points Throat symptoms are common Laryngeal SCC is not that common History is key Reassurance very therapeutic If in doubt-refer.

Help ENT SpR H&N CNS -Claire Barber - Julie Northcott SALTs -Camilla Dawson -Claire Higgins

Help Head and Neck Voice Thyroid Mr Andrew Brightwell Mr Andrew Husband Voice Mr Malcolm Hilton Thyroid Mr Dick Garth.

The End

Thank you.