1. Hoarseness and Sore Throat Dr Deborah Amott ENT Surgeon dhamott@hotmail.com

2. Core Presentations By the end of this year, you should be able to perform a competent medical interview, physical examination and suggest a basic investigational plan for a patient presenting with this symptom.

3. An accurate diagnosis is: 90% History 9% Examination 1% Investigations

4. General Pathological Processes VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid-base imbalance/auto-immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic: too much vs. too little of an otherwise good thing

5. What is Hoarseness? What is the Throat?

6. What is Hoarseness? “A noisy quality to the voice”

7. What is the Throat?

8. Function of the Upper Aerodigestive Tract Nose Oral Cavity Nasopharynx Oropharynx Hypopharynx Oesophagus Larynx Trachea

9. Function of the Upper Aerodigestive Tract Nose: airway, humidification, warming, smell, filtration Oral Cavity: airway, mastication, swallowing, articulation Nasopharynx: airway, Eustachian tube function, immune surveillance Oropharynx: airway, swallowing, voice production Hypopharynx: airway, swallowing Oesophagus: food, prevention of reflux Larynx: airway, airway protection, voice Trachea: airway

10. Larynx : symptoms? 3 ish

11. Larynx : symptoms Airway Airway protection Too little Too much Voice

12. Pharynx Symptoms? 7

13. Pharynx Lumpiness/foreign body sensation Pain: general, specific Obstruction Bleeding Poor co-ordination Regurgitation/reflux Change in secretions: too wet, too dry, too thick

14. Context of the Hoarseness/Sore Throat Symptom itself: acuity, duration, severity, variability, progression, triggers/relievers. Patient: age, sex, race, lifestyle (profession, hobbies, smoking, alcohol, other drugs, other carcinogens/toxins, diet), immune status (Immunosuppressed? Atopic? Autoimmune conditions?), geography. Associated features: what else is changing? Local, adjacent structures Regional Distant organ dysfunction Systemic symptoms

15. Ask 4 Questions… What is the most likely diagnosis? What is the most IMPORTANT diagnosis? Could this be life-threatening? What information do I need to confirm my diagnosis? What’s my time frame?

16. What do you need to ask the patient about?

17. You ask about: All laryngeal and pharyngeal symptoms Reach a common understanding Trigger/s Ongoing exacerbating factors Risk profile of patient

18. You ask about: All laryngeal and pharyngeal symptoms Reach a common understanding Triggers: acute vocal injury, URTI, trauma Ongoing exacerbating factors: vocal use, hydration, smoking, reflux, inhaled steroids. Risk profile of patient: malignancy, infection

19. Concerning Symptoms?

20. Concerning Symptoms Rapid, severe onset of pain Airway symptoms Constant symptoms Progressive symptoms Anything that lasts >2weeks Patient factors: risk factors for malignancy or uncontrolled infection

21. Examination

22. Is the airway threatened?

23.  Exercise tolerance Dyspnoea with minor exertion (  RR) Dyspnoea at rest (  HR) Can’t lie flat Stridor (O 2 Sat n WNL) Eerie silence Cyanosis (  Sat n ) Death Variable Min - Sec

24. Do not ‘tick the boxes’ if the airway is threatened

25. CALL FOR HELP

26. Likely Diagnosis? 18yo male, previously well Sore throat for 24hrs. Built from nothing over a few hours, quite localised to the throat Hurts to talk, to eat and to swallow. Both ears hurt. Febrile Breathing easily.

27. Likely Diagnosis? 3yo boy from Daylesford Mild URTI beginning yesterday. This evening, he developed a high fever and mild hoarseness. He is refusing to eat or drink. You notice he’s drooling. When you ask him to lie back to examine him, he refuses and becomes more upset.

28. Likely Diagnosis? 55yo male, singer and actor PHx adult onset asthma, recurrent bronchitis, chest pain last year during a gig (not investigated). Intermittent sore throat and hoarse voice, gradually getting worse over last 3mths on tour. Now hoarse all the time, coughs +++ when drinks cold fluids.

29. Likely Diagnosis? 94yo male, Nursing Home resident Intermittent hoarseness – a ‘gurgly voice’ Coughs ++ during meals and for several hours afterwards 2 admissions to RMH for pneumonia in the last 12 months

31. Investigations Know the question you want to answer. Only order an investigation if the result will affect your management A proper initial clinical assessment and then repeated thorough clinical assessment is always much better than multiple non-targeted tests. Recruit help

32. Investigations Blood tests Microbiology: bacteria, fungal, viral, parasitic Biopsies Imaging Other: resp function tests, endoscopy, oximetry, ABGS etc. Operations: diagnostic endoscopy, open operations

33. Imaging Plain XRs Fluoroscopy Ultrasound Computed Tomography Magnetic Resonance Imaging Positron Emission Tomography Nuclear Medicine Scans The weird and wonderful

34. Treatment Behavioural: avoid triggers, diet, exercise, sleep, environmental modification, mood management Non-pharmacological treatments: hygiene measures, moisturisers, saline rinsing, dietary supplements etc Pharmacologic: topical, enteral, transcutaneous, injections Interventional Minimal: endoscopic, angiography, etc Maximal: open surgery, radiation etc What’s the Cost vs. Benefit?

35. ?

36. References