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“There’s a frog in my throat, Dr”
Mr Richard Harris. ENT SpR Royal Devon & Exeter NHS Foundation Trust
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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!
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My favourite subject
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Background Birmingham graduate Currently on Peninsula SpR rotation
Work at RD&E Fellow in Head & Neck Surgery at Royal Melbourne Hospital.
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Stupid questions
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Specialists’ bugbears
Missed red flags Lack of information on 2ww referrals Longstanding misdiagnosis Poor descriptions of anatomy
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Who’s the Daddy?
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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?”
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Is it this…..
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……..or this
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Common pathology LPR Vocal cord dysfunction Reinke’s oedema
Laryngeal SCC Vocal cord nodules Catarrh/postnasal drip/phlegm/sinusitis
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History Absolutely key Endoscopic predictor
GP advantage of knowing the pt- use it!
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What should you ask?
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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
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Case 1 81 years old Male non smoker Wife has trouble hearing him
Voice feels weaker Has got worse over last 12 months
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Presbyphonia Harmless Due to VC atrophy Rule out neoplasia Sympathy
Speech therapy VC augmentation
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Case 2 63 year old male smoker 3 months constant hoarseness Cough
Husky voice No weight loss Neck normal
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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!
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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.
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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
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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
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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
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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
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LPR Reflux of acid and pepsin Often silent Symptoms often fluctuate
Lifestyle change PPI twice daily (pre-prandial) Gaviscon advance nocte
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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
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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
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Examination ?need to do it Absolutely!
Helps get a good idea of “normal”
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Examination Airway! Oral cavity Oropharynx Neck
General appearance -cachexia -nicotine stains
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Key points Throat symptoms are common Laryngeal SCC is not that common
History is key Reassurance very therapeutic If in doubt-refer.
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Help ENT SpR H&N CNS -Claire Barber - Julie Northcott
SALTs -Camilla Dawson -Claire Higgins
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Help Head and Neck Voice Thyroid Mr Andrew Brightwell
Mr Andrew Husband Voice Mr Malcolm Hilton Thyroid Mr Dick Garth.
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The End
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Thank you.
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