Hoarseness 1

Take a history from this 48 year old teacher with a hoarse voice.

Example answer

 

History

  • Onset
  • Duration
  • Timing – episodic or constant
  • Voice quality – gravelly, breathy, weak/whispering
  • Severity – complete loss of voice?
  • Progression – does hoarseness worsen during the day? 
  • Exacerbating and relieving factors
  • Associated symptoms – reflux, stridor, sore throat, neck lumps, post-nasal drip, generalised weakness 
  • Predisposing events – voice abuse or overuse, URTI, recent intubation
  • Red flag symptoms – odynophagia, referred otalgia, dyspnoea, dysphonia, haemoptysis, haematemesis
  • Past Medical History – respiratory disease, thyroid disease, recent surgery (e.g. cervical spine, thyroid/parathyroid, mediastinal, carotid artery, neck dissection)
  • Drug History – inhaled corticosteroids
  • Social History – smoking, alcohol, occupation (high-risk occupations include teaching, acting, singing and stockbrokers), hobbies (e.g. singing)
  • Family History – Family history of cancer 
  • Systems review
  • Elicit the patient’s ideas, concerns and expectations 

 

Conclusion

  • Summarise consultation
  • Thank patient
  • Offer appropriate differential diagnosis

Differential diagnoses to consider*

Benign

  • Benign vocal cord lesions
    • Vocal cord polyp
    • Vocal cord nodules (Singer’s nodules)
    • Vocal cord granuloma
  • Reinke’s Oedema
  • Laryngeal papillomatosis
  • Muscle tension dysphonia

Malignant

  • Neoplasm

Infective

  • Viral laryngitis
  • Epiglottitis

Other

  • Laryngeal trauma
  • Post-nasal drip
  • Habitual throat clearing
  • Inhaled corticosteroids – dry mucous membranes

Autoimmune

  • Hypothyroidism
  • Inflammatory arthritis

Neurological

  • Parkinson’s plus syndrome
  • Myasthenia gravis
  • Multiple sclerosis

*Table not exhaustive

 

Management

 

You will be asked to suggest an appropriate management plan based on your presumed diagnosis. Ensure that you offer a complete ENT examination including nasendoscopy prior to further investigations. 

Some examples are below:-

Suspected diagnosis

The following investigations/management strategies may be indicated however you must offer based on the clinical scenario you are given

Suspected malignancy

Microlaryngoscopy ± biopsy, CT larynx, MRI neck, CT thorax

Benign pathology

Microlaryngoscopy ± biopsy, voice rest, speech and language therapy

Neurological disorder

Neurology referral 

Rheumatological disorder

Rheumatology referral 

Post-nasal drip

Treat chronic rhinosinusitis

Inhaled steroids

Patient education – rinse mouth after use, ask GP/Respiratory to consider changing inhalers

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