Hoarseness 3

Take a history from this 60 year old lady who has had a hoarse voice following discharge from ITU, where she was ventilated after a cardiac arrest.

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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