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

2. 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!

3. My favourite subject

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

5. Stupid questions

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

7. Who’s the Daddy?

9. 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?”

10. Is it this…..

11. ……..or this

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

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

14. What should you ask?

15. 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

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

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

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

22. 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!

23. 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.

25. 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

26. 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

28. 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

29. 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

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

32. 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

34. 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

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

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

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

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

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

41. The End

42. Thank you.