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“There’s a frog in my throat, Dr”

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Presentation on theme: "“There’s a frog in my throat, Dr”"— Presentation transcript:

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.

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