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HEENT Potpourri

Outline of Topics. HoarsenessSnoringHiccupsTinnitus. Goals. Discuss evaluation of these symptoms from the internist's perspectiveProvide a thoughtful approach to ancillary testing and referralIdentify ?red flags"Briefly mention some aspects of treatment for the more common diagnoses. Hoarsen

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HEENT Potpourri

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    1. HEENT Potpourri May S. Jennings, MD 11/21/06

    2. Outline of Topics Hoarseness Snoring Hiccups Tinnitus

    3. Goals Discuss evaluation of these symptoms from the internist’s perspective Provide a thoughtful approach to ancillary testing and referral Identify “red flags” Briefly mention some aspects of treatment for the more common diagnoses

    4. Hoarseness Any change in vocal quality “Dysphonia”

    5. Anatomy of the Larynx

    6. Anatomy of the Larynx

    7. Anatomy of the Larynx

    8. Important History Elements Qualities of the vocal disorder Vocal History PMHx Medications Tobacco, Alcohol and Chemical Exposure Complete ROS with attention to symptoms common in head/neck/thorax malignancies

    9. Qualities of the Vocal Disorder Duration Sudden or Gradual Onset Description of the Change in Phonation

    10. Vocal History Vocal Personality Type Occupation Vocal Abuse Hearing Loss

    11. PMHx GERD Allergic Rhinitis/Chronic Sinusitis Surgical History

    12. Medications Aspirin, NSAIDS and anticoagulants Antihistamines and diuretics

    13. ROS Screen for symptoms of: GERD Post nasal drip Upper Respiratory Infection Malignancy (focus on head, neck, and thorax) Hypothyroidism Don’t forget to ask about otalgia

    14. Exam: Voice Quality Coarse/Rough/Gravelly/Husky Weak and Breathy/Persistent Glottic Gap with Phonation and Air Escape Loss of Vocal Ranges with weakness and cracking Low-Pitched Tremor Intermittent Whispering/Complete Aphonia Halting/Strained/Strangled

    15. Exam: Laryngoscopy PATIENTS WITH HOARSENESS LASTING MORE THAN 2 WEEKS SHOULD BE REFERRED FOR LARYNGOSCOPY

    16. Differential Diagnosis Acute Laryngitis Chronic Laryngitis Vocal Cord Edema Polyps, Nodules and Tumors Neuromuscular Dysfunction Unilateral Vocal Cord Paralysis Conversion Disorders

    17. Acute Pharyngitis Upper respiratory infection Viral Bacterial Moraxella catarrhalis Hemophilus influenza Acute vocal strain

    18. Acute Pharyngitis: Treatment Vocal Rest, Humidification and Hydration Systemic corticosteriods? No role for antibiotics

    19. Chronic Laryngitis Chronic irritant exposure Chemical Fumes Chronic Tobacco Use Chronic Alcohol Use Chronic Vocal Strain Reflux Disease GERD Laryngopharyngeal Reflux

    20. GERD Causes reflux of gastric contents into the hypopharynx Chronic laryngitis as well as contact ulceration and granuloma formation 40% complain of heartburn symptoms May require 8 weeks of therapy Treatment: Conservative Bedtime H2-blocker PPI

    21. Laryngopharyngeal Reflux Retrograde movement of gastric contents into the laryngopharynx Acid Enzymes (Pepsin) Typical symptoms include: Globus sensation Mild dysphagia Chronic cough Nonproductive throat clearing

    22. GERD LPR More heartburn (?) More esophagitis LES Lying down More esophageal dysmotility Stomach/esophagus have more protection H2 blocker/PPI Less heartburn Less esophagitis UES Standing, exertion Less esophageal dysmotility Larynx has less protection High dose PPI

    23. LPR What is the clinical significance of this diagnosis? Is it just a variant of GERD?

    24. Vocal Cord Edema Polypoid corditis or Reinke’s edema Bilateral, enlarged, floppy vocal cords Seen with tobacco, GERD and hypothyroidism

    25. Polyps, Nodules and Tumors: Vocal Cord Polyps

    26. Polyps, Nodules and Tumors: Laryngeal Cancer

    27. Neuromuscular Dysfunction Spasmodic dysphonia Muscle tension dysphonia Parkinson’s disease

    28. Unilateral Vocal Cord Paralysis

    29. Conversion Disorder Somatization disorder Intermittent symptoms Paradoxical vocal cord motion Significant inspiratory stridor Often receive substantial pulmonary workup prior to accurate diagnosis

    30. Case #1 50YO obese salesman 3 month hoarseness, worse in AM Sour taste in his mouth and “chokes on fluid” during sleep No heartburn or chest pain Chronic tobacco use Recent job promotion

    31. Case #1 Laryngoscopy: Edema of the posterior larynx Rx: PPI for GERD, smoking cessation

    32. Case #2 24 YO F 3 months of hoarseness Rejoined the choir 6 months ago No tobacco or alcohol

    33. Case #2 Laryngoscopy: Vocal nodules Rx: Vocal training

    34. Case #3 67YO M Recent onset of hoarseness and fatigability of his voice Difficulty raising his voice in a crowd Recent cough when drinking liquids Tobacco abuse No surgical history

    35. Case #3 Laryngoscopy: Unilateral vocal cord paralysis Dx: Adenocarcinoma of the lung

    36. Case #4 35YO M with 1 month hoarseness Change in voice described as “rough and gravelly” Tobacco abuse, 2 beers per week No other symptoms

    37. Case #4 Laryngoscopy: Irregular nodule Bx: Squamous cell carcinoma of the larynx

    38. “Case report” differential diagnoses Use of systemic isoretinoids Cardiovocal syndrome (Ortner’s) Unusual tumors (primary and metastases) Spontaneous pneumomediastinum Infections (cryptococcus, histoplasmosis, human papilloma virus, herpes, mycobacteria) Madelung’s disease Gout Relapsing polycondritis

    39. Conclusions A careful history and physical can make the presumptive diagnosis Be aggressive about ruling out laryngeal cancer Patients with 2 weeks of hoarseness should be referred for laryngoscopy Although hoarseness tends to be a minor complaint, it is can be a clue to significant disease

    40. Snoring An inspiratory sound produced by vibration of the soft tissues of the upper airway during sleep

    41. Spectrum of Upper Airway Resistance Primary Snoring Upper Airway Resistance Syndrome (UARS) Obstructive Sleep Apnea (OSA)

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