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“There’s a frog in my throat, Dr ”

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

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“There’s a frog in my throat, Dr ”

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

  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?

  8. 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?”

  9. Is it this…..

  10. ……..or this

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

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

  13. What should you ask?

  14. 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

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

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

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

  18. 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!

  19. 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.

  20. 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

  21. 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

  22. Vocal cord dysfunction • Common! • Due to loss of synergy in laryngeal muscles • Often globusSx accompany • Often psychological component • SALT/ENT collaboration to treat • Response to PPI usually placebo

  23. 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

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

  25. 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

  26. 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

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

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

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

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

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

  32. The End

  33. Thank you.

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