HEENT Potpourri

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)

42. Associated Co-morbidities Primary snoring is not associated with hypertension UARS and OSA are associated with hypertension Hypertension puts the patient at increased risk of cardiovascular and cerebrovascular disease Caveat: remember the spectrum�

43. Important History Elements Obtain history from spouse/roommate Ask about observed apnea, snoring pattern, sleeping position and gasping/choking Daytime somnolence (Epworth scale) Allergy/sinus disease, nasal polyps, nasal trauma or nasal surgery

44. Important Exam Elements Blood pressure Calculate BMI and note obesity pattern Neck circumference Complete nasal exam Evaluate oropharynx Consider classifying using anesthesia assessment Uvula enlargement may be due to snoring Check for retrognathia

45. Modifiable Risk Factors Chronic Post-Nasal Drainage Nasal Polyps, Enlarged Tonsils or other Nasopharyngeal Pathology Hypothyroidism Acromegaly Medications (Sedatives, Muscle Relaxants) Pregnancy Tobacco Abuse (includes passive exposure) Alcohol Use

46. Primary Snoring vs UARS/OSA Clinically difficult to distinguish Several clinical prediction models exist for OSA that have improved accuracy over physician judgment Sleep study is the gold standard

47. Indications for Sleep Study Apnea observed by patient�s bed partner Awakening by gasping or choking sensation Loud or disruptive snoring pattern Shirt collar size has increased by 2 sizes Daytime sleepiness not explained by sleep deprivation Driving accidents related to sleepiness Unexplained or difficult to manage hypertension Angina or arrythmias during sleep Morning headache

48. A proposed approach to snoring�

49. Barriers to Definitive OSA Testing It is not cost-effective to have all snoring patients undergo a sleep study Sleep study is prohibitively expensive Could consider lateral neck xrays to evaluate upper airways, however these have not been proven to predict OSA

50. Treatment of Primary Snoring Conservative Management Weight Loss Avoid Alcohol and Tobacco Positional Therapy Medications Improving Nasal Patency Oral Appliances Nasal CPAP Surgery

51. Treatment of Primary Snoring Poor objective data to support ESSENTIALLY THE SAME AS TREATMENT FOR OSA However, the treatment generally works better for OSA than it does for primary snoring

52. Conclusions Be aggressive about ruling out OSA Primary snoring is not associated with vascular disease Spectrum of progression from Primary Snoring to OSA Evaluation and treatment of snoring is extremely similar to that of OSA

53. Major References www.uptodateonline.com Clark, AR et al. Evaluating Hoarseness: Keeping Your Patient�s Voice Healthy. American Family Physician. June 1998;57(11). Parker, RJ Snoring. BMJ. 2005 November 5;331(7524):1063. Barker LR et al. Principles of Ambulatory Medicine 6th edition, 2003.