“there’s a frog in my throat, dr ”
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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“There’s a frog in my throat, Dr”
Mr Richard Harris. ENT SpRRoyal Devon & Exeter NHS Foundation Trust
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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!
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My favourite subject
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Background
Birmingham graduate Currently on Peninsula SpR rotation Work at RD&E Fellow in Head & Neck Surgery at
Royal Melbourne Hospital.
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Stupid questions
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Specialists’ bugbears
Missed red flags Lack of information on 2ww referrals Longstanding misdiagnosis Poor descriptions of anatomy
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Who’s the Daddy?
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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?”
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Is it this…..
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……..or this
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Common pathology
LPR Vocal cord dysfunction Reinke’s oedema Laryngeal SCC Vocal cord nodules
Catarrh/postnasal drip/phlegm/sinusitis
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History
Absolutely key Endoscopic predictor GP advantage of knowing the pt- use
it!
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What should you ask?
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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
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Case 1
81 years old Male non smoker Wife has trouble hearing him Voice feels weaker Has got worse over last 12 months
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Presbyphonia
Harmless Due to VC atrophy
Rule out neoplasia Sympathy Speech therapy VC augmentation
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Case 2
63 year old male smoker 3 months constant hoarseness Cough Husky voice No weight loss Neck normal
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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!
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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.
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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
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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
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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
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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
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LPR
Reflux of acid and pepsin Often silent Symptoms often fluctuate
Lifestyle change PPI twice daily (pre-prandial) Gaviscon advance nocte
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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
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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
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Examination
?need to do it Absolutely!
Helps get a good idea of “normal”
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Examination
Airway! Oral cavity Oropharynx Neck General appearance -cachexia
-nicotine stains
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Key points
Throat symptoms are common Laryngeal SCC is not that common History is key Reassurance very therapeutic
If in doubt-refer.
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Help
ENT SpR H&N CNS -Claire Barber
- Julie Northcott SALTs -Camilla Dawson
-Claire Higgins
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Help
Head and Neck▪ Mr Andrew Brightwell▪ Mr Andrew Husband
Voice▪ Mr Malcolm Hilton
Thyroid▪ Mr Dick Garth.
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The End
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Thank you.