Mr Richard Harris. ENT SpR Royal Devon & Exeter NHS Foundation Trust 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! Birmingham graduate Currently on Peninsula SpR rotation Work at RD&E Fellow in Head & Neck Surgery at Royal Melbourne Hospital. Missed red flags Lack of information on 2ww referrals Longstanding misdiagnosis Poor descriptions of anatomy “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?” LPR Vocal cord dysfunction Reinke’s oedema Laryngeal SCC Vocal cord nodules Catarrh/postnasal drip/phlegm/sinusitis Absolutely key Endoscopic predictor GP advantage of knowing the pt- use it! Duration Constant/intermittent Pain Dysphagia Try to avoid the pt naming a condition Voice change Voice fluctuation Social history Symptoms through the day 81 years old Male non smoker Wife has trouble hearing him Voice feels weaker Has got worse over last 12 months Harmless Due to VC atrophy Rule out neoplasia Sympathy Speech therapy VC augmentation 63 year old male smoker 3 months constant hoarseness Cough Husky voice No weight loss Neck normal 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 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. 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 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 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 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 Reflux of acid and pepsin Often silent Symptoms often fluctuate Lifestyle change PPI twice daily (pre-prandial) Gaviscon advance nocte 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 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 ?need to do it Absolutely! Helps get a good idea of “normal” Airway! Oral cavity Oropharynx Neck General appearance -cachexia -nicotine stains Throat symptoms are common Laryngeal SCC is not that common History is key Reassurance very therapeutic If in doubt-refer. ENT SpR H&N CNS SALTs -Claire Barber - Julie Northcott -Camilla Dawson -Claire Higgins Head and Neck ▪ Mr Andrew Brightwell ▪ Mr Andrew Husband Voice ▪ Mr Malcolm Hilton Thyroid ▪ Mr Dick Garth.