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Hoarse voice 137
HOARSE VOICE
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What is the important nding on examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.21 –
Hoarse voice 1
A female teacher aged 45 has an intermittent hoarse voice and is concerned that this may affect her job.
CASE 2.22 –
Hoarse voice 2
A 63-year-old heavy smoker presents with a progressive hoarse voice of 6 weeks’ duration.
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138 Ear, nose and throat (ENT)
OSCE Counselling case
OSCE COUNSELLING CASE 2.17 –
A woman with an intermittent hoarse
voice is worried about her career as a
teacher and her voice problem. What
advice would you give?
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Hoarse voice 139
Key concepts
Intermittent hoarse voice is benign.
Continual hoarse voice in a smoker is malignant.
Speech and language therapy should be tried before surgery in benign conditions.
Smokers may have more than one neoplasm.
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140 Ear, nose and throat (ENT)
Answers
Clinical cases
CASE 2.21 –
Hoarse voice 1
A1: What is the likely differential diagnosis?
Vocal cord nodules, muscle tension dysphonia and laryngopharyngeal reux
A2: What additional features in the history would you like to elicit?
Ask about the nature of the job and when the hoarseness comes on. See whether the voice goes back
to normal. If it is intermittent and comes on during the day, or during times of persistent voice use, it is
almost certainly benign. Find out about hobbies such as singing. Ask about stress and the voice. Enquire
about the symptoms of hiatus hernia and thyroid disease, and also whether the patient smokes or has
chest disease such as asthma. Ask about nasal symptoms and snoring because this may dry the throat.
Sinusitis is a rare cause of the problem and is often secondary to asthma and coughing.
A3: What is the important nding on examination?
Examination of the neck is usually uneventful. A exible nasendoscopy in the clinic may show how the
vocal apparatus is working and whether there are any lesions on the vocal cords. Singers’ nodules are
a sign of vocal misuse and occasionally a unilateral vocal cord polyp may be found. Bilateral diffuse
oedema suggests chronic persistent abuse but may be found in conditions such as thyroid disease. In
patients with laryngopharyngeal reux the posterior larynx appears inamed. Muscle tension dysphonia
is a common problem in professional voice users and leads to insufcient adduction of the cords on
phonation.
A4: What investigations would be most helpful and why?
These are rarely needed but do include an FBC and thyroid function tests.
A5: What are the treatment options?
Vocal hygiene should be practiced, such as frequent drinks to keep the larynx moist (not alcohol).
Refrain from smoking if the patient is a smoker. Trials have shown that speech and language therapy is
effective. Surgery is occasionally needed in patients with hoarseness. If the patient has asthma, therapy
may improve the voice but sometimes the irritation is the result of the inhalers, or Candida species, on
the vocal cords.
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Hoarse voice 141
CASE 2.22 –
Hoarse voice 2
A1: What is the likely differential diagnosis?
Carcinoma of nasopharynx/larynx
A2: What additional features in the history would you like to elicit?
The history should be taken similar to that in the previous case. The smoking history is most important
here. Progressive hoarseness that lasts longer than 6 weeks is most likely to be a neoplasm. Examination
of the neck is often uneventful because secondary nodes rarely occur in a simple carcinoma of the
larynx as it presents relatively early.
A3: What is the important nding on examination?
Examination of the larynx will show a laryngeal cancer. This is classied by the TNM (tumours, node,
metastases) classication, which helps to determine the treatment.
A4: What investigations would be most helpful and why?
A neck and chest CT should always be taken because secondary neoplasm in the chest occurs in 10
per cent of patients, this also aids in staging the disease. Similarly, an FBC, U&Es and liver function
tests, together with thyroid function tests, may be required before radiotherapy or surgery.
A5: What are the treatment options?
Treatment depends on the TNM classication. Very small malignant squamous cell tumours can be
removed with LASER once a biopsy has conrmed it. These patients should be followed up closely. The
conventional treatment for small tumours is radiotherapy. However, this results in disability to the larynx
and pharynx, with dryness and soreness as well as mucositis, and is best given in a fractionated regimen
over a 6-week period rather than a shorter one. Larger tumours require surgery and radiotherapy. There
is a move at present to more conservative surgery rather than laryngectomy and block dissection.
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142 Ear, nose and throat (ENT)
OSCE Counselling case
OSCE COUNSELLING CASE 2.17 –
A woman with an intermittent hoarse
voice is worried about her career as a
teacher and her voice problem. What
advice would you give?
Explain that voice care and rest are the most appropriate treatment. Whispering strains the voice more
than talking normally. Avoid singing and shouting. Stress the value of speech and language therapy,
which allows voice training and counselling at the same time. The voice may return to normal.
REVISION PANEL
Intermittent hoarseness, especially in non-smokers, is typically benign and can be conrmed
endoscopically.
Benign hoarseness responds well to speech therapy and improved vocal hygiene.
Progressive hoarseness, especially in smokers, is likely to represent malignant disease.
Malignant neoplasms of the larynx are managed by conrmation of diagnosis (by biopsy) followed
by staging of the disease (by clinic examination and imaging).
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Painless neck lump 143
PAINLESS NECK LUMP
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What should one look for in the examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.23 –
Painless neck lump 1
A woman aged 52 has just returned from India and has noticed a painless lump in the mid cervical region.
CASE 2.24 –
Painless neck lump 2
A Chinese man aged 33 presents with a painless left jugulodigastric swelling.
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144 Ear, nose and throat (ENT)
OSCE Counselling case
OSCE COUNSELLING CASE 2.18 –
The woman who has had the neck
biopsy that shows TB returns to clinic.
What advice would you give her?
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Painless neck lump 145
Key concepts
Lymph nodes >2 cm are abnormal.
Painless neck lumps in Asians are frequently tuberculosis (TB).
Painless neck lumps in Chinese adults are often postnasal space squamous cell carcinoma
metastases.
Always undertake a ne-needle aspiration sample for cytology before surgery.
Lymphoma and carcinoma may occur.
Reactive lymph node swelling is the most common cause.
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146 Ear, nose and throat (ENT)
Answers
Clinical cases
CASE 2.23 –
Painless neck lump 1
A1: What is the likely differential diagnosis?
Tuberculosis, laryngeal/pharyngeal carcinoma
A2: What additional features in the history would you like to elicit?
Determine whether there are any night sweats, rigors or any other features of TB such as respiratory
symptoms. Ask direct questions about difculty in swallowing, voice changes or any other constitutional
symptoms – indicating laryngeal/pharyngeal carcinoma. Enquire about any family history/social contacts
with TB.
A3: What should one look for in the examination?
Examination of the neck will often reveal that there is a collection of nodes that are discrete and
rubbery, but not attached to the skin or deeper structures. Measure the size because a node >2
cm diameter is always trouble. A lymphoma may feel the same. A full ENT examination including
visualization of the larynx and pharynx should also be undertaken.
A4: What investigations would be most helpful and why?
FBC, Mantoux test, chest radiograph and ne-needle aspiration (FNA) of the neck lump are useful.
Undertake excision biopsy with histology and culture after the result of the FNA cytology.
A5: What are the treatment options?
The treatment depends on the nature of the lesion. The most likely cause of this type of lesion is a
tuberculous node. The key point in management is to undertake an FNA before one goes to excision
biopsy as FNA can direct the appropriate treatment early on. If TB is suspected an open biopsy with
both culture and histology is required. Acid-fast bacilli may be exceptionally difcult to identify on
histological specimens and grown only on culture. However, if the diagnosis is suspected, it is important
to notify the authorities and to send the patient for appropriate antituberculous chemotherapy.
CASE 2.24 –
Painless neck lump 2
A1: What is the likely differential diagnosis?
Postnasal space squamous cell carcinoma
A2: What additional features in the history would you like to elicit?
Ask which part of China the patient is from because patients from southern China have a high risk of
postnasal space carcinoma. Ask about nasal symptoms such as nose bleeding and blockage of the nose.
Ask about neurological symptoms such as numbness of the face. Undertake a general history.
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