CNS/ HN - Hoarseness Flashcards
Differentials of Hoarseness
Hoarseness
Lung Cancer*
Differential Diagnosis
- Acute laryngitis (viral, overuse)
- Vocal cord polyp/cyst/nodule
- Thyroid problems
- Allergies
- Neurological conditions (TIA, stroke, neuromuscular)
- Cancer of lung, larynx or esophagus
Hoarseness - Key history
Key history
- Note the nature and duration of the voice change.
- Enquire about corticosteroid inhalations, excessive or unaccustomed voice straining, especially singing, recent surgery, possible reflux, smoking or exposure to environmental pollutants.
Elicit associated respiratory or general symptoms such as cough and weight loss
Hoarseness - Key PE
Key examination
- Palpate the neck for enlargement of the thyroid gland or cervical nodes
- Perform a simple oropharyngeal examination except if epiglottitis is suspected
- Check for signs of hypothyroidism, such as coarse dry hair and skin, slow pulse and mental slowing
- Perform indirect laryngoscopy if skilled in the procedure
Hoarseness - Key Investigations
Key investigations
Consider:
•thyroid function tests
•chest X-ray if it is possibly due to lung carcinoma with recurrent laryngeal nerve palsy
•indirect laryngoscopy (the gag reflex may preclude this)
•a special CT scan to detect suspected neoplasia or laryngeal trauma.
Hoarseness - Diagnostic Tips
Diagnostic tips
•Acute hoarseness rarely causes any diagnostic problem or concern but the chronic cases are often cause for concern.
•Remember that intubation causes transient hoarseness.
•Consider gastro-oesophageal reflux disease in the elderly
History - Lung Cancer
- HOPI - Hoarseness
- I understand from the notes that you have hoarseness?
- When did it start?
- on and off or continuous
- did it appear sudden or gradual?
- anything that makes it better or worse?
- Is it the first time?
Associated Symptoms
- Do you notice any pain or difficulty in swallowing?
- sorethroat?
- cough?
- Fever?
- LOA, LOW, LBBB
DDX AND RISK FACTORS
- Any weather preferences?
- Feeling of lump in the throat? Fatigue?
- Exposure to air pollution or allergies?
- What’s your occupation?
- Hobby - singing?
- Smoking
- Medication - use of inhalation steroid
- Recent surgery?
- History of reflux disease
- Bowel habits? Waterworks?
- PMHx
- FHx: Cancers?
- SADMA
Physical Examination - Lung Cancer
Physical examination
- General appearance: pallor, cachectic features, BMI, jaundice, rash
- Vital signs
- ENT: Indirect laryngoscopy; (proptosis, miosis, and anhydrosis)
- Neck: Thyroid, Lymph nodes
- Cranial nerve examination
- Chest:
o Inspection: chest lag and asymmetry
o Palpation: Vocal Fremitus
o Percussion: Dullness in the right lower lobe
o Auscultation: bilateral air entry; other adventitious sounds
- Heart and abdomen
- CNS
- Urine dipstick and BSL
Diagnosis - Lung Cancer
- From history and examination, we have found some changes in the right side of your chest. Most likely, there is a solid or fluid on the right side of the chest which could be associated with the hoarseness. At this stage, I am concerned about your smoking history as it could lead to a nasty growth, but the reason for you hoarseness could also be overuse as you are a teacher or maybe benign growth in your vocal cord.
Management - Lung Cancer
- I will also refer you to the ENT specialist to have a look at your vocal cords and larynx. I would like to see you once the results are back.
- If I find any abnormal, I might refer you to the chest physician.
- Can I just have antibiotics? As I said, there are a lot of causes for your hoarseness, so it is important to exclude nasty growths from your lung.
- I am really worried now. I cannot say for now, but do not worry. You will be taken cared by a MDT. The earlier we pick it up the better the outcome.
- I would like to book another appointment to talk about smoking cessation.
- Reading material. Review.
- Red flags: SOB, worsening/persistent hoarseness
Investigation - Lung Cancer
- FBE
- TFT
- Indirect laryngoscopy
- Chest Xray
- CT Scan chest and neck
