Hoarseness

Question 1

Causes of hoarseness?

Answer 1

Voice overuse e.g. vocal cord nodules
Smoking
Viral illness e.g. laryngitis
Hypothyroidism
GORD
Laryngeal carcinoma
Lung cancer e.g. small cell
thyroid carcinoma
hypopharyngeal carcinoma

Question 2

What is the guidelines for who to suspect having laryngeal cancer?

Answer 2

People aged 45 and over with:
Persistent unexplained hoarseness OR unexplained lump in neck

Question 3

What does head and neck cancer encompass?

Answer 3

Oral cavity cancers
cancers of the pharynx
Cancer of the larynx

Question 4

Features of head and neck cancers? (90% are squamous cell carcinomas)

Answer 4

Neck lump / pain
Hoarseness >6 weeks
sore throat > 6 weeks
Persistent mouth ulcer (painless)
mouth bleeding
mouth numbness
sore tongue
patches on tongue
earache / effusion
lumps (lip, mouth, gum)
speech change
dysphagia

Question 5

Oral cancer 2WW referral guidelines?

Answer 5

Unexplained ulceration in oral cavity lasting more than 3 weeks OR persistent and unexplained neck lump

Question 6

Thryoid cancer 2WW referral guidelines?

Answer 6

Unexplained thyroid lump

Question 7

Red flags for laryngeal cancer?

Answer 7

Persistent, unilateral, throat discomfort
Dysphagia, odynophagia
Persistent hoarseness

Question 8

RF for laryngeal cancer?

Answer 8

Tobacco use > 40 pack years
Alcohol use >8 units a day
GORD
achlorhydria
Fhx
Black
Male
Hx of radiotherapy

Question 9

Features of laryngeal cancer?

Answer 9

Hoarseness
Dysphagia
Odynophagia
Cervical lymphanedopathy
supraglottic or glottic mass
lesional erythroplasia, ulceration, necrosis or bledding

Question 10

Investigations for laryngeal cancer?

Answer 10

Neck CT with contrast- to check lymphnode mets

Chest CT with contrast- most common site of H&N cancers to metastise to is the lungs

FNA of neck mass- cytological analysis (usually confirms squamous cell carnicoma)

Flexible fibre- optic laryngoscopy- can visualise the larynx- given to pts referred via 2WW

Question 11

RIsk factors for H&N cancer?

Answer 11

Smoking
chewing tobacco
chewing betel leaf
alcohol
HPV (16)
EBV

Question 12

Red flags for H&N cancer?

Answer 12

Lump in mouth or lip
Unexplained uclers in mouth lasting more than 3 weeks
Erythroplakia or erythroleukoplakia
Persistent neck lump
Unexplained hoarseness of voice
Unexplained thyroid lump

Question 13

What staging is used for H&N cancer?

Answer 13

TNM

Question 14

Management of H&N cancer?

Answer 14

May involve any combo of:
Chemotherapy
Radiotherapy
Surgery
Targeted cancer drugs (i.e., monoclonal antibodies)
Palliative care

Question 15

What is cetuximab?

Answer 15

Monoclonal ab
Used in treating squamous cell carcinomas of head and neck
May be used in bowel cancer
Targets epidermal growth factor receptor- blocking this activation and inhibiting growthy and mets of the tumour

Question 16

What is laryngopharyngeal reflux?

Answer 16

Condition caused by GORD resulting in inflammatory changes to the larynx/hypopharynx muscosa

Question 17

Features of Laryngopharyngeal reflux?

Answer 17

Globus- typically felt in the midline, worse when swallowing saliva rather than eating or drinking
Hoarseness
Chronic cough
Dysphagia
Heartburn
Sore throat

Question 18

Examination findings in Laryngopharyngeal reflux?

Answer 18

External exam of neck- normal w NO masses
Posterior pharynx may appear erythematous

Question 19

How do you diagnose Laryngopharyngeal reflux?

Answer 19

Absence of Red flags- clinical diagnosis
If red flag symptoms are present, need to refer via 2WW

Question 20

Management of laryngopharyngeal reflux?

Answer 20

Lifestyle measures- avoid triggers e.g. fatty foods, caffeine, chocolate, alcohol
PPI
Sodium alginate liquids- Gaviscon

Question 21

How does lung cancer cause hoarseness?

Answer 21

Pancoast tumour pressing on recurrent laryngeal nerve

Question 22

What is Reinke’s Oedema

Answer 22

Thickening and enlargement (chronic irritation) of vocal cords causing prolonged and persistent hoarseness caused by smoking +/- chronic voice abuse

Deep, gruff voice i.e. woman (elderly, smoker, hypothyroid say sound like a man)

Associated with hypothyroidism

Treat: supportive, stop smoking, SALT, laser therapy may help

Question 23

Describe the different pathophysiology for how different H&N cancers can cause hoarseness

Answer 23

Hoarseness = alteration in quality of phonation

Caused by:
- Direct invasion of the larynx by a tumour e.g. laryngeal cancers
- Invasion of recurrent laryngeal nerve -> vocal cord paresis e.g. cancers of the thyroid, oesophagus, apex of lung (i.e. pancoast)

Question 24

Do oropharyngeal cancers cause hoarseness ?

Answer 24

Oropharyngeal cancers = tongue base and tonsils

DO NOT CAUSE HOARSENESS - they cause a CHANGE in voice, called “ a hot potato” quality in advanced cases.

This is due to the compromised enunciation and altered vocal resonance.

Question 25

Chronic hoarseness in a patient with a concurrent neck mass and smoking history should be considered ….?

Answer 25

cancer until proven otherwise

always investigate hoarseness (esp in smokers) >6 weeks often the only symptom of larygneal carcinoma

Question 25

Chronic hoarseness in a patient with a concurrent neck mass and smoking history should be considered ….?

Answer 25

cancer until proven otherwise

always investigate hoarseness (esp in smokers) >6 weeks often the only symptom of larygneal carcinoma