Mr Richard Harris.
ENT SpR
Royal Devon & Exeter NHS Foundation Trust
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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
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Nimita asked me to!
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Birmingham graduate
Currently on Peninsula SpR rotation
Work at RD&E
Fellow in Head & Neck Surgery at Royal
Melbourne Hospital.
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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?”
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LPR
Vocal cord dysfunction
Reinke’s oedema
Laryngeal SCC
Vocal cord nodules
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Catarrh/postnasal drip/phlegm/sinusitis
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Absolutely key
Endoscopic predictor
GP advantage of knowing the pt- use it!
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Duration
Constant/intermittent
Pain
Dysphagia
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Try to avoid the pt
naming a condition
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Voice change
Voice fluctuation
Social history
Symptoms through the
day
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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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Harmless
Due to VC atrophy
Rule out neoplasia
Sympathy
Speech therapy
VC augmentation
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63 year old male smoker
3 months constant hoarseness
Cough
Husky voice
No weight loss
Neck normal
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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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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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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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57 year old female
Ex smoker
Intermittent voice change
Sometimes has to strain to speak
Can feel a lump in her throat
No dysphagia
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Examination NAD
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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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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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Reflux of acid and pepsin
Often silent
Symptoms often fluctuate
Lifestyle change
PPI twice daily (pre-prandial)
Gaviscon advance nocte
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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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Chronic vocal cord oedema
Almost exclusive to smokers
50-60 common age at onset
Deeper pitch
Gruff voice
Effortful speaking
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Stop smoking
Vocal hygiene
Surgery
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?need to do it
Absolutely!
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Helps get a good idea of “normal”
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Airway!
Oral cavity
Oropharynx
Neck
General appearance
-cachexia
-nicotine stains
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Throat symptoms are common
Laryngeal SCC is not that common
History is key
Reassurance very therapeutic
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If in doubt-refer.
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ENT SpR
H&N CNS
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SALTs
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-Claire Barber
- Julie Northcott
-Camilla Dawson
-Claire Higgins
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Head and Neck
▪ Mr Andrew Brightwell
▪ Mr Andrew Husband
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Voice
▪ Mr Malcolm Hilton
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Thyroid
▪ Mr Dick Garth.