Problemática de las celdas li-ion

teacher and her voice problem. What

advice would you give?

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.

answers

Clinical cases

CASE2.21–  Hoarse voice 1

A1: Whatisthelikelydifferentialdiagnosis?

Vocal cord nodules, muscle tension dysphonia and laryngopharyngeal reflux

A2: Whatadditionalfeaturesinthehistorywouldyouliketoelicit?

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: Whatistheimportantfindingonexamination?

Examination of the neck is usually uneventful. A flexible 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 reflux the posterior larynx appears inflamed. Muscle tension dysphonia is a common problem in professional voice users and leads to insufficient adduction of the cords on phonation.

A4: Whatinvestigationswouldbemosthelpfulandwhy?

These are rarely needed but do include an FBC and thyroid function tests.

A5: Whatarethetreatmentoptions?

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.

Hoarse voice 141

CASE2.22–  Hoarse voice 2

A1: Whatisthelikelydifferentialdiagnosis?

Carcinoma of nasopharynx/larynx

A2: Whatadditionalfeaturesinthehistorywouldyouliketoelicit?

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: Whatistheimportantfindingonexamination?

Examination of the larynx will show a laryngeal cancer. This is classified by the TNM (tumours, node, metastases) classification, which helps to determine the treatment.

A4: Whatinvestigationswouldbemosthelpfulandwhy?

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: Whatarethetreatmentoptions?

Treatment depends on the TNM classification. Very small malignant squamous cell tumours can be removed with LASER once a biopsy has confirmed 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.

OSCE Counselling case

OSCECOUNSELLINGCASE2.17–  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 confirmed 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 confirmation of diagnosis (by biopsy) followed by staging of the disease (by clinic examination and imaging).

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?