🤔 MEDIUM

Hoarseness is a very common presentation.  It be can anything from infecious, neurological or simple trauma from talking too much.   Because I myself don’t, ironically, want to talk too much, how about we just crack on with the questions?  Good luck!

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Approach to the Patient with Hoarseness

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Question 1

Stem 1 of 3

A 47 year old female operatic singer presents to GP with difficulty singing for 100 days. She states her voice is more hoarse. She is a 20-year pack history smoker with no other medical conditions.

According to NICE 2020 guidelines, how many red flags does this patient have?
A
1
B
2
C
3
D
4
E
5
Question 1 Explanation: 
≥3 month history of hoarseness that is unexplained in a smoker over the age of 45 are three red flags (NICE 2020).
Question 2

Stem 2 of 3

What is the next best step to investigate this patient?
A
Chest X-ray
B
CT head and neck
C
Fibreoptic laryngoscopy
D
MR head and neck
E
Nerve conduction study
Question 2 Explanation: 
Ideally all patients with unexplained hoarseness ± red flags should have a FNE from a specialist to investigate causes.
Question 3

Stem 3 of 3

The patient has a nodule, seen on the true vocal fold, preventing complete adduction across the rima glottidis. Select all the options you would advise as first-line management.
A
Adequate hydration
B
Do not whisper
C
Speech and language therapy exercises
D
Surgical ablation of nodule
E
Voice rest
Question 3 Explanation: 
Phonotrauma-induced vocal cord nodules, once safety-netted, can be treated with vocal rest (including whispering), hydration and behavioural therapy exercises. Surgery is kept for refractory, or time critical, cases that are often privately funded.
Question 4

Stem 1 of 4

A 71 year old type two diabetic, with stage one hypertension controlled by first-line medication, presents with a change of voice over the last few weeks.

Select all the medications below that may cause hoarseness
A
Antispasmodic for overactive bladder
B
Cyclizine
C
Ipratropium bromide
D
Muscarinic receptor antagonists
E
Urticaria-treating H1-R blockade
Question 4 Explanation: 
All medications which either antagonise the parasympathetic nervous system, or are anti-inflammatory, will reduce the moisture of mucosal membranes and can cause hoarseness.
Question 5

Stem 2 of 4

A flexible nasal endoscope (FNE) is undertaken as the patient also complained of dysphagia. During examination, the quadrangular membrane is notably dry and painful on irritation. What is the innervation of this region?
A
External branch of the inferior laryngeal nerve
B
External branch of the superior laryngeal nerve
C
Internal branch of the glossopharyngeal nerve
D
Internal branch of the inferior laryngeal nerve
E
Internal branch of the superior laryngeal nerve
Question 6

Stem 3 of 4

The patient’s anti-hypertensive is switched as per NICE 2020 guidelines to lessen the side effect. Which of the following is the best-matched medication to give?
A
Bendroflumethiazide
B
Bisoprolol
C
Losartan
D
Spironolactone
E
Verapamil
Question 6 Explanation: 
Due to the patient’s diabetes, NICE recommends first line ACE inhibitor or angiotensin receptor blocker. Thus, due to the non-tolerable side effects of ACEi, switch to losartan (an ARB).
Question 7

Stem 4 of 4

The patient is concerned about side effects of the new medication. Select from the following the least likely recognised things he should be concerned to develop from this new regimen.
A
Ankle swelling
B
Dry cough
C
Fatigue
D
Hypotension
E
Muscle paresis
Question 7 Explanation: 
Muscle paresis would be more expected of hyperkalaemia of ACEi. Dry cough is also an ACEi cause. Ankle swelling is more the remit of a calcium channel blocker.
Question 8

Stem 1 of 3

A 3 year old, drooling patient presents with acute pyrexia, hoarseness, stridor and difficulty in breathing.

What is the most likely diagnosis?
A
Epiglottitis
B
Foreign body aspiration
C
Acute Laryngitis
D
Peritonsillar abscess
E
Tonsillitis
Question 9

Stem 2 of 3

Given your working diagnosis, which vaccinations is this child more likely to have missed?
A
Diphtheria
B
Group-A streptococcus
C
Haemophilus influenzae type B
D
Poliovirus
E
Tetanus
Question 9 Explanation: 
Epiglotitis is classically caused by HiB. Successful vaccines programmes mean it is much rarer now in the UK. But due to its medical emergency nature, it is essential learning for a medical student.
Question 10

Stem 3 of 3

How would you initially manage this patient?
A
Flexible nose endoscopy
B
Inhaled fluticasone
C
IV ceftriaxone
D
Mask ventilation and intubation
E
Oral amoxicillin
Question 10 Explanation: 
Usually the patient will have mask ventilation and then intubation as a primary priority of definitively securing the airway. IV ceftriaxone (or similar per trust guidelines) is started first line. FNE should only be undertaken by specialists if the patient is an adult. Inhaled glucocorticosteroids have limited evidence base in the first line, but could be adjunctively considered. PO antibiotics are appropriate once the patient is extubated and stabilised.
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References

  • BMJ. (2020). Epiglottis. Available: https://bestpractice.bmj.com/topics/en-gb/452/treatment-algorithm#patientGroup-0-0. Last accessed September 2020.
  • House, S et al. (2017). Hoarseness in Adults. Available: https://www.aafp.org/afp/2017/1201/p720.html. Last accessed September 2020.
  • Knott, L et al. (2014). Hoarseness. Available: https://patient.info/doctor/hoarseness-pro. Last accessed September 2020.
  • Moore, A (2017). Moore’s Clinically Oriented Anatomy. London: Lippincott Williams and Wilkins. page X.
  • Raftery, A et al (2014). Churchill’s Differential Diagnosis. 4th ed. London: Churchill Livingstone. pX.