Approach to the Patient with Hoarseness

≥3 month history of hoarseness that is unexplained in a smoker over the age of 45 are three red flags (NICE 2020).

Ideally all patients with unexplained hoarseness ± red flags should have a FNE from a specialist to investigate causes.

Phonotrauma-induced vocal cord nodules, once safety-netted, can be treated with vocal rest (which includes not whispering), hydration and behavioural therapy exercises. Surgery is kept for refractory, or time critical, cases that are often privately funded.

All medications which either antagonise the parasympathetic nervous system, or are anti-inflammatory, will reduce the moisture of mucosal membranes and can cause hoarseness.

See next question for an explanation...

As the patient is diabetic, NICE guidelines recommend an ACE inhibitor or angiotensin receptor blocker (ARB). In practice, ACE inhibitors are normally offered first line, and a cough is a classic side effect, although they can also cause GI upset and muscle spasms. If the side effects of ACE inhibitors are intolerable, an ARB should be offered instead, hence losartan is the correct answer. Note that losartan can cause anaemia and hypoglycaemia.

If the patient did not have diabetes, they would be recommended a calcium channel blocker (CCB)instead of an ACE inhibitor, as they are over 55. These can cause ankle swelling. Both amlodipine and verapamil are CCBs; however, verapamil is used for stable angina and supraventricular arrhythmias while amlodipine is used for hypertension.

Bendroflumethiazide is a thiazide diuretic, and can cause gout. Tinnitus can be caused by furosemide, although typically only at high doses.

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.

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.