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Probability diagnosis

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Viral URTI: acute laryngitis

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Non-specific irritative laryngitis (Reinke oedema)

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Vocal abuse (shouting, screaming, etc.)

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Smoking

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Nodules and polyps of cords

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Presbyphonia in elderly: ‘tired’ voice

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Hypothyroidism

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Acute tonsillitis

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Serious disorders not to be missed

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Cancer:

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  • larynx, lung, including recurrent laryngeal nerve palsy, oesophagus, thyroid

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Imminent airway obstruction (e.g. acute epiglottis, croup)

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Rare other severe infections (e.g. TB, diphtheria)

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Foreign body

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Motor neurone disease

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Myasthenia gravis

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Pitfalls (often missed)

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Toxic fumes

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Vocal abuse

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Benign tumours of vocal cords (e.g. polyps, ‘singer’s nodules’, papillomas)

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Gastro-oesophageal reflux → pharyngolaryngitis

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Goitre

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Dystonia

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Physical trauma (e.g. post-intubation), haematoma

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Fungal infections (e.g. Candida with steroid inhalation, immunocompromised)

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Allergy (e.g. angioedema)

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Leucoplakia

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Systemic autoimmune disorders (e.g. SLE, Wegener granulomatosis)

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Masquerades

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Consider:

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  • drugs: antipsychotics, anabolic steroids

  • smoking → non-specific laryngitis

  • hypothyroidism, acromegaly

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Is the patient trying to tell me something?

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Consider:

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  • functional aphonia

  • functional stridor

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Key history

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Note the nature and duration of the voice change. Enquire about corticosteroid inhalations, excessive or unaccustomed voice straining, especially singing, recent surgery, possible reflux, smoking or exposure to environmental pollutants. Elicit associated respiratory or general symptoms such as cough and weight loss.

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Key examination

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  • Palpate the neck for enlargement of the thyroid gland or cervical nodes

  • Perform a simple oropharyngeal examination except if epiglottitis is suspected

  • Check for signs of hypothyroidism, such as coarse dry hair and skin, slow pulse and mental slowing

  • Perform indirect laryngoscopy if skilled in the procedure

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Key investigations

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Consider:

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  • thyroid function tests

  • chest X-ray if it is possibly due to lung carcinoma with recurrent laryngeal nerve palsy

  • indirect laryngoscopy (the gag reflex may preclude this)

  • a special CT scan to detect suspected neoplasia or laryngeal trauma.

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Diagnostic tips

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  • Acute hoarseness rarely causes any diagnostic problem or concern but the chronic cases are often cause for concern.

  • Remember that intubation causes transient hoarseness.

  • Consider gastro-oesophageal reflux disease in the elderly.

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