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Must GPs heed 3-week rule for hoarseness?

Q - Should all patients with persistent hoarseness after three weeks be referred to ENT?

A - The proportion of patients presenting with persistent hoarseness who have laryngeal carcinoma is only about 3 per cent. Some with voice change have a particularly small chance that the symptom is caused by laryngeal carcinoma. Examples include young patients and those with fluctuating hoarseness, especially if there are periods of time with normal voice, previous history of benign laryngeal pathology and a clear history of vocal abuse or onset following upper respiratory tract infection.

Other patients have a higher risk of malignancy: over-45s, smokers, heavy drinkers and those with other symptoms such as a lump in the neck, dysphagia, otalgia or stridor.

Whatever the cause of the hoarseness, a definitive examination is required.

This necessitates ENT outpatient assessment and laryngoscopy. Those patients with a benign cause for their hoarseness will benefit from treatment ­ typically speech and language therapy and/or phonosurgery.

Hoarseness is a presenting symptom in a majority of patients with laryngeal carcinoma. This is particularly true in patients with small tumours on the vocal cord.

These early glottic carcinomas are relatively easy to treat, usually by radiotherapy, sometimes by laser excision. The prognosis is excellent (more than 90 per cent cure rate).

Advanced laryngeal carcinoma has a much worse prognosis and there is a greater chance that the patient will require laryngectomy. The advantage of early diagnosis to the patient is considerable.

Mr Theo Joseph is ENT consultant and Mr Nicholas Saunders is specialist registrar at The Royal National Throat Nose and Ear Hospital, London

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