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Singer complains of persistent hoarse voice

Dr Tanvir Jamil considers whether the show can still go on

Dr Tanvir Jamil considers whether the show can still go on

Case History

John is a 60-year old smoker who has had a dry throat and hoarse voice for more than a month. He is otherwise well. His hobby is singing and amateur dramatics and he is playing the lead role in The Merchant of Venice in six weeks.

How would you define John's problem?

Hoarseness is a change in normal voice quality. It can affect pitch, volume or resonance.

Acute hoarseness lasts less than three weeks. Anything over this and the hoarseness becomes chronic, and needs a much more detailed examination and referral.

What are the main causes of acute hoarseness?

Viral ­ acute laryngitis; allergy; epiglottitis; exposure to smoke or chemicals; instrumentation such as intubation; trauma such as shouting, singing, coughing or vomiting.

Most of these will become obvious from a good history. Don't forget to ask about occupations and hobbies to detect any exposure to chemicals, smoke or fumes.

Epiglottitis, although rare in adults, does occur and the main clues are throat pain and an inability to swallow. Patients typically present with a handkerchief at their mouth, unable to swallow.

Most patients with acute hoarseness have laryngitis. Treatment is resting the voice and steam inhalation for two weeks.

John has had his problem for more than a month. What causes should I be thinking about?

There are lots, but the one you do not want to miss is laryngeal cancer. Other causes include: smoking; hypothyroidism; laryngeal papilloma; vocal cord nodule/ polyp; vocal cord paralysis; neurological conditions.

It sounds as though John will need referral to an ENT specialist with 'query laryngeal cancer'. Why bother with any other detailed history?

Even if it is obvious that a patient needs referral you need to gather information, attempt a diagnosis, and refer appropriately. You will need to give the specialist as much information as you can.

What clues in the history point to a diagnosis?

Smoking can cause chronic laryngitis and laryngeal cancer, as can alcohol abuse.

John's hobby is singing. Chronic straining and misuse of the voice can lead to vocal cord nodules, polyps or a granuloma. Vocal abuse can also cause chronic laryngitis.

Hypothyroidism can cause chronic hoarseness ­ look for dry hair, dry skin, weight gain and fatigue. A history of bitter taste and halitosis upon awakening points to reflux, which can cause laryngitis. Ask also about retrosternal pain on bending or lying down. In some patients it is worth asking about head or neck surgery. All may damage the nerves or larynx. Ask about rhinitis and chronic sinusitis. The inflammation, reactive glottic oedema, repetitive throat clearing and continous mucosal secretions can all contribute to hoarseness.

Lastly, look for neurological causes, such as Parkinson's, myasthenia gravis, motor neurone disease, muscular dystrophy, Huntington's and multiple sclerosis.

Medications that can cause changes in voice quality include antihistamines, cough suppressants, SSRIs, tricyclics, decongestants, diuretics and chemotherapeutics.

What do I need to know about laryngeal cancer?

This accounts for almost 2 per cent of malignancies. Ten times as many men are affected as women. Mean age is 45 to 75.

The presentation depends on the location of the lesion:

  • Glottic cancer (at the vocal cords) ­ hoarseness is an early symptom
  • Supraglottic (above the cords) ­ hoarseness presents late. The first symptom is often a feeling of something in the throat. Some patients complain of dysphagia. These cancers tend to metastasise more frequently
  • Subglottic (below the cords) ­ hoarseness is a late presentation. Airway obstruction may occur before any signs of hoarseness
  • Other symptoms include sore throat, otalgia and persistent cough.

Radiotherapy is given to most tumours and the neck is irradiated in patients with nodal disease. Laryngectomy and radical neck dissection is performed in residual or recurrent disease. Primary surgery may be offered for advanced disease. If detected early, the five-year cure rate is 90 per cent. Survival rates are better than for oral or pharyngeal cancer.

What if investigations reveal nothing?

  • Psychogenic dysphonia ­ stress
  • Medications (see above) ­ consider use of OTC treatments
  • Normal ageing ­ with age the voice can become tremulous and weak. Examination of the vocal cords can reveal bowing secondary to muscle atrophy

Will John make it to The Merchant of Venice?

If all is clear I would advise John to stop smoking, cut down alcohol, learn some simple relaxation techniques, rest his voice and take regular steam inhalations.

Tanvir Jamil is a GP in Burnham, Buckinghamshire

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