HEENT Potpourri

1. HEENT Potpourri May S. Jennings, MD 11/21/06

2. Outline of Topics Hoarseness Snoring Hiccups Tinnitus

3. Goals Discuss evaluation of these symptoms from the internist�s perspective Provide a thoughtful approach to ancillary testing and referral Identify �red flags� Briefly mention some aspects of treatment for the more common diagnoses

4. Hoarseness Any change in vocal quality �Dysphonia�

5. Anatomy of the Larynx

6. Anatomy of the Larynx

7. Anatomy of the Larynx

8. Important History Elements Qualities of the vocal disorder Vocal History PMHx Medications Tobacco, Alcohol and Chemical Exposure Complete ROS with attention to symptoms common in head/neck/thorax malignancies

9. Qualities of the Vocal Disorder Duration Sudden or Gradual Onset Description of the Change in Phonation

10. Vocal History Vocal Personality Type Occupation Vocal Abuse Hearing Loss

11. PMHx GERD Allergic Rhinitis/Chronic Sinusitis Surgical History

12. Medications Aspirin, NSAIDS and anticoagulants Antihistamines and diuretics

13. ROS Screen for symptoms of: GERD Post nasal drip Upper Respiratory Infection Malignancy (focus on head, neck, and thorax) Hypothyroidism Don�t forget to ask about otalgia

14. Exam: Voice Quality Coarse/Rough/Gravelly/Husky Weak and Breathy/Persistent Glottic Gap with Phonation and Air Escape Loss of Vocal Ranges with weakness and cracking Low-Pitched Tremor Intermittent Whispering/Complete Aphonia Halting/Strained/Strangled

15. Exam: Laryngoscopy PATIENTS WITH HOARSENESS LASTING MORE THAN 2 WEEKS SHOULD BE REFERRED FOR LARYNGOSCOPY

16. Differential Diagnosis Acute Laryngitis Chronic Laryngitis Vocal Cord Edema Polyps, Nodules and Tumors Neuromuscular Dysfunction Unilateral Vocal Cord Paralysis Conversion Disorders

17. Acute Pharyngitis Upper respiratory infection Viral Bacterial Moraxella catarrhalis Hemophilus influenza Acute vocal strain

18. Acute Pharyngitis: Treatment Vocal Rest, Humidification and Hydration Systemic corticosteriods? No role for antibiotics

19. Chronic Laryngitis Chronic irritant exposure Chemical Fumes Chronic Tobacco Use Chronic Alcohol Use Chronic Vocal Strain Reflux Disease GERD Laryngopharyngeal Reflux

20. GERD Causes reflux of gastric contents into the hypopharynx Chronic laryngitis as well as contact ulceration and granuloma formation 40% complain of heartburn symptoms May require 8 weeks of therapy Treatment: Conservative Bedtime H2-blocker PPI

21. Laryngopharyngeal Reflux Retrograde movement of gastric contents into the laryngopharynx Acid Enzymes (Pepsin) Typical symptoms include: Globus sensation Mild dysphagia Chronic cough Nonproductive throat clearing

22. GERD LPR More heartburn (?) More esophagitis LES Lying down More esophageal dysmotility Stomach/esophagus have more protection H2 blocker/PPI Less heartburn Less esophagitis UES Standing, exertion Less esophageal dysmotility Larynx has less protection High dose PPI

23. LPR What is the clinical significance of this diagnosis? Is it just a variant of GERD?

24. Vocal Cord Edema Polypoid corditis or Reinke�s edema Bilateral, enlarged, floppy vocal cords Seen with tobacco, GERD and hypothyroidism

25. Polyps, Nodules and Tumors:Vocal Cord Polyps

26. Polyps, Nodules and Tumors: Laryngeal Cancer

27. Neuromuscular Dysfunction Spasmodic dysphonia Muscle tension dysphonia Parkinson�s disease

28. Unilateral Vocal Cord Paralysis

29. Conversion Disorder Somatization disorder Intermittent symptoms Paradoxical vocal cord motion Significant inspiratory stridor Often receive substantial pulmonary workup prior to accurate diagnosis

30. Case #1 50YO obese salesman 3 month hoarseness, worse in AM Sour taste in his mouth and �chokes on fluid� during sleep No heartburn or chest pain Chronic tobacco use Recent job promotion

31. Case #1 Laryngoscopy: Edema of the posterior larynx Rx: PPI for GERD, smoking cessation

32. Case #2 24 YO F 3 months of hoarseness Rejoined the choir 6 months ago No tobacco or alcohol

33. Case #2 Laryngoscopy: Vocal nodules Rx: Vocal training

34. Case #3 67YO M Recent onset of hoarseness and fatigability of his voice Difficulty raising his voice in a crowd Recent cough when drinking liquids Tobacco abuse No surgical history

35. Case #3 Laryngoscopy: Unilateral vocal cord paralysis Dx: Adenocarcinoma of the lung

36. Case #4 35YO M with 1 month hoarseness Change in voice described as �rough and gravelly� Tobacco abuse, 2 beers per week No other symptoms

37. Case #4 Laryngoscopy: Irregular nodule Bx: Squamous cell carcinoma of the larynx

38. �Case report� differential diagnoses Use of systemic isoretinoids Cardiovocal syndrome (Ortner�s) Unusual tumors (primary and metastases) Spontaneous pneumomediastinum Infections (cryptococcus, histoplasmosis, human papilloma virus, herpes, mycobacteria) Madelung�s disease Gout Relapsing polycondritis

39. Conclusions A careful history and physical can make the presumptive diagnosis Be aggressive about ruling out laryngeal cancer Patients with 2 weeks of hoarseness should be referred for laryngoscopy Although hoarseness tends to be a minor complaint, it is can be a clue to significant disease

40. Snoring An inspiratory sound produced by vibration of the soft tissues of the upper airway during sleep

41. Spectrum of Upper Airway Resistance Primary Snoring Upper Airway Resistance Syndrome (UARS) Obstructive Sleep Apnea (OSA)