Common Laryngeal Disorders in Primary Care Final handout.pdf · 9 Objectives At the conclusion, primary care practitioners will understand: • Red flags and high-suspicion cases

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Common Laryngeal Disorders in Primary Care


Laura Matrka, MDBrandon Kim, MDLaura Matrka, MDBrandon Kim, MD

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The following program is a Continuing Medical Education Activity sponsored by The Ohio State University Wexner Medical Center. The design and production of this CME Activity is the sole responsibility of the Center for Continuing Medical Education.

Accreditation Statement

The Ohio State University’s Center for Continuing Medical Education (CCME) is accredited by the Accreditation Council for Continuing Medical Education (ACCME®) to provide continuing medical education for physicians.

AMA Designation Statement

The Ohio State University’s Center for Continuing Medical Education designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

As an enduring material this CME Activity is approved for three years from original release. Original release 12/06/19. Termination date 12/06/22.

CCME Disclosure Statement

As a provider of AMA PRA Category 1 Continuing Medical Education, it is the policy of CCME to adhere to the ACCME Standards for Commercial Support to avoid any conflict of interest and/or commercial bias and must ensure balance, independence, objectivity and scientific rigor in all its sponsored educational activities. All individuals who are in a position to control content of an educational activity, including presenters, panel members and moderators, must to disclose any relevant financial relationships that create a conflict of interest.

Nothing in this program is intended to imply that any off-label or unapproved product use discussed is reimbursed by any government or private payor or that submission of a claim for such use is proper.

Presentation may include discussion of services and unapproved or off-label usage of commercial products or devices. Log on to ccme.osu.edu for more information.

The following program is a Continuing Medical Education Activity sponsored by The Ohio State University Wexner Medical Center. The design and production of this CME Activity is the sole responsibility of the Center for Continuing Medical Education.

Accreditation Statement

The Ohio State University’s Center for Continuing Medical Education (CCME) is accredited by the Accreditation Council for Continuing Medical Education (ACCME®) to provide continuing medical education for physicians.

AMA Designation Statement

The Ohio State University’s Center for Continuing Medical Education designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

As an enduring material this CME Activity is approved for three years from original release. Original release 12/06/19. Termination date 12/06/22.

CCME Disclosure Statement

As a provider of AMA PRA Category 1 Continuing Medical Education, it is the policy of CCME to adhere to the ACCME Standards for Commercial Support to avoid any conflict of interest and/or commercial bias and must ensure balance, independence, objectivity and scientific rigor in all its sponsored educational activities. All individuals who are in a position to control content of an educational activity, including presenters, panel members and moderators, must to disclose any relevant financial relationships that create a conflict of interest.

Nothing in this program is intended to imply that any off-label or unapproved product use discussed is reimbursed by any government or private payor or that submission of a claim for such use is proper.

Presentation may include discussion of services and unapproved or off-label usage of commercial products or devices. Log on to ccme.osu.edu for more information.

The following planning committee members have no relevant financial relationships with commercial interests to disclose:

James Allen, MD

Ruthann Kennedy, CNP

Barbara Berry

Derrick Freeman

The following planning committee members’ educational unit does not have a financial interest or affiliation with an organization that may receive direct benefit from the subject of the proposed CME activity, and they will not be personally compensated for their role in the planning or execution of this proposed CME activity by an organization other than The Ohio State University:

James Allen, MD

Ruthann Kennedy, CNP

Barbara Berry

Derrick Freeman

Planning Committee DisclosuresPlanning Committee Disclosures

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Speaker DisclosuresSpeaker DisclosuresThe following presenters for this educational activity disclose that they have no relevant relationships with commercial interests to disclose.

Their presentation will not include discussion of unapproved or “off-label” usage of commercial products and/or services.

Laura Matrka, MD

Brandon Kim, MD

Agenda Disclaimer

CCME presents this activity for educational purposes only. Participants are expected to utilize their own expertise and judgment while engaged in the practice of medicine. The content of the presentations is provided solely by presenters who have been selected for presentations of recognized expertise in their field.

No further reproduction or distribution is permitted by electronic transmission or any other means. The presentations during this webcast are the intellectual property of the presenter and require his/her permission for further use.

This activity will discuss Common Laryngeal Disorders in Primary Care.

Agenda Disclaimer

CCME presents this activity for educational purposes only. Participants are expected to utilize their own expertise and judgment while engaged in the practice of medicine. The content of the presentations is provided solely by presenters who have been selected for presentations of recognized expertise in their field.

No further reproduction or distribution is permitted by electronic transmission or any other means. The presentations during this webcast are the intellectual property of the presenter and require his/her permission for further use.

This activity will discuss Common Laryngeal Disorders in Primary Care.

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Image: Wellcome Collection CC BY 4.0

Benjamin Babington

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Manuel Garcia

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Image: KARL STORZ Endoskope CC BY 4.0

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Common laryngeal disorders in primary

care medicine

Common laryngeal disorders in primary

care medicine

Common tests performed in the

laryngeal disease clinic

Common tests performed in the

laryngeal disease clinic

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Laura Matrka, MDAssociate Professor

Department of OtolaryngologyThe Ohio State University Wexner Medical Center


How Not to Miss Something Important

“You don’t have to treat it, you just need to catch it” –Janet Gick, MD, family

medicine physician

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ObjectivesObjectivesAt the conclusion, primary care practitioners will understand:

• Red flags and high-suspicion cases

‒ i.e. when to call the ENT directly and ensure a more expeditious referral

• When to refer non-smokers who are hoarse

• What to do about the PPI question

CaseCase• Patient is a 46yo female with 6 weeks of

increased hoarseness absent any illness‒ Never smoker‒ Obese‒ Significant increase in family-related

stress

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First steps?First steps?• Which do you do?

‒ Referral to ENT for scope of vocal cords

‒ Check for red flags and gather more history

‒ Treat empirically for infection, GERD or allergies

‒ Take a closer look at her medication list






Let’s go to the guidelines!

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First steps?First steps?

• Which do you do?


• Always ok – guidelines recommend referral within 4 weeks if no serious underlying cause suspected

But how quickly?But how quickly?• Which do you do?





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Immediate referral?Immediate referral?• Recent head, neck,

chest surgery

• Recent intubation

• Smoker

• Neck mass

• New dyspnea

• Professional voice user‒ Teacher

‒ Doctor

‒ Lawyer

‒ Singer

‒ Call center employee

‒ Most people w jobs

Immediate referral?Immediate referral?

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Immediate referral?Immediate referral?

Additional historyAdditional history• High-yield history:

‒ Recent head, neck, chest surgery?

‒ Recent intubation?

‒ New dyspnea?

‒ Smoker or significant smoking hx?

‒ Professional voice user?

• High-yield physical exam:

‒ neck mass?

‒ stridor?

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Our patientOur patient• No recent surgery or intubation

• Non-smoker

• No change in breathing

• She is a homemaker and does not have special voice-related needs

• No neck mass or stridor

Our patientOur patient

• So no red flags, but has been long enough that a (non-urgent) referral is reasonable

• But in the meantime…?

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• YES


• YES



Let’s go to the guidelines!

NO empiric treatment!NO empiric treatment!

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NO antibiotics!NO antibiotics!

• Do NOT get imaging

• Do NOT give steroids and antibiotics

• You can consider treating for allergies or reflux, but only if there are other reasons for this besides the dysphonia alone

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DOsDOs• Hydrate and humidify

• Voice rest

• Amplify

DON’TsDON’Ts• Smoking or secondhand

• Voice overuse, whispering, yelling

• Caffeine, alcohol, drying meds thick mucus

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• YES


• YES


• NO


Our patientOur patient• No drying meds

• Hydrates well

• 1 small cup of coffee in morning, no other caffeine

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Our patientOur patient• She notes occasional heartburn and

frequent thick mucus in her throat

• Worse after meals

• Tends to eat late at night

• Remember her recent family stress?

• This is a patient who could be treated with an anti-reflux diet

‒ Or even an H2 blocker or PPI prior to referral

• But ONLY as you would treat her if she didn’t have the dysphonia

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Key point - Red flagsKey point - Red flagsHistory:

• Recent head, neck, chest surgery

• Recent intubation

• Smoker

• Neck mass

• New dyspnea

• Professional voice user

PE findings:

•Stridor

•Neck mass

Case 2Case 2• 67yo male with hoarseness

‒ He’s sounded like this for a while

‒ His wife made him come in, he doesn’t know why

• High-yield history and PE

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Additional historyAdditional history• High-yield questions:


‒ New dyspnea?






• NO

‒ New dyspnea?




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‒ New dyspnea?

• YES






‒ New dyspnea?


• NO



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‒ New dyspnea?



• 55 pack-years




‒ New dyspnea?




• Still works in carpentry occasionally

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PEPE• High-yield physical exam:

‒ neck mass?

‒ stridor?


‒ neck mass?

• YES

‒ stridor?

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‒ neck mass?

‒ stridor?

• No….?

• You didn’t think so, but something sounded odd when he started laughing

SummarySummary• High-yield questions:

‒ New dyspnea?

• YES (Can’t sleep lying flat)


• 55 pack-years

‒ Neck mass?

• YES

‒ Stridor?

• Maybe

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IMMEDIATE REFERRALIMMEDIATE REFERRAL

• He is scheduled with local ENT for 7 weeks later.

• You call the office and ask that he be seen sooner.

• ENT sees this:


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• T3N2Mx laryngeal cancer

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To PPI or not to PPI?To PPI or not to PPI?• Recent large studies showing association

(but not causation) between PPI use and 1) dementia 2)kidney disease

• Already known that PPIs increase fracture risk, PNA and C diff risk, and are associated with nutritional deficiencies

To PPI or not to PPI?To PPI or not to PPI?• Could be a good thing

• Bringing more attention to PPI overuse

• But some patients do benefit…

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To PPI or not to PPI?To PPI or not to PPI?• Simple approach

‒ Do they feel miserable when they wean off?

‒ Do they know why they are taking it?

• If no, stop the PPI

To PPI or not to PPI?To PPI or not to PPI?• What about Barrett’s?

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To PPI or not to PPI?To PPI or not to PPI?• Esophageal adenoCA

‒ With a 600% rise in incidence since advent of PPIs, could they be masking symptoms that would otherwise lead to earlier detection??

• 95% of patients are never selected for screening

To PPI or not to PPI?To PPI or not to PPI?• AND….

‒ It turns out PEPSIN may be the oncogenic factor

• Not the acid

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Source: Nikki Johnston, PhD

% Cells S Phase

Dose Response Increase in % Cells S Phase FaDu cells exposed to pepsin at concentration indicated for 1 hr at 37C, washed and incubated in fresh media for 24 hrs at 37C

* * *


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% Cells S Phase

Dose Response Increase in % Cells S Phase FaDu cells exposed to pepsin at concentration indicated for 1 hr at 37C, washed and incubated in fresh media for 24 hrs at 37C

* * *

0

5

10

15

20

25

30

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Untreated with taxol 0.01 mg/ml pepsin with taxol 0.1 mg/ml pepsin with taxol

Average Cell Count

*


Pepsin detected in larynges of cancer pts, but absent in pts without clinical signs of reflux/inflammatory/neoplastic disease Pepsin induces a dose & time‐dependent promotion of proliferation in both normal &

transformed epithelial cultures This induction of proliferation is associated with gene and microRNA expression changes

that are consistent with promotion of neoplasia

Chronic pepsin exposure caused resistance to apoptosis In vivo HBP study revealed active pepsin increases tumor volume

Chronic pepsin, pH7, exposure increases cell colony forming ability


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PPI usePPI use• Hard question to answer

• Use PPIs when they help clinically

• Weaning trials frequently

• Consider non-acid reflux

• Remember sodium alginates!

‒ Food thickener made of seaweed

‒ Forms a raft that physically blocks reflux

Sodium alginatesSodium alginates

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Sodium alginatesSodium alginates• Take 1000mg after meals and before bed

• No active drug

• Raft remains intact until you eat again

• Could also recommend only the before-bed dose and after meals where they overeat or eat reflux-inducing foods

LaryngitisLaryngitis

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Laryngitis mimicsLaryngitis mimics

Brandon Kim, MDAssistant Professor-Clinical

Department of OtolaryngologyThe Ohio State University Wexner Medical Center


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CaseCase• Patient is a 21 yo male college runner with

increasing shortness of breath during exercise.

‒ Prior diagnosis of exercise-induced asthma but has minimal benefit with inhalers

‒ History of anxiety

‒ History of recent intubation after motor vehicle accident

‒ Never smoker


‒ Recent head, neck, chest surgery or trauma?

‒ Prior tracheostomy or intubation history?

‒ Timing of dyspnea?‒ Dysphonia or dysphagia?‒ Noisy breathing? ‒ Triggers of stress, exercise, or odors?‒ History of sinusitis or GERD? ‒ Smoker or significant smoking hx?

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Physical ExaminationPhysical Examination• Any evidence of prior head and neck

surgery or trauma?

• Biphasic stridor vs. inspiratory stridor vs. end-expiratory wheeze?

TestingTesting• Usually expect CXR.

• Consideration has often already been given for pulmonary, cardiac, or deconditioning etiology at the time of referral.

• Pulmonary function tests:

‒ What diagnosis is supported with flattening of the inspiratory loop?

‒ What diagnosis is supported with flattening of both the inspiratory and expiratory loop?

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LaryngoscopyLaryngoscopy• Evaluate for masses or lesions

• Vocal fold motion to rule out paralysis

• Observe vocal folds at rest, with exercise, vocal cord dysfunction protocol, and/or with odors (imperfect proxy)

• Evaluate subglottis

Flexible LaryngoscopyFlexible Laryngoscopy

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Post-operative LaryngoscopyPost-operative Laryngoscopy

Subglottic StenosisSubglottic Stenosis• Etiologies:

‒ Intubation

‒ Tracheostomy

‒ Trauma

‒ Prior surgery (head and neck, thyroid)

‒ Idiopathic

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Subglottic StenosisSubglottic Stenosis• Etiologies:

‒ Intubation

‒ Tracheostomy

‒ Trauma

‒ Prior surgery (head and neck, thyroid)

‒ Idiopathic

Vocal Cord Dysfunction/Paradoxical Vocal Fold Movement


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CaseCase• 78 yo M with history of repeated

pneumonias over the past 3 years, becoming more frequent.

• Upon questioning, he endorses globus sensation and “mucous.”

• Occasionally, “things come back up” and he coughs more after meals.

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CaseCase• PMH: History of melanoma previously,

history of GERD diagnosis

• PSH: Knee surgery

• Social: Denies tobacco, occasional wine


‒ History of esophageal procedures or oropharyngeal trauma?

‒ Globus or mucous sensation?

‒ Food sticking?

‒ Differential dysphagia to liquids vs. solids?

‒ Choking or coughing?

‒ Reflux or regurgitation?

‒ Weight loss or pneumonia?

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‒ History of abdominal thrusts or loss of consciousness for choking?

‒ Drooling? Food escaping into the nose?

‒ Odynophagia (pain with swallowing)?

‒ Avoiding foods or difficulty with certain consistencies?

‒ Change in voice (especially wet quality)?

‒ Behavior: Eating and talking?

‒ Neurological signs/symptoms?

Physical ExaminationPhysical Examination• Neurological Examination to assess for

focal weakness, gait abnormality, cogwheeling, or cranial nerve weakness.

• Oral examination:

‒ Tongue weakness?

‒ Incomplete dentition?

‒ Poor-fitting dentures?

• Voice (wet? Weak?)

• Lungs

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Testing or ReferralsTesting or Referrals• May consider modified barium swallow

(MBS) or referral to laryngology for functional endoscopic evaluation of swallow (FEES) with speech language pathology for concern for oropharyngeal dysphagia.

• May consider esophagram or referral to gastroenterology for concern for esophageal dysphagia.

On Esophagrams and DysphagiaOn Esophagrams and Dysphagia

• Able to assess anatomy (masses, strictures, Zenker’s, Schatzki’s ring, hiatal hernia).

• Able to assess motion (dysmotility, spasms, achalasia, may catch or miss reflux events).

• Unable to assess many mucosal abnormalities.

• Unable to allow for biopsy.

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On EGD and dysphagiaOn EGD and dysphagia• Does not examine causes of oropharyngeal

dysphagia.

• Not a dynamic study examining motion of the patient’s esophagus during swallow.

• Able to assess for mucosa (esophagitis, ulcer, lesions) and anatomy (strictures, Schatzki’s ring, hiatal hernia).

• Able to biopsy (eosinophilic esophagitis)

Functional Endoscopic Evaluation of SwallowFunctional Endoscopic Evaluation of Swallow

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Modified Barium SwallowModified Barium Swallow

Modified Barium SwallowModified Barium Swallow

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Post-operative LaryngoscopyPost-operative Laryngoscopy

Dysphagia PrevalenceDysphagia Prevalence

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FEES versus modified barium swallow

FEES versus modified barium swallow

Diagnosing paradoxical vocal cord

dysfunction

Diagnosing paradoxical vocal cord

dysfunction

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Treatment of paradoxical vocal cord

dysfunction

Treatment of paradoxical vocal cord

dysfunction

Vocal cord nodulesVocal cord nodules

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Risk factors for laryngeal cancerRisk factors for laryngeal cancer

Vocal cord hemorrhageVocal cord

hemorrhage

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LaryngospasmLaryngospasm

Documents

Common Laryngeal Disorders in Primary Care Final handout.pdf · 9 Objectives At the conclusion, primary care practitioners will understand: • Red flags and high-suspicion cases