Chief Complaint:
Persistent hoarseness and vocal fatigue for 3 months.
Assessment:
Sarah Jenkins is a 45-year-old female with a history of gastro-oesophageal reflux disease (GORD), presenting with persistent hoarseness and vocal fatigue. Examination showed mild erythema of the vocal cords. Scope demonstrated a vocal cord polyp on the left vocal fold, with normal vocal cord mobility. Labs remarkable for negative thyroid function tests. Imaging showing no significant laryngeal pathology on initial neck MRI. Clinical picture consistent with benign vocal cord lesion (polyp), although vocal cord cyst and vocal nodule are within the differential diagnosis.
Subjective:
History of Presenting Illness:
Sarah Jenkins is a 45-year-old female presenting with the above chief complaint for which Otolaryngology is consulted.
* Persistent hoarseness.
* Vocal fatigue.
* Duration: 3 months.
* Timing: Constant, worse with prolonged speaking.
* Location: Throat/larynx area.
* Quality: Raspy, breathy voice.
* Severity: Moderate, impacting daily communication.
* Context: Started after a period of increased vocal use due to a new teaching role.
* Worsened by: prolonged speaking, shouting, singing.
* Alleviated by: voice rest.
* Self-treatment: Tried lozenges and warm tea with temporary, minimal relief.
* Symptoms started subtly and have gradually worsened over three months, with increased difficulty projecting her voice.
* No previous episodes of similar symptoms.
* Significant impact on her new teaching career, leading to frustration and reduced confidence in professional settings. Also affecting social interactions.
* Associated symptoms: Mild throat clearing, occasional sensation of a lump in the throat (globus sensation).
* Past medical history: GORD, well-controlled with omeprazole. No significant surgical history. No prior investigations for voice changes.
* Social history: Non-smoker, occasional alcohol. Works as a primary school teacher, which involves significant vocal demands. Enjoys singing in a local choir.
* Family history: Mother had benign vocal cord nodules. No family history of laryngeal cancer.
* Exposure history: No known environmental or occupational exposures linked to laryngeal issues.
* Immunisation history: Up-to-date with routine immunisations, including influenza.
* Patient expresses concern about potential long-term damage to her voice and impact on her career.
Objective:
Physical Examination:
* General: Alert and cooperative, no respiratory distress.
* Neck: Supple, no palpable lymphadenopathy, no masses.
* Oral Cavity/Oropharynx: Mucosa moist, no lesions. Tonsils 1+.
* Laryngeal Palpation: No tenderness.
Flexible Fibreoptic Laryngoscopy:
After obtaining verbal consent, the nasal passage(s) were prepared with a topical mixture of 4% topical lidocaine and 0.05% oxymetazoline.
* Epiglottis: Normal.
* Arytenoids: Symmetrical, no oedema.
* Pyriform Sinuses: Patent.
* Vocal Cords: Left vocal fold shows a small, sessile polyp on the free edge, anterior one-third. Right vocal fold appears normal. Both vocal cords have full, symmetrical mobility with good adduction and abduction.
* Subglottis: Clear.
Plan:
* Interventions or procedures planned for the patient:
* Micro-laryngoscopy with excision of left vocal cord polyp.
* Investigations planned for the patient:
* Voice therapy consultation.
* Referral for speech and language pathology assessment prior to surgery.
* Treatments planned for the patient:
* Continue omeprazole for GORD.
* Strict voice rest for one week post-surgery.
* Other relevant actions including counselling, consults and referrals:
* Discussed surgical risks and benefits, including potential for voice changes.
* Patient provided with vocal hygiene instructions.
* Referral to Speech and Language Therapy for pre-operative voice assessment and post-operative voice rehabilitation.
* Follow-up outpatient in 2 weeks post-surgery for review and pathology results.
