Many patients presenting with hoarseness do not have an underlying head and neck malignancy. Hence, ordering imaging initially does not help to make a diagnosis. Persistent hoarseness, lasting greater than 6 weeks, can be one of the first signs of malignancy of the larynx or voice box. This is particularly true in current or ex-smokers and individuals with a current or previous history of alcohol abuse. Laryngoscopy as part of a thorough physical examination is the best initial investigation of persistent hoarseness. If the laryngoscopy demonstrates a vocal cord paralysis or a mass/lesion of the larynx, imaging to further evaluate is evidence-based.
Hoare TJ, et al. Detection of laryngeal cancer–the case for early specialist assessment. J R Soc Med. 1993 Jul;86(7):390-2. PMID: 8053995.
Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009 Sep;141(3 Suppl 2):S1-S31. PMID: 19729111.
Syed I, et al. Hoarse voice in adults: an evidence-based approach to the 12 minute consultation. Clin Otolaryngol. 2009 Feb;34(1):54-8. PMID: 19260886.Share on Facebook Share on Twitter
A fine needle aspiration biopsy (FNA) is the gold standard for initial work up for a neck mass and has numerous advantages over an open neck biopsy. FNA holds less risk and avoids the chance of seeding cancer cells in the neck and making subsequent treatment of a confirmed malignancy more challenging. It is also inexpensive, quickly obtained without a general anaesthetic, and can be performed with or without the use of imaging to assist with the placement of the needle depending on the location of the neck mass, particularly if it is partially cystic or near vital structures. Open neck biopsies should only be considered for a neck mass if the result of a FNA biopsy is non-diagnostic and no primary carcinoma is identified upon a complete head and neck examination. If there is a strong suspicion of lymphoma (previous history of lymphoma, night sweats, weight loss, wide spread lymphadenopathy) an open or core biopsy can be considered in lieu of a FNA.
Choosing Wisely Canada. Canadian Hematology Society: Five Things Physicians and Patients Should Question [Internet]. 2014 Oct 29 [cited 2017 Jun 13].
Haynes J, et al. Evaluation of neck masses in adults. Am Fam Physician. 2015 May 15;91(10):698-706. PMID: 25978199.
Layfield LJ. Fine-needle aspiration of the head and neck. Pathology (Phila). 1996;4(2):409-38. PMID: 9238365.Share on Facebook Share on Twitter
Odynophagia and globus sensation are common symptoms and the differential diagnosis can be extensive, including inflammatory, infectious, neoplastic, autoimmune and traumatic causes. Odynophagia and globus sensation are infrequently due to an underlying neck mass, and if so, the underlying lesion is usually quite apparent on physical examination. Neck or thyroid ultrasonography ordered to investigate patients with odynophagia and globus sensation are more likely to detect other entities such as benign thyroid nodules, rather than confirming a diagnosis that explains the patient’s symptoms and can lead to a cascade of other unnecessary tests that can be harmful to patients. Unfortunately, using tests to exclude conditions, can sometimes identify other diseases such as thyroid nodules, leading to further testing such as a FNA or repeat ultrasounds and in some cases treatment in the form of a thyroidectomy that may be unnecessary or harmful to patients.
Hall SF, et al. Access, excess, and overdiagnosis: the case for thyroid cancer. Cancer Med. 2014 Feb;3(1):154-61. PMID: 24408145.
Hall SF, et al. Increasing detection and increasing incidence in thyroid cancer. World J Surg. 2009 Dec;33(12):2567-71. PMID: 19789911.Share on Facebook Share on Twitter
The diagnosis of the dizzy patient should be guided by the presenting symptoms and office examination. Tests such as ABR (auditory brainstem response), ECOG (electrocochleography), ENG/VNG (electronystagmography/ videonystagmography), VEMP (vestibular evoked myogenic potential), vHIT (video head impulse test), CDP (computerized dynamic posturography) and RCT (rotational chair testing) should only be ordered if clinically indicated. In general, advanced balance tests should be ordered and interpreted by otolaryngologists with specialized training in the diagnosis and treatment of vestibular disorders (otologists/neurotologists). Clinical indications for testing can include: side localization and stage of progression for Meniere’s disease, assessment of central compensation for acute vestibular loss and confirmation of superior semicircular canal dehiscence syndrome. Specialized tests are rarely indicated in the management of benign paroxysmal positional vertigo.
Furman JM, et al. Vestibular disorders. 3rd ed. New York: Oxford University Press; 2010. Chapter 4, Vestibular laboratory testing; p. 30-40.
Johnson JT, et al. Bailey’s head and neck surgery: otolaryngology. 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013. Chapter 165, Clinical evaluation of the patient with vertigo; p. 2673-700.Share on Facebook Share on Twitter
Blood work which typically would consist of a CBC, differential and electrolytes along with an autoimmune panel are often normal and would not change initial clinical management if abnormal. The CT scan which is done to rule out central causes is not sensitive enough to pick up most cases of retrocochlear pathology. MRI scans should be considered instead. If verified to be sensorineural with audiometric testing, urgent treatment with steroid therapy can be initiated. There is no role for antiviral treatment, thrombolytics or vasoactive substances.
Stachler RJ, et al. Clinical practice guideline: sudden hearing loss. Otolaryngol Head Neck Surg. 2012 Mar;146(3 Suppl):S1-35. PMID: 22383545.Share on Facebook Share on Twitter
If there is no obvious cause of the asymmetry such as unilateral trauma or unilateral noise exposure like gun blasts, a MRI should be ordered. MRI scans are superior in sensitivity for detecting retrocochlear pathologies such as vestibular schwannoma when compared to ABR testing.
Bozorg Grayeli A, et al. Diagnostic value of auditory brainstem responses in cerebellopontine angle tumours. Acta Otolaryngol. 2008 Oct;128(10):1096-100. PMID: 18607985.
Fortnum H, et al. The role of magnetic resonance imaging in the identification of suspected acoustic neuroma: a systematic review of clinical and cost effectiveness and natural history. Health Technol Assess. 2009 Mar;13(18):iii-iv, ix-xi, 1-154. PMID: 19358774.
Koors PD, et al. ABR in the diagnosis of vestibular schwannomas: a meta-analysis. Am J Otolaryngol. 2013 May-Jun;34(3):195-204. PMID: 23332407.Share on Facebook Share on Twitter
First line therapy constitutes a short course of topical antibiotic/steroid drops. The potential ototoxicity of any topical medication entering the middle ear space should be considered in selecting an appropriate agent. Where available, fluoroquinolone combination preparations (e.g., ciprofloxacin and dexamethasone) should be used as a first choice and caution should be exercised in using topical aminoglycosides. Microdebridement and further assessment should be considered in the following circumstances: (a) failure to respond after a 7 day course, or (b) where follow up does not permit a clear view of a normal tympanic membrane allowing the exclusion of more sinister middle ear disease such as cholesteatoma.
Dohar J, et al. Topical ciprofloxacin/dexamethasone superior to oral amoxicillin/clavulanic acid in acute otitis media with otorrhea through tympanostomy tubes. Pediatrics. 2006 Sep;118(3):e561-9. Epub 2006 Jul 31. PMID: 16880248.
Hannley MT, et al. Use of ototopical antibiotics in treating 3 common ear diseases. Otolaryngol Head Neck Surg. 2000 Jun;122(6):934-40. PMID: 10828818.
Roland PS, et al. Consensus panel on role of potentially ototoxic antibiotics for topical middle ear use: Introduction, methodology, and recommendations. Otolaryngol Head Neck Surg. 2004 Mar;130(3 Suppl):S51-6. PMID: 15054363.
World Health Organization. Chronic suppurative otitis media Burden of illness and management options. Geneva, Switzerland: WHO; 2004.Share on Facebook Share on Twitter
Posterior semicircular canal benign paroxysmal positional vertigo should be diagnosed and confirmed with a positive Dix-Hallpike test, and only then should a particle repositioning maneuver be performed. If a patient with positional vertigo has a Dix-Hallpike test that is repeatedly negative or results in atypical nystagmus, less common BPPV variants or central positional vertigo should be considered.
Hilton MP, et al. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014 Dec 8;12:CD003162. PMID: 25485940.Share on Facebook Share on Twitter