Hoarseness
Hoarseness is an abnormal change in voice quality, typically characterized by a rough, breathy, or strained sound, resulting from disorders affecting the vocal folds or laryngeal function.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Acute viral laryngitis | Hoarseness < 3w with preceding URTI symptoms | 「之前有冇傷風感冒先？」 | ~40% |
| Vocal cord nodules ("singer's/screamer's nodes") [1][3] | Bilateral, at junction of anterior 1/3 & posterior 2/3; voice abuse history | 「你係唔係要成日大聲講嘢？」 | ~15% | |
| Vocal cord polyp [1][3] | Usually unilateral; smoker; hoarseness ± diplophonia | 「有冇兩種唔同嘅聲同時出嚟？」(diplophonia) | ~5% | |
| Serious Not To Miss | Laryngeal carcinoma (SCC) [1][7] | Progressive hoarseness > 3w in smoker; airway obstruction; LN mets | 「你有冇食煙？把聲有冇越嚟越差？」 | ~2% |
| Lung carcinoma (RLN invasion) [5] | Hoarseness + haemoptysis + weight loss + bovine cough; left-sided tumour | 「有冇痰帶血？有冇消瘦？」+ bovine cough on examination | ~1% | |
| Thyroid carcinoma (RLN invasion) [4] | Enlarging thyroid nodule + hoarseness + stridor | 「頸前面有冇腫大？」+ palpate thyroid | < 1% | |
| Pitfalls | Laryngopharyngeal reflux (LPR) | Chronic throat clearing, globus, heartburn; hoarseness worse in AM | 「朝早起身把聲係唔係特別沙？有冇成日想清痰？」 | ~15% |
| Reinke's oedema | Chronic smoker with characteristic low-pitched, coarse voice | 「你把聲係唔係變到好低沉粗糙？」 | ~5% | |
| Unilateral vocal cord paralysis (post-surgical RLN injury) | Post-thyroidectomy/neck surgery; breathy voice + bovine cough | 「之前有冇做過頸手術？」+ test cough quality | ~2% | |
| Masquerades | Drugs – inhaled corticosteroids [5] | Chronic ICS use for asthma/COPD; dose-related | 「有冇用吸入劑？」 | ~5% |
| Hypothyroidism (myxedema of vocal cords) [5] | Weight gain, cold intolerance, constipation, slow relaxing reflexes | 「有冇怕凍、肥咗、便秘？」 | ~2% | |
| Trying to Tell Me Something? | Anxiety / cancer phobia / functional dysphonia | Hoarseness with normal larynx; situational; recent bereavement or cancer in family | 「你最擔心嘅係咩？屋企有冇人試過有類似嘅問題？」 | ~10% |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日會同你傾下你嘅情況。你最擔心邊方面呢？」"Hi, I'm Dr X, let's chat about your situation. What concerns you most?" | Interpersonal marks: greeting, warmth, open-ended |
| 0:30–2:00 | HPI – symptom analysis | 「你把聲沙咗幾耐？係慢慢嚟定突然嚟？有冇好過又差過？有冇嘢令到佢嚴重啲或者好啲？」 | Chief complaint, onset, course, aggravating/relieving. Core HPI marks |
| 2:00–3:00 | Red flags & targeted review | 「有冇吞嘢困難？有冇頸度摸到粒嘢？有冇痰帶血？有冇唞氣困難？有冇消瘦？你有冇食煙飲酒？」 | Must-not-miss: laryngeal CA, lung CA, thyroid CA |
| 3:00–4:00 | PMH, drugs, allergy, FH, social & occupational | 「你之前有冇做過手術？有冇食開咩藥？你做咩工作㗎？平時要唔要成日大聲講嘢？」 | Past thyroid/neck surgery → RLN injury; teacher/singer → voice abuse; GERD drugs |
| 4:00–5:00 | ICE – Ideas, Concerns, Expectations | 「你自己覺得可能係咩事？你最擔心嘅係咩？你今日嚟最希望我可以點樣幫到你？」 | Uncovers hidden agenda & scores ICE marks directly |
| 5:00–5:30 | Summarise & check understanding | 「等我總結下：你把聲沙咗（X星期），冇痰帶血，你最擔心嚇咗係唔係癌症——我有冇聽漏咗？」 | Shows active listening, confirms accuracy |
| 5:30–6:00 | Safety-net & close | 「我建議你轉介耳鼻喉專科照下聲帶。如果中間有吞嘢困難或者唞唔到氣，要即刻去急症室。」 | Safe closure; demonstrates responsible FM referral behaviour |
Uncovering the hidden agenda: The patient may present with "hoarseness" but actually fear throat/lung cancer or worry about job impact (e.g. teacher, singer). Always ask: 「你今日嚟，其實最想解決邊樣嘢？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset & duration | How long have you been hoarse? Sudden or gradual? | 「把聲沙咗幾耐？係突然定慢慢嚟？」 | Acute ( < 3w) → infection/inflammation; Chronic ( > 3w) → structural/neoplastic | Acute: laryngitis; Chronic: tumour, polyp, nodule |
| Course | Getting worse, staying the same, or improving? | 「有冇越嚟越差？定係時好時壞？」 | Progressive → malignancy; Fluctuating → functional/nodules | Progressive: laryngeal CA |
| Voice use | Do you need to talk loudly or sing for work? | 「你份工要唔要成日大聲講嘢或者唱歌？」 | Voice abuse is the commonest cause of vocal cord nodules [1] | Vocal cord nodules/polyps |
| Smoking & alcohol | Do you smoke? How much alcohol? | 「你有冇食煙？飲幾多酒？」 | Smoking is the key risk factor for laryngeal cancer [1] | Laryngeal SCC, Reinke's oedema |
| Dysphagia | Any difficulty swallowing? | 「有冇吞嘢困難？」 | Suggests pharyngeal/oesophageal tumour, extrinsic compression | Oesophageal CA, thyroid mass, Ortner syndrome |
| Haemoptysis | Any blood in sputum? | 「有冇痰帶血？」 | Red flag for lung CA or laryngeal CA | CA lung, CA larynx [5] |
| Neck lump | Have you felt any lump in your neck? | 「頸度有冇摸到粒嘢？」 | Thyroid mass, cervical LN metastasis | Thyroid CA, laryngeal CA with LN mets |
| Stridor/SOB | Any noisy breathing or difficulty breathing? | 「有冇唞氣時聽到怪聲？有冇唞氣困難？」 | Airway obstruction is a feature of advanced laryngeal cancer [1] | Laryngeal tumour, upper airway obstruction |
| GERD symptoms | Any heartburn or acid taste? | 「有冇胃酸倒流、火燒心嗰種感覺？」 | GERD is a common cause of chronic laryngitis / laryngopharyngeal reflux | Reflux laryngitis |
| Weight loss | Any unintended weight loss? | 「有冇唔覺意瘦咗？」 | Constitutional symptom → malignancy | CA larynx, lung, oesophagus, thyroid |
| Preceding URTI | Did you have a cold or sore throat before this started? | 「之前有冇傷風感冒先？」 | Acute laryngitis is most commonly post-viral | Acute viral laryngitis |
| PMH – thyroid/neck surgery | Any previous neck or thyroid surgery? | 「你之前有冇做過頸或者甲狀腺手術？」 | Iatrogenic RLN injury → vocal cord paralysis [3] | Unilateral RLN palsy |
| Drug history | Any inhalers? ACE inhibitors? | 「有冇用噴嘴（吸入劑）？有冇食血壓藥？」 | Inhaled corticosteroids cause hoarseness [5]; ACEI → cough → laryngeal irritation | ICS-related dysphonia |
| Hypothyroid symptoms | Any cold intolerance, weight gain, constipation? | 「有冇怕凍、肥咗、便秘？」 | Hypothyroidism causes myxedema of vocal cords [5] | Hypothyroidism |
| Occupation/functional impact | How does this affect your work and daily life? | 「呢個問題對你返工同生活有咩影響？」 | Functional impact → biopsychosocial; may be reason for consultation | Voice-dependent occupation |
| Psychological | Are you stressed or worried about this? | 「你有冇因為呢樣嘢覺得好擔心或者壓力大？」 | Anxiety about cancer; performance anxiety; muscle tension dysphonia | Psychological component |
Case Report Form Answer Builder
- Hoarseness for [X] duration (state weeks/months)
- Onset (acute/gradual), course (progressive/intermittent/improving), severity
- Aggravating factors: voice use, smoking, GERD
- Associated symptoms: sore throat, dysphagia, odynophagia, stridor, SOB, haemoptysis, neck lump, weight loss
- Preceding URTI symptoms (if present)
- Red flags explored and documented
- Examples: "Concerned about throat cancer because hoarseness is not improving" / "Persistent hoarseness affecting work as a teacher" / "GP referred for specialist assessment of chronic hoarseness"
- Phrase as the patient's own reason, not your differential
| Example Wording | |
|---|---|
| Idea | "I think it might be throat cancer because I've been smoking for many years" |
| Concern | "I'm worried it could be serious / that I might need surgery / that I'll lose my voice" |
| Expectation | "I'd like to have my throat checked / get a referral to ENT / get some reassurance" |
- If acute ( < 3 weeks) with URTI prodrome → Acute viral laryngitis
- If chronic ( > 3 weeks), smoker, progressive → Laryngeal carcinoma [1][7]
- If chronic, voice abuse, teacher/singer → Vocal cord nodules [1][3]
- Minimum supporting evidence: Duration, smoking history, voice-use history, examination findings (e.g. visible lesion on laryngoscopy)
From past paper: A 73-year-old chronic smoker with blood-stained sputum, progressive hoarseness and SOB for 2 months → Answer: Carcinoma of larynx [7]
| DDx | Key Discriminator |
|---|---|
| 1. Vocal cord polyp/nodules | Voice abuse history; non-progressive; no red flags [1][3] |
| 2. Laryngeal carcinoma | Progressive hoarseness > 3w; smoker; haemoptysis; weight loss [1][7] |
| 3. Laryngopharyngeal reflux | Heartburn, globus, chronic throat clearing; hoarseness worse in AM |
(Adjust based on the specific patient stem – always have one serious DDx)
| Domain | Example |
|---|---|
| Biological | Progressive hoarseness requiring laryngoscopy to exclude malignancy |
| Psychological | Anxiety about cancer / fear of losing voice |
| Social | Functional impairment at work (especially if voice-dependent occupation, e.g. teacher) |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Acute viral laryngitis | Erythematous, oedematous pharynx; no laryngeal mass | Inspect oropharynx with torch & tongue depressor; note coryzal signs | Inflamed mucosa without structural lesion confirms infective aetiology |
| Vocal cord nodules/polyp | Visible nodule/polyp on indirect laryngoscopy [1][3] | Indirect laryngoscopy / flexible nasendoscopy (ENT referral) | Directly visualises the lesion at the vocal fold |
| Laryngeal carcinoma | Cervical lymphadenopathy [1] | Palpate anterior and posterior cervical lymph node chains | Nodal metastasis from laryngeal SCC; hard, non-tender, fixed nodes |
| Lung CA (RLN palsy) | Bovine cough [5] | Ask patient to cough; note lack of explosive onset | Indicates vocal cord paralysis from RLN invasion |
| Hypothyroidism | Slow-relaxing ankle jerks; dry skin; non-pitting oedema | Test ankle reflexes; inspect skin | Systemic signs confirm hypothyroidism as cause of myxedematous vocal cords |
| Thyroid carcinoma | Palpable hard, fixed thyroid nodule [4] | Palpate thyroid from behind; ask patient to swallow | Hard fixed nodule with hoarseness suggests local invasion of RLN |
Must-Not-Miss Red Flags – Urgent ENT Referral
- Hoarseness > 3 weeks in a smoker → suspect laryngeal carcinoma until proven otherwise [1][7]
- Progressive dysphagia + hoarseness → oesophageal / hypopharyngeal carcinoma
- Stridor / airway compromise → emergency referral
- Haemoptysis + hoarseness → lung CA with RLN invasion [5]
- Fixed cervical lymphadenopathy → metastatic disease
- Unilateral vocal cord paralysis (bovine cough) → investigate for malignancy along the course of RLN
Common exam traps:
- Forgetting GERD/LPR as a cause of chronic hoarseness – very common pitfall in primary care
- Not asking about inhaled corticosteroids – easily reversible cause, frequently examined [5]
- Ignoring hypothyroidism – a classic masquerade [5]
- Not asking about neck surgery history – iatrogenic RLN injury is a common cause of vocal cord paralysis
- Confusing vocal cord nodules vs polyps: Nodules = bilateral, voice abuse, voice therapy first; Polyps = unilateral, smoking-related, often need surgery [3]
- Writing "hoarseness" as the reason for consultation – the RFC is WHY they came TODAY (e.g. fear of cancer, job impact), not just the symptom
Shortest safe management/safety-net line: 「如果你把聲沙超過三個星期，我會建議你睇耳鼻喉專科照聲帶。如果中間有唞唔到氣或者吞嘢困難，要即刻去急症室。」
High Yield Summary
What to ASK: Duration ( > 3w = urgent); smoking/alcohol; voice abuse; GERD symptoms; dysphagia/stridor/haemoptysis; neck surgery; ICS use; hypothyroid symptoms; ICE.
What to WRITE: RFC = the patient's real worry (usually cancer fear or functional impact), NOT just "hoarseness." Most likely diagnosis hinges on duration + risk factors. Always include one serious DDx (laryngeal CA). BPS must include psychological (anxiety) and social (work/voice impact).
What NOT to MISS: Hoarseness > 3 weeks in a smoker = laryngeal cancer until proven otherwise. Bovine cough = vocal cord paralysis. Always safety-net for stridor/airway compromise.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 216. Dysphonia Laryngitis, voice abuse, tumour and laryngeal cancer.pdf [2] Lecture slides: GC 220. Upper airway obstruction and tracheostomy.pdf [3] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (pp. 215, 264) [4] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (pp. 1593–1595) [5] Senior notes: Ryan Ho Respiratory.pdf (pp. 5, 48, 141–142) [6] Senior notes: Ryan Ho Fundamentals.pdf (pp. 44, 100) [7] Past papers: 2024 Fourth Summative MCQ.pdf (Q64)
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