Cases corner – 46 years old with hoarseness

18th June 2019

Alan, a 46 year old man who works as a carpenter, presents to you with a three week history of hoarseness. He denies any cough or infective symptoms. He is a non-smoker and reports heavy drinking. He denies any respiratory symptoms. You ask about a sore throat or any pain and he only reports discomfort with no pain. He denies any difficult swallowing or gastrointestinal symptoms. His weight is stable and he has no symptoms of fatigue or appetite loss.

He came in one month ago and saw colleague for a ‘health check up.’ At the time he was asymptomatic and routine bloods were organised which were unremarkable. He has no past medical history to note and does not take any medication. You conduct an examination of the oropharynx which is unremarkable, with no cervical lymphadenopathy.

What would you do next?

  1. Reassure the patient that it is likely self-limiting but to come back if it persists for more than 4 weeks
  2. Refer the patient for a full blood count
  3. Refer the patient for a chest x-ray
  4. Refer the patient for a 2-week-wait suspected cancer referral

Alan is at risk of laryngeal cancer. The NICE guidelines recommend referring patients along a suspected cancer pathway (for an appointment within 2 weeks) in people aged 45 and over with persistent unexplained hoarseness, or, an unexplained lump in the neck.

Laryngeal cancer is uncommon in the UK, but with higher incidences in men over 40. There is a strong correlation with the amount an individual drinks alcohol and smokes with the risk of developing laryngeal cancer. People who smoker more than 1 pack per day or who have smoked for greater than 40 years, are 40 times more likely to develop laryngeal cancer compared to those who do not smoker. Similarly, with alcohol, people who drink excessive amounts are 3 times more likely to develop laryngeal cancer. Having a first degree relative with a head and neck cancer will double an individual’s likelihood of developing laryngeal cancer. Processed food, red meats and an unhealthy diet have also been shown to increase the likelihood of developing laryngeal cancer.

There is also evidence to show that HPV (Human Papilloma virus), more commonly associated with cervical cancer, has a similar impact on the cells of the throat and can increase the likelihood of developing laryngeal cancer.

People exposed to certain chemicals over many years, such as wood dust, coal, paint fumes and fuels and other chemicals due to the irritation they can cause to the lining of the larynx. Alan works as a carpenter which will therefore, also increase his likelihood of developing laryngeal cancer.