In nurse practitioner school, we were taught to identify the zebras in medicine. While most of what we come across on a day-to-day basis as medical providers will be a variety of horses (sinus infection, UTI, or hypertension). Rarely we’ll catch a once in a life-time diagnosis, a zebra, causing us to call in our collaborative teammates to marvel at the medical complexities while appropriately treating this unique patient. Basically, the medical community is trained to identify the zebras, but expect to catch the horses. A while back, I had a lovely experience visiting a local drive-through animal zoo. Sometime between the man-sized emu ripping the food cup from my hand (as I shrieked like a 5-year-old girl) and before the giant water buffalo licked my steering wheel, I came across an unusual creature that appeared to be half zebra and half horse. A zorce. Knowing that I have an immense passion for writing and for treating ENT conditions, this peculiar little creature peaked not only my equine-passion (my dad didn’t get me a horse for my 13th birthday and I’m still not over it) but also fired up my left-brain hamster-wheel motor neurons alerting me that my article on hoarseness should include the theory that not all hoarseness equals common horses. While zebras are rare, we are seeing more and more zorces.
Hoarseness is a medical symptom described as a harsh, raspy, breathy, or strained voice caused by a multitude of conditions. Generally, hoarseness stems from a problem involving the vocal cords or “voice box”. The most common “horses” we find in otolaryngology include reflux, irritant laryngitis, and post nasal drip with allergies. Laryngopharyngeal reflux (or LPR) is a common condition found in the ENT world and involves stomach acid that refluxes up the esophagus and through the upper esophageal sphincter causing backflow onto the voice box. Associated symptoms include dry cough, globus (sensation of a lump in the throat), and repeated throat clearing. Postnasal drainage from allergic and nonallergic rhinitis can also cause laryngitis with thick mucus irritating the delicate vocal cord mucosa. Other common primary causes of hoarseness include acute laryngitis, sinusitis, and vocal cord strain. Most of these conditions, once identified, can be treated appropriately based upon diagnosis.
Now let’s delve into horses of a different color: the zorces and sometimes zebras of hoarseness. Vocal hemorrhage, laryngeal cancer, vocal polyps, thyroid cancer, post-surgical vocal cord paralysis, lung cancer, esophageal cancer, neurological diseases, and neck trauma are the causes of hoarseness you don’t want to miss as a clinician. As a provider, the appropriate question is, “When do I refer a patient with hoarseness to the ENT for further evaluation?” According to the American Academy of Otolaryngology – Head and Neck Surgery, hoarseness that persists beyond three weeks should be evaluated. Smokers are at particularly high risk and so consider referral sooner. Hoarseness with difficulty breathing warrants urgent intervention. Additional symptoms such as coughing up blood, difficulty swallowing, neck mass, and pain when speaking or swallowing are suggestive of malignancy.
What should you and your patients expect when coming to an ENT for evaluation of hoarseness? A detailed history of present illness is crucial, followed by a thorough ENT head and neck examination. ENTs can visualize the vocal cords via indirect examination using a mirror placed at the back of the tongue or with a flexible laryngoscope. The latter procedure utilizes a tiny fiber-optic scope that is slowly passed through the nose and down towards the larynx to visualize the vocal cords in more detail. We take the time to numb the patient well with nasal and throat sprays. “Trust me, I’m a wimp and I’ve had it done” is usually the first thing I tell my big burly fellows with the tattoos up their arms when I see their eyes get wide at first sight of our tiny scope. We even pass out our popular candy lolly-pops to help clear the taste of the numbing sprays, like in the good ‘ole days. Appropriate treatment is recommended based upon visualization of the vocal cords. We sometimes have our speech pathologist perform a video stroboscopy in the office which displays the vocal cords on a large TV monitor allowing slow motion assessment for better visualization and understanding of vocal cord mobility. This is especially useful in patients with vocal cord dysfunction, laryngospasm, muscle tension dysphonia, and vocal cord nodules. Our speech pathologist’s name is Bambi and she’s actually cuter than a zorce!
In the primary care world, prevention is critical. Teaching your patients to quit smoking, stay hydrated, and to treat allergies and reflux certainly helps. Encourage patients with hoarseness to use a microphone for public speaking, or avoid speaking or singing all together if the voice is weak or hoarse. And if ever you are concerned that you might have a zorce on your hands, lasso that baby, and send them over to ENT!