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Chapter 16
Primary Care Otolaryngology
Many different approaches to the evaluation of this tumor have been uti-
lized in the past. Often a physician would perform an open biopsy of the
lump in the patient’s neck, and discover that it was squamous cell carci-
noma. The fact is that this neck mass represents a metastatic node from
the upper aerodigestive tract, in this particular case the
pyriform sinus of
the hypopharynx.
However, the more modern approach for this type of lesion is a fine-nee-
dle aspirate biopsy of the neck mass in the clinic following a complete
head and neck exam. A CT scan of the neck and chest and possible posi-
tron emission tomography (PET) scan for complete staging and treatment
planning should be ordered. The patient may be taken to the operating
room for “panendoscopy” (i.e., laryngoscopy, esophagoscopy, bronchos-
copy), although imaging has all but erased the need for intraoperative
bronchoscopy as a screening tool.
Hoarseness
Patients who have been hoarse for more than two weeks should also be
referred to an otolaryngologist for laryngeal examination. The most com-
mon cause of hoarseness is a URI with edema (swelling) of the true vocal
cords. This often lasts several weeks, but it rarely lasts six weeks. Six weeks
of hoarseness in an adult is very suspicious for a precancerous (dysplasia)
or cancerous lesion of the larynx. If the lesion is not cancerous, other
causes of hoarseness may include inflammation from
gastroesophageal
reflux disorder (GERD), also known as laryngopharyngeal reflux
, aller-
gic rhinitis causing postnasal drip,
laryngeal papillomatosis
, vocal cord
nodules, vocal cord polyps, and
unilateral vocal cord paralysis
.
Otalgia
A patient who has cancer may also present to a primary care physician
with pain in the throat or pain in the ear (
otalgia
) that has no obvious
cause. The oropharynx and hypopharynx are innervated by the ninth and
tenth cranial nerves. These also send branches to the ear, and sometimes a
cancer in the throat can generate referred pain to the ear. The oral tongue
is served by the lingual nerve (fifth cranial nerve), and may cause jaw pain
and otalgia as well. If a patient comes in with ear pain and the ear looks
normal to you, it probably is normal and the pain is probably being caused
by some other otolaryngologic problem.
The most common cause of ear pain with a normal ear exam
is temporo-
mandibular joint syndrome (TMJ)
. This inflammation of the joint of the
jaw can be diagnosed by pain on palpation of the joint (just in front of the