Hot Potato

Part 1

Scenario

You are working in a regional Emergency Department in the town where you live. As a keen darts player you frequent the local Royal Oak Hotel each week for a competition and practice. On entering the hotel for the purposes of practicing on a Tuesday night, you note that the usual suspects are lined up at the bar. There is Mick, Jim, 'Bubbles' and Glenn. You proceed to the back of the room where the dart board is set up and meet the rest of the team.

Mick, Jim, 'Bubbles' and Glenn are an interesting group. They all attended the local Primary school in the 1940s being too young to go to the war. You do however hear them often boast about the extent of their battlefield bravery given the opportunity. Although Jim was married and had 3 children, he has not seen them for at least 10 years. From previous conversations you have gleaned the information the his wife disappeared one afternoon. The four men all meet at the Oak about 1pm and are always there at closing. They occupy the side of the bar opposite the main entrance. They are rarely abusive but do not leave the bar at lunch or dinner time. In fact the only time they leave their chairs is to attend the toilet close by, or to go out the back door for a cigarette. They all smoke regularly and their fingers are heavily stained with tar.

During a lull in the conversation there is an unusual lapse and you can clearly hear Jim talking. Intrigued, you wander over to the bar to talk to Jim. A couple of times you have picked Jim up from lying inebriated outside the pub and taken him home to his house which is just on the way to your house. He considers you to be a mate, so he complies when you ask him to say something.

Tasks

  • Listen to Jim's speech again and characterize the abnormality. (You may wish to ask an ENT surgeon or H&N oncologist to listen to the voice.)
  • Provide a list of differential diagnoses for this speech pattern.
  • What additional history will enable you to determine the most likely cause?
  • What examination would you undertake?

Part 2

Scenario

You ask Jim if he wouldn't mind coming to see you tomorrow morning (on his way to the hotel) when you are at work and ask him to ask for you by name.

Jim comes in the next day and asks for you. You tell him that you are concerned about his voice and that it may need treatment. He agrees to be examined and so you perform a fibre-optic nasopharyngolaryngoscopy which looks like this. You ring the ENT surgeon in the nearest city to refer Jim, and unusually the secretary puts you through to the ENT to whom you describe the endoscopy findings and detail for him the likely social/health issues that Jim has. ENT surgeon sees Jim the next day and repeats the endoscopy with a biopsy. The report is provided here.

Tasks

  • Provide a description of your view of the endoscopy seen in the provided image.
  • Describe for the ENT surgeon the likely social/health issues that will be relevant.
  • Looking at the biopsy report, describe the significant histopathological terms, what they mean and how they deviate from normal histology.

Part 3

Scenario

The biopsy confirms that a malignant neoplasm (squamous cell carcinoma) is present on the posterior pharyngeal wall.

Tasks

  • Having identified the nature of the problem, describe the next steps in management.
  • Identify the non-medical people involved in his initial assessment, the specific problems that they are assessing and subsequent management activities and why they are needed.
  • Discuss with the H&N oncologists (surgical & radiation) the management of this case, in particular when surgery, radiation, chemotherapy, palliative care and combinations are the best approach.
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