At the Update Pharmacy Stephanie Lennard, a patient who presents frequent prescriptions for trivial conditions, has asked to speak to pharmacist David Spencer. in the consultation area David asks how he can help.Miss Lennard replies: “Three weeks ago I had influenza – although Dr Merali said it was just a cold – and it’s left me with this hoarseness in the throat. What should I do about it?”“Have you seen Dr Merali?” asks David.“Not this time, I’m a bit afraid to. last time I went he more or less told me not to keep coming about minor things. I think he thinks I’m a hypochondriac. But I really worry every time I get a symptom that this time it’s something serious.” “Alright,” David says, “tell me a bit more about it.”“well, I think you can hear that my voice is a bit croaky, although the hoarseness does come and go. On top of that, it feels like I’ve got phlegm in my throat all the time that I want to keep clearing. and being a schoolteacher doesn’t help, I’m always having to raise my voice to be heard in the class. Be honest with me, I’ve got throat cancer, haven’t I?”“I think that’s most unlikely,” David answers. “But I’m going to ask you some more questions and if I think there’s anything that needs further investigation, I’ll get in touch with Dr Merali for you.”QUESTIONS1 how common is hoarseness, and how likely is the symptom to indicate laryngeal cancer?2 Is Miss Lennard’s feeling of phlegm in the throat an indicator of serious disease? 3 What symptoms should make David refer Miss Lennard to Dr Merali? 4 Assuming that David rules out the likelihood of anything serious, what advice could he give to help Miss Lennard to clear her hoarseness and minimise the chance of it recurring? ANSWERS1 Hoarseness has a prevalence of 6 per cent in the general population, rising to 11 per cent for professional voice users. most episodes are benign. It often follows a viral upper respiratory tract infection. Hoarseness after prolonged use of the voice, or strain, suggests a benign cause. Incidence of laryngeal cancer is five per 100,000 in males and one per 100,000 in females. most patients with laryngeal cancer have risk factors, mainly smoking, high alcohol intake and increasing age. Heavy smoking and drinking are synergistic risk factors, and together increase risk 80-fold.2 Associated symptoms, such as throat clearing, a sensation of a lump in the throat and cough are common, but are usually benign.3 Persistent, rather than intermittent, hoarseness lasting more than three weeks; difficulty or pain on swallowing; haemoptysis; ear ache; weight loss.4 Avoid: cigarette smoke, dry atmospheres, dust, fumes; excessive alcohol or caffeine; decongestant drugs, as they can dry out the throat; prolonged use and straining of the voice; repetitive throat clearing and coughing. try: yawning and humming to relax the voice box; drink plenty of water.REFERENCEJudd O. 10 Minute Consultation: Hoarse Voice. BMJ 2010; 340:c522 Have you got a suggestion for a Practical Approach scenario? Email haveyoursay@chemistand druggist.co.ukMore Practical Approach scenarios