The Tortoise and the Hare: Winning the Race Against Head and Neck Cancers

This article was created with contributions from an accredited otolaryngologist.

For many circumstances in life conventional wisdom tells us that, as with the tale of the tortoise and the hare, slow and steady wins the race. As we enter the business world, that cliché shifts easily into, “It’s a marathon, not a sprint.” In both cases, the lesson is the same: patience, conscientiousness, and deliberate action always prevail. While this is certainly true, when practicing medicine it’s often more important to move quickly, and refer a patient to the appropriate specialist. It can be crucial—sometimes literally life or death—not to refer to a specialist for testing and treatment when warranted. A good way to illustrate this is through providing a couple of case scenarios. Let’s start with a common condition—reflux.

Scenario 1: Reflux

When a patient presents with hoarseness of voice, throat redness, and/or complaints of heartburn, a common first clinical consideration is reflux. From there, the first line, treatment protocol might be to prescribe proton pump inhibitors¹. Prescription of PPIs is common practice but has associated risk for associated diseases such as Clostridium difficile infection; in the US we spend more than $10 billion a year on proton pump inhibitors². The potential issue with this approach is the risk that patients will receive a diagnosis of reflux without confirmation via videolaryngostroboscopy (VLS), which is considered an essential component of laryngeal/voice disorder assessment³. As a technique that allows for close examination of the vocal folds, VLS plays a vital role in differentiating reflux from more serious conditions, such as laryngeal cancer³. When physicians make the assumption that hoarseness, redness, and heartburn are a result of reflux, without utilizing technology for further investigation, patients may be given costly treatments and medications, sometimes for years, that they might not need^1,2. In addition the diagnosis of a serious medical condition can be potentially delayed or overlooked³. 

Scenario 2: Polyps and papillomas

VLS is also advantageous for the diagnosis of benign vocal cord polyps, which often present initially with hoarseness.³ Vocal cord polyps can also be differentiated from papillomas using VLS. While also benign, papillomas must be diagnosed promptly to rule out pre-cancerous dysplasia. VLS is ideal for diagnosing benign vocal cord lesions; compared to more basic cameras, VLS generates superior image quality needed to identify these lesions. In addition, VLS-guided biopsy is preferable to an open procedure that may cause injury to the vibratory layers of the vocal cords³. According to a 2015 article entitled “Change in Diagnosis and Treatment Following Specialty Voice Evaluation: A National Database Analysis,” half the patients had a change in laryngeal diagnosis after specialty voice evaluation.³ Impressively, 20% of patients who were initially diagnosed with benign vocal cord pathology were found to have multiple, additional diagnoses following specialty voice evaluation.³Visiting a laryngologist first can, in many cases, greatly reduce the need for frequent or repeated trips to the operating room and improve patient outcomes³. The biggest challenge is to ensure that a patient who has hoarseness first gets the referral to see the proper specialist, and second, gets the proper diagnostic tests⁴.

Conclusion

When it comes to head and neck cancers, it’s important to remember that the ENT and the laryngologist are not like the tortoise and the hare competing against one another to win a foot race, but rather, two marathon racers passing the baton, working toward a common goal of improving patient outcomes. In this vein, specialty voice evaluation should be considered standard of care for these patients, as it’s been shown to alter diagnoses and likely lead to changes in management.³

References

¹ Heidelbaugh JJ, Kim AH, Chang R, Walker PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therapeutic Advances in Gastroenterology. 2012;5(4):219-232. doi:10.1177/1756283X12437358.

² Lazarus B, Chen Y, Wilson FP, et al. Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease. JAMA Intern Med. 2016;176(2):. doi:10.1001/jamainternmed.2015.7193. http://www.medscape.com/viewarticle/857060.

³ Cohen SM, et al. Change in diagnosis and treatment following specialty voice evaluation: A national database analysis. Laryngoscope. 2015;125(7):1660-6.⁴ Teppo H, Alho OP. Relative importance of diagnostic delays in different head and neck cancers. Clin Otolaryngol. 2008;33(4):325-30.