EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Sarah’s presentation?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What alternative diagnoses should be considered?

Q2. What are the red flags that would indicate a more serious condition?

• Prompt: How would you assess for airway compromise?
• Prompt: When should Sarah be referred for urgent care?

Q3. How would you manage Sarah’s condition?

• Prompt: Would you prescribe antibiotics or corticosteroids?
• Prompt: What non-pharmacological advice would you give?

Q4. Sarah is concerned about returning to work. What advice would you provide?

• Prompt: How should she modify her voice use during recovery?
• Prompt: When is it safe for her to resume full duties?

Q5. What preventive strategies can Sarah use to avoid recurrent laryngitis?

• Prompt: What lifestyle modifications are recommended?
• Prompt: When should she seek further medical assessment?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Sarah’s presentation?

Sarah’s most likely diagnosis is acute laryngitis, given her history of progressive hoarseness, sore throat, and dry cough over five days, without signs of systemic illness. The most common cause is viral laryngitis, often secondary to rhinovirus, influenza, or parainfluenza.

Differential diagnoses include:

1. Bacterial tracheitis – Considered in patients with worsening respiratory symptoms, high fever, significant stridor, or toxic appearance.
2. Epiglottitis – Less common in adults but presents with rapid onset, severe throat pain, drooling, and stridor.
3. Reflux laryngitis – Associated with gastroesophageal reflux disease (GORD), nocturnal symptoms, and frequent throat clearing.
4. Vocal cord dysfunction or nodules – Common in professions requiring voice strain, such as teaching.
5. Allergic laryngitis – Presents with hoarseness and throat irritation but is associated with allergic triggers.

A focused history and examination help to differentiate benign viral laryngitis from serious airway pathologies requiring urgent intervention.

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Q2: What are the red flags that would indicate a more serious condition?

Red flags suggesting urgent intervention or referral include:

• Stridor or respiratory distress – Suggests bacterial tracheitis, epiglottitis, or anaphylaxis.
• Severe pain with difficulty swallowing or drooling – Consider epiglottitis or abscess formation.
• Rapid deterioration or high fever (>38.5°C) – Suggests a bacterial aetiology requiring antibiotics.
• Neck swelling or fluctuance – Suggests peritonsillar or retropharyngeal abscess.
• Persistent symptoms beyond 3 weeks – May indicate chronic laryngitis, malignancy, or GORD-related inflammation.

If any of these are present, urgent airway assessment and specialist referral should be arranged.

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Q3: How would you manage Sarah’s condition?

Management of viral laryngitis is largely symptomatic:

• Voice rest – Avoid whispering, as it strains vocal cords.
• Hydration and steam inhalation – Helps maintain vocal cord function.
• Analgesia – Paracetamol or ibuprofen for throat discomfort.
• Avoid irritants – Smoking, alcohol, and caffeine exacerbate symptoms.

Medications:

• Corticosteroids (e.g., dexamethasone 4mg single dose) may be considered for severe hoarseness impacting function.
• Antibiotics are not indicated unless secondary bacterial infection is suspected (e.g., worsening fever, purulent sputum).

Follow-up if symptoms persist beyond 2–3 weeks.

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Q4: Sarah is concerned about returning to work. What advice would you provide?

• Limit voice use – Avoid speaking for prolonged periods or whispering.
• Use amplification devices if speaking is essential.
• Allow adequate recovery time before resuming full voice demands.
• Consider medical certificate for voice-intensive professions.

Sarah should return to work when her symptoms improve, typically within 7–10 days, with precautions to prevent vocal strain.

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Q5: What preventive strategies can Sarah use to avoid recurrent laryngitis?

• Hydration and humidification – Prevents vocal cord irritation.
• Limit voice strain – Use a microphone or voice training techniques.
• Manage GORD if present – Avoid late meals, caffeine, and alcohol.
• Vaccination – Annual influenza vaccine may reduce risk of viral laryngitis.

If laryngitis recurs frequently or lasts beyond 3 weeks, referral to an ENT specialist for laryngoscopy is warranted.

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SUMMARY OF A COMPETENT ANSWER

• Systematic differential diagnosis, recognising common and serious causes.
• Identification of red flags indicating urgent intervention.
• Appropriate symptomatic management, avoiding unnecessary antibiotics.
• Clear communication about work-related implications and voice recovery.
• Preventive strategies to reduce recurrence and optimise vocal health.

PITFALLS

• Failing to identify red flags, delaying escalation of care.
• Prescribing unnecessary antibiotics, as most cases are viral.
• Not providing adequate voice care advice, leading to prolonged symptoms.
• Overlooking occupational factors, such as voice strain in teachers.

REFERENCES

• RACGP – RACGP Guidelines on Acute Laryngitis Management
• GP Exams – Laryngitis/tracheitis, acute

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively about self-limiting conditions.
1.2 Provides clear safety-netting and follow-up advice.

2. Clinical Information Gathering and Interpretation

2.1 Takes a focused history on acute upper airway symptoms.
2.2 Conducts an appropriate physical examination for suspected laryngitis/tracheitis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between viral laryngitis and bacterial tracheitis.
3.2 Recognises red flags requiring urgent intervention.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan for acute laryngitis.
4.2 Identifies cases requiring antibiotics or specialist referral.

5. Preventive and Population Health

5.1 Educates patients on voice care and prevention of recurrent laryngitis.

6. Professionalism

6.1 Provides reassurance while managing patient expectations about recovery.

7. General Practice Systems and Regulatory Requirements

7.1 Documents appropriately and considers work-related implications.

9. Managing Uncertainty

9.1 Identifies cases where a broader differential diagnosis should be considered.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and escalates cases with signs of airway compromise.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD