1. Hoarse voice
This is when the voice sounds more rough and gravelly than normal. The possible causes of this depend on the way in which the hoarse voice developed and whether there are any other risk factors that could aggravate the problem, such as smoking, having an occupation or hobby which involves lots of talking or shouting (eg. an actor or teacher). Also heartburn, acid reflux, thyroid conditions and the use of asthma inhalers can also cause hoarseness.
Despite the above, the commonest cause for a hoarse voice is due to a viral cold or ‘flu. This would be expected to cause other ‘flu like symptoms, and the hoarseness should resolve within 3-4 weeks or so. For this reason, if the hoarseness persists for more than 3-4 weeks, a referral to an ENT surgeon is recommended. This may even need to be on an urgent basis if the patient is older with any of the risk factors above, or if there are any other clinical features such as a neck swelling, a red patch in the mouth or difficulty in swallowing.
2. Head and neck lump
Any swelling or lump in the head and neck should be taken seriously. In children, these are almost always due to ‘reactive lymphadenopathy’, or swollen lymph glands which increase in size usually due to infection. They also usually reduce in size once the infection settles although not always. In adults, the cause of the neck lump is largely dictated by the location. A swelling in the lower part of the neck, roughly in the middle, may signify a thyroid swelling, whilst just under the jaw or in front of the ear is more likely to represent a salivary gland swelling.
Questions must be asked regarding the presence of any risk factors or ‘red flag’ symptoms, such as a hard irregular lump which has been gradually enlarging, difficulty in swallowing, earache, weight loss or coughing up blood, as these features, particularly in an older patient or a smoker, need to be investigated urgently to rule out more serious pathology.
3. Sore throat
The causes of a sore throat are numerous, the more common of which are listed here:
- Tonsillitis: Severe sore throat with high temperature, referred ear pain, inability to eat or painful eating
- Viral sore throat/pharyngitis: such as with the common cold or ‘flu
- Candidal fungal infection such as due to the use of steroid asthma inhalers
- Dry/sore throat caused by mouth breathing which in turn could be due to a blocked nose. Therefore any cause of a blocked nose should be considered
- Vitamin deficiencies, eg. vitamin B12, vitamin D, folate
- Certain drugs or medications eg. carbimazole for thyroid disease
- Acid reflux/heartburn
Whilst most sore throats are harmless, the presence of any serious or red flag symptoms (such as a neck lump, weight loss, smoking, elderly patient, ear ache or blood in the phlegm) should prompt an urgent medical review.
4. Difficulty in breathing
When due to a blockage or inflammation of the larynx (inlet to the windpipe and lungs), this can cause ‘stridor’, which is a harsh tight sound on breathing in, due to a narrowing of the upper airways. This can be due to an infection/inflammation (eg. epiglottitis), a swelling or tumour. or a failure of one or both laryngeal nerves to function (such as after thyroid surgery or a severe viral infection). In all cases, an urgent ENT review is important.
However many cases of difficulty in breathing have a perfectly normal larynx and are instead due to a problem with the lungs or cardiovascular system, which your GP will be able to investigate and advise further.
In children, snoring is almost always due to enlarged tonsils and/or adenoids. Where snoring becomes more severe and causes disruption to a good night’s sleep (such as with frequent wakefulness, excessive nighttime sweating or restlessness), this could indicate that there are obstructive breathing episodes. In such circumstances, it may be best to consider an ENT referral as surgery may be required.
In adults, the assessment of snoring is not quite so simple. It is often due to a high body mass index (BMI) and weight loss often helps, however other causes need to be considered. Enlarged tonsils and adenoids are rarely the main cause! A blocked nose may cause increased mouth breathing for example, which could cause snoring particularly if there is a long, floppy soft palate or if the lower jaw is receded. If there are any features like this, or if you think that you might have some features of obstructive sleep apnoea (eg. witnessed episodes of stopping breathing at night, excessive daytime tiredness), then an ENT referral would be recommended so that further tests can be arranged and treatment commenced.
6. White or red patch in the mouth
A white patch is known as leukoplakia, from the Greek work leukos meaning white. They are often caused by localized trauma, which in turn results in inflammation and thickening. There is some debate as to whether leukoplakia is premalignant, ie. might develop into a cancerous swelling in the future. Any persistent lesion should therefore be biopsied. Lichen planus is another example of a white lesion in the mouth. This can also occur on other parts of the body and in its erosive form can be quite painful and can rarely transform into a malignant lesion.
Another cause of a whitish lesion in the mouth is due to candida infection, which also causes a sore throat and/or burning and which is effectively treated by topical antifungal solutions. It is more likely to occur in patients who have a reduced immune system, in patients with diabetes or who have been on antibiotics or in patients on asthma inhalers (usually the steroid one). There is no suggestion that oral candida infection is premalignant.
A red patch, either on its own (erythroplakia) or in combination with a white patch (erythroleukoplakia), is more likely to be premalignant, and therefore any persistent lesion for more than 3-4 weeks should be biopsied. Other potentially reversible causes of a red patch in the mouth include vitamin deficiencies (eg. B12, folate) and iron deficiency (inflammation and cracking at the corners of the mouth).
7. ‘Feeling of a lump in the throat’
It is quite common to feel that there might be a lump in your throat on the inside. A careful history needs to be taken to distinguish this from a true difficulty in swallowing food or liquids (dysphagia, from the Greek dys meaning abnormal and phagos meaning to eat). When there is a feeling of something stuck in the throat but no true dysphagia, and assuming that nothing abnormal has been found on examination, then the condition is called globus pharyngeus. In globus, the feeling of something stuck in the throat usually disappears temporarily whilst swallowing food. The single biggest risk factor for this condition is anxiety or stress, although acid reflux and heartburn can be contributory. A full examination and reassurance is usually sufficient.