Common Throat Symptoms

 

Sorethroat

Sorethroat is one of the most common symptoms seen by an ENT surgeon. There are many causes of sorethroat including infection, allergy and reflux disease. Generally, it is important to distinguish between sorethroat with fever and sorethroat without fever.

Sorethroat with fever is most commonly due to infection. Tonsillitis is caused by a bacterial infection of the tonsils (see Tonsillitis under Tonsils and Adenoids). It can also be due to a viral pharyngitis or laryngitis. This kind of sorethroat usually last one to two weeks and patients usually feel sufficiently ill to take time off school or work.

The causes of sorethroat without fever include postnasal drip, reflux of gastric acid secretions. Nasal secretions from allergy or sinus infection can trickle into the throat and cause irritation and pain. Gastric acid secretions can track up the esophagus and irritate the throat. Patients may also complain of a sour or bitter taste in the mouth and frequent hoarseness.

Treatment is targeted at the root cause of the problem. Antibiotics generally do not help unless a bacterial infection is the cause.

Hoarseness

Hoarseness refers to a change in quality of voice. Patients suffering from this problem have described it as rough, husky, squeaky, weak and breathy among others. The changes in sound quality usually result from conditions affecting vocal cords which is the sound producing part of the voice box. While breathing, the vocal cords stay apart but come together when phonation starts. Any condition that interrupts the smooth apposition of the vocal cords during this time leads to hoarseness.

Causes of Hoarseness include:

  1. Acute Infections – the commonest cause of hoarseness is a viral or bacterial infection of the larynx. This usually follows an upper respiratory tract infection made worse by shouting or excessive talking. Fortunately, the condition is self-limiting and supportive treatment is all that is required.
  2. cough | throatVoice Abuse/ Overuse – excessive or improper use of the voice box can lead to prolonged hoarseness. Vocal cord nodules (Figure 1) form as a result of repeated trauma of the vocal cords from excessive voice use. As the nodules enlarge, more force is required to generate speech and this in turn results in worsening of the nodules. Vocal cord polyps are singular swellings on one vocal cord and usually results from a sudden shout.
  3. Smoking – smoking is another cause of hoarseness and is related to laryngeal cancer. All smokers who are hoarse should have an examination of their voice box.
  4. Smoking – smoking is another cause of hoarseness and is related to laryngeal cancer. All smokers who are hoarse should have an examination of their voice box.
  5. Functional Dysphonia – hoarseness without any obvious pathology is usually due to poor functioning of the larynx as a whole. This involves the movement and coordination of the laryngeal muscles.
  6. Others – many unusual causes of hoarseness include allergies, hormonal changes, neurological disorder and trauma.

When should I see an ENT specialist?

Patients should seek an ENT specialist opinion and assessment when

  1. hoarseness lasts more than 3 weeks. This is especially so in smokers.
  2. hoarseness is associated with
    1. blood-stained phlegm
    2. neck lump
    3. difficulty swallowing
    4. pain

Treatment

The management depends on the cause. Treatment options usually involve medical therapy for infections, reflux disease and allergies. Surgery may be necessary for nodules and polyps. Speech therapy is usually an important part of treatment in chronic hoarseness.

Globus Syndrome/ Sensation (Lump in the throat sensation)

Some patients experience a sensation of something stuck in the throat, a lump in the throat feeling, a blockage in the throat. Some patients even feel a difficulty breathing and a shortness of breath. However, examination of the throat with a nasopharyngoscope reveals a clear throat and no obvious mass or growth.

The cause is unknown but many theories have been put forward. This include

  1. Cricopharyngeal spasm – the cricopharyngeus muscle found at the top end of the esophagus and goes into spasm when there is failure of relaxation of swallowing muscles or premature closure during swallowing.
  2. Reflux Esophagitis – escape of gastric acid juices can track up the esophagus and irritate the throat causing the sensation. It can also cause cricopharyngeal spasm.
  3. Postnasal Drip – allergy resulting in excessive mucous production from the postnasal space can track down into the throat can cause globus sensation.
  4. Psychological – there is some degree of anxiety associated with this condition and patients present with a worry of a growth in the throat.

Diagnosis

The first and important step is to obtain an accurate history and perform a full examination to exclude significant disease such as tumor, neurological conditions. The diagnosis of Globus syndrome is dependent on 3 criteria:

  1. A sensation of something stuck in the throat, whether in the midline or one side of the throat.
  2. No true dysphagia (difficulty swallowing) with solids or liquids.
  3. No physical signs.

Treatment

Patients with symptoms of reflux disease should be treated with anti-reflux medications. Investigations such as barium swallow, rigid esphagoscopy under general anaesthesia will help exclude oropharyngeal and hypopharyngeal disease. Counseling and reassurance is an important part of treatment once exclusion of pathology is confirmed.

Chronic Cough

A cough is one of the most common symptoms that bring a patient to the doctor. Apart from smokers’ cough, most coughs are due to viral infections and are self-limiting in nature. A cough lasting more than 4 to 6 weeks requires investigation by a specialist. Coughing is an important reflex action that protects the airway from unwanted and foreign particles. The cough reflex is triggered by receptors in the pharynx, nose, larynx, trachea, bronchi, ear canal, esophagus, stomach and heart.

Common causes of cough include

  1. Postnasal drip – mucous or pus from allergy or sinusitis dripping down from the nose into the throat can cause irritation to the pharynx and induce a cough. Certain foods also aggravate the throat by causing more phlegm production and inducing a cough. The cough can start anytime after a meal but generally comes on soon after.
  2. Gastroesophageal reflux disease (GERD) – GERD is common problem in the population (Fig 2). Proving GERD as a cause of a chronic cough can be difficult, as many patients do not have gastric symptoms. One does not need to have gastric symptoms to have GERD. If GERD was the cause of a chronic cough, aggressive anti-reflux medication will usually result in resolution of symptoms.
  3. Post-infectious Cough – some patients experience a persistence of cough despite the resolution of an acute upper respiratory infection. This may be due to hyperresponsiveness of the airway after an infection. Treatment with anti-inflammatories such as steroids and bronchodilators usually help.
  4. Medications – Angiotensin Converting Enzyme Inhibitors (ACEI) are medications for heart failure, hypertension and heart attacks. 10 to 20% of patients develop a cough while on this medication. The cough settles once the medications are removed.
  5. Asthma – cough is one of the symptoms from hypersensitivity of the lower airway. Brochodilators and inhaled steroids usually afford good control of symptoms.
  6. Less common causes include benign and malignant tumors, psychogenic (or habitual) or stress-induced cough.
  7. cough | Gastroesophageal reflux disease

Management

The start of the management is to obtain a good history of possible inciting factors. Important features to rule out include blood-stained phlegm with coughing, night sweats, loss of weight, exposure to noxious agents or allergens. Does the cough start at night, is worse on lying down and associated with shortness of breath?

A full examination would include a nasopharyngoscope to assess the nasal cavity, pharynx and larynx. Lung auscultation for wheezing and rhonchi should be performed. Ear disease such as wax or hair in the ear canal can cause irritation of the throat and cough.

Basic investigations such as chest x-ray, spirometry should be performed. Skin prick tests for allergy will confirm the presence of inhalant and food allergies. Serology for mycoplasma infection, tests for tuberculosis are also available if infection is suspected. A CT scan of the thorax will give greater definition of the lung and mediastinum.

Treatment will depend on the cause of the cough. Often, there may be multiple factors causing the cough and treatment for each problem is equally important. This may require the involvement of other specialists such as respiratory physicians, gastroenterlogists, allergists and infectious disease physicians.

Dr Gerard Chee

MBBS (S'pore), FRCS (Edin), FRCS (Glasg) Fellow, Otology / Neurotology (Can)

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