ENT: Common Nose and Throat disorders

👃 The nose and throat -rhinitis, sinusitis and sore throats are among the commonest reasons people see a GP, and most need no antibiotics. Your job is to treat symptoms well, use scoring tools to target antibiotics, and spot the few patients with something serious: a one-sided nasal problem (tumour), persistent hoarseness or mouth ulcer (cancer), or sleep apnoea affecting driving.
Your four questions for every patient: Is it one-sided (always suspicious) or both sides? How long has it lasted (over 3 weeks for hoarseness or ulcers is a red flag)? Does this need antibiotics at all (FeverPAIN, duration)? Are there red flags -weight loss, neck lump, bleeding, smoking, eye or neurological signs?

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Allergic Rhinitis

• What it is: IgE-mediated inflammation of the nose -hay fever (seasonal, pollen) or year-round (house dust mite, pets, moulds). Affects about 1 in 4 people in the UK.
• Features:
  • Sneezing, itchy nose, watery discharge, blocked nose.
  • Itchy, watery eyes.
  • Pale, swollen turbinates; "allergic salute" and nasal crease in children.
  • Linked with asthma and eczema -poorly controlled rhinitis worsens asthma.
• Tests (if unclear or considering immunotherapy): skin prick tests or specific IgE.
• Treatment (step up):
  • Avoid triggers (pollen counts, bedding covers, pets out of bedrooms); saline nasal rinses.
  • Oral non-sedating antihistamines -cetirizine, loratadine, fexofenadine -for mild or intermittent symptoms.
  • Intranasal corticosteroid -mometasone, fluticasone, beclometasone -the most effective treatment, especially for blockage. Takes days to work fully; use regularly through the season; teach technique (aim away from the septum).
  • Intranasal antihistamine (azelastine) or a combined steroid–antihistamine spray for more severe symptoms.
  • Eye drops -sodium cromoglicate, olopatadine.
  • Short course of oral prednisolone -occasionally for severe symptoms before an important event (e.g. exams).
  • Montelukast -if asthma too (MHRA warning about neuropsychiatric effects).
  • Allergen immunotherapy (sublingual tablets or injections) -specialist, for severe disease not controlled by medicines.
  • Avoid depot steroid injections (IM triamcinolone) -side effects outweigh benefit.
• Refer if one-sided symptoms, bleeding, crusting, pain, or failure of treatment.

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Non-allergic and Drug-induced Rhinitis

• Infective rhinitis -the common cold; self-limiting over 7–10 days.
• Vasomotor rhinitis -watery discharge and blockage triggered by temperature change, spicy food, alcohol, smells; older adults. Ipratropium nasal spray helps a runny nose.
• Rhinitis medicamentosa -rebound blockage from using decongestant sprays (xylometazoline, oxymetazoline) for more than 5–7 days. Stop the decongestant; use an intranasal steroid.
• Drug-induced:
  • Alpha-blockers, beta-blockers, ACE inhibitors.
  • Oral contraceptives; PDE-5 inhibitors.
  • Aspirin and NSAIDs -in aspirin-exacerbated respiratory disease (asthma, nasal polyps, aspirin sensitivity -Samter's triad).
  • Cocaine -crusting, bleeding, septal perforation.
• Hormonal -pregnancy (resolves after birth), hypothyroidism.
• Atrophic rhinitis -dry, crusty, smelly nose (after surgery, older people); nasal douching.
• Systemic disease -GPA (crusting, bloody discharge, septal perforation, saddle nose), sarcoidosis, EGPA (polyps and asthma).

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Acute Sinusitis

• What it is: Inflammation of the sinuses for under 12 weeks, usually after a cold. Mostly viral; only a small minority are bacterial.
• Features:
  • Blocked nose, nasal discharge (any colour), facial pain or pressure (worse bending forward), reduced smell.
  • Toothache in the upper teeth (maxillary sinus); fever.
• Management (NICE NG79):
  • Symptoms for 10 days or less -no antibiotic; self-care (paracetamol or ibuprofen, fluids, saline); most get better in 2–3 weeks.
  • Symptoms over 10 days with no improvement:
    • Consider a high-dose nasal steroid (e.g. mometasone 200 micrograms twice daily for 14 days) in people aged 12 or over.
    • No antibiotic or a back-up antibiotic.
  • Immediate antibiotic if systemically very unwell or at high risk of complications.
  • Antibiotic choice: Phenoxymethylpenicillin 500 mg four times daily for 5 days first line; doxycycline or clarithromycin if allergic; co-amoxiclav if very unwell or high risk.
• Red flags (refer immediately) -eye swelling or redness, double vision, reduced vision, severe frontal headache, forehead swelling, neurological signs, meningism, sepsis. See the ENT Emergencies chapter.
• Dental cause -one-sided maxillary sinusitis with foul smell may come from an upper tooth infection.

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Chronic Rhinosinusitis and Nasal Polyps

• Definition (EPOS) -12 weeks or more of two or more symptoms, one of which is nasal blockage or discharge, plus facial pain or pressure, or reduced smell.
• Two types:
  • Without polyps.
  • With nasal polyps -pale grey, glistening, insensitive grapes in the nose (unlike turbinates, which are pink and tender). Strong link with asthma and aspirin sensitivity.
• Treatment:
  • Saline irrigation (large-volume douching).
  • Intranasal corticosteroid -sprays, or drops for polyps (head-down position); used long-term.
  • Short course of oral steroids for large polyps (shrinks them temporarily).
  • Long-term low-dose macrolide (clarithromycin) -specialist option for disease without polyps.
  • Functional endoscopic sinus surgery (FESS) -if medical treatment fails.
  • Biologics (e.g. anti-IL-4/13, anti-IL-5) for severe recurrent polyps -specialist; availability varies.
• Red flags -refer urgently:
  • One-sided polyp or one-sided symptoms -exclude tumour (inverted papilloma, cancer).
  • Bleeding, crusting, facial swelling or numbness, eye symptoms, loose teeth.
• Nasal polyps in a child -test for cystic fibrosis.

💡 Clinical Pearl: In the nose, "one-sided" is the key red flag. Bilateral blockage is usually rhinitis or polyps; one-sided blockage with bloody discharge in an adult is a tumour until proven otherwise.

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Loss of Smell

• Anosmia (no smell), hyposmia (reduced), parosmia (distorted -things smell unpleasant). Taste usually seems affected too (flavour is mostly smell).
• Causes:
  • Post-viral -including COVID-19; may recover over months.
  • Chronic rhinosinusitis and nasal polyps (often fluctuates).
  • Head injury (olfactory nerve shearing).
  • Ageing.
  • Neurodegenerative -early sign of Parkinson's disease and Alzheimer's disease.
  • Drugs; smoking.
  • Kallmann syndrome -congenital anosmia with hypogonadotrophic hypogonadism (delayed puberty).
  • Tumours -olfactory groove meningioma (with personality change), sinonasal tumours.
• Management:
  • Examine the nose (nasendoscopy); MRI if no clear cause or neurological signs.
  • Smell training (sniffing four strong scents twice daily for months) -helps post-viral loss.
  • Treat sinus disease (steroids).
  • Safety advice -smoke and gas alarms, food dates (can't smell gas, smoke or spoiled food).

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Septal Problems and Nasal Blockage

• Deviated septum -common; may cause one-sided blockage. Septoplasty if troublesome.
• Septal perforation:
  • Causes -previous surgery, nose picking, cocaine, GPA, nasal steroids (rare), sarcoidosis, TB, syphilis, cancer, untreated septal haematoma.
  • Crusting, whistling, nosebleeds.
  • Investigate -ANCA, ACE, syphilis serology; biopsy edge if unexplained.
  • Saline, emollients; septal button or repair.
• Saddle-nose deformity -collapse of the nasal bridge: GPA, relapsing polychondritis, cocaine, trauma (septal haematoma), congenital syphilis.
• Children:
  • Enlarged adenoids -mouth breathing, snoring, sleep apnoea, nasal voice, glue ear. Adenoidectomy if severe.
  • Choanal atresia -blocked back of the nose in a newborn: cyanosis when feeding, pink when crying (babies are nasal breathers). Bilateral is an emergency (oral airway). Linked to CHARGE syndrome.
  • Foreign body -one-sided smelly discharge.

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Sinonasal Tumours

• Rare, but often diagnosed late because early symptoms look like sinusitis.
• Risk factors:
  • Hardwood dust (woodworkers, furniture makers) -adenocarcinoma of the ethmoid sinus.
  • Leather dust, nickel, chromium, formaldehyde.
  • Smoking.
• Features:
  • One-sided blockage, bloody or foul discharge, one-sided nosebleeds.
  • Facial swelling, pain or numbness (cheek -infraorbital nerve).
  • Eye symptoms -proptosis, double vision, watering.
  • Loose teeth, swelling of the palate.
• Types: Squamous cell carcinoma, adenocarcinoma, inverted papilloma (benign but can become malignant), olfactory neuroblastoma, melanoma, lymphoma; juvenile angiofibroma (adolescent boys with nosebleeds -don't biopsy in clinic, very vascular).
• Management: Urgent ENT; CT and MRI; biopsy; surgery and radiotherapy.
• Nasopharyngeal carcinoma -see the Neck Lumps, Salivary Glands and Head and Neck Cancer chapter.

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Sore Throat and Tonsillitis

• Causes: Mostly viral; group A streptococcus in a minority (more common in children aged 5–15).
• Most settle within a week without antibiotics (antibiotics shorten symptoms by only about a day).
• Scoring tools (NICE NG84):

Tool	Score one point for each
FeverPAIN	Fever (past 24 hours); Purulence (pus on tonsils); Attend rapidly (within 3 days of onset); Inflamed tonsils; No cough or cold symptoms
Centor	Tonsillar exudate; tender anterior neck lymph nodes; fever over 38 °C; no cough

• Using the scores:
  • FeverPAIN 0–1 or Centor 0–2 -no antibiotic.
  • FeverPAIN 2–3 -no antibiotic or a back-up prescription.
  • FeverPAIN 4–5 or Centor 3–4 -immediate or back-up antibiotic.
  • Immediate antibiotic also if systemically very unwell or at high risk of complications.
• Treatment:
  • Paracetamol or ibuprofen; fluids; medicated lozenges.
  • Phenoxymethylpenicillin 500 mg four times daily (or 1 g twice daily) for 5–10 days.
  • Penicillin allergy -clarithromycin (or erythromycin in pregnancy).
  • Avoid amoxicillin -causes a rash in glandular fever.
• Admit if unable to swallow fluids, drooling, stridor, quinsy or severe systemic illness.
• Red flags -persistent one-sided sore throat over 3 weeks, especially in smokers or with ear pain, voice change or a neck lump (cancer); immunosuppression (check FBC -agranulocytosis from carbimazole, clozapine, sulfasalazine or chemotherapy).

⚠️ Safety Pearl: A sore throat in a patient on carbimazole, clozapine or chemotherapy needs an urgent FBC -it may be neutropenia, not tonsillitis.

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Glandular Fever

• Infectious mononucleosis -Epstein–Barr virus (EBV); teenagers and young adults ("kissing disease").
• Features:
  • Severe sore throat with large tonsils, often with a white or grey coating; palatal petechiae.
  • Fever; marked tiredness (can last weeks to months).
  • Swollen lymph nodes -especially the back of the neck (posterior chain).
  • Enlarged spleen; sometimes liver (mildly raised LFTs, jaundice).
  • Rash with amoxicillin or ampicillin (almost all).
• Tests:
  • FBC -lymphocytosis with atypical lymphocytes.
  • Monospot (heterophile antibody) -can be negative in the first week and in young children; EBV serology (VCA IgM).
  • LFTs.
• Management:
  • Supportive -rest, fluids, paracetamol or ibuprofen.
  • Avoid contact sports and heavy lifting for at least 4 weeks (risk of splenic rupture).
  • Avoid alcohol while LFTs are raised.
  • Steroids only for airway obstruction from very large tonsils, or severe complications (haemolytic anaemia, low platelets).
• Complications: Airway obstruction, splenic rupture (sudden left upper abdominal pain), hepatitis, haemolytic anaemia, thrombocytopenia, Guillain–Barré, post-viral fatigue. Long term -linked to Hodgkin lymphoma, nasopharyngeal carcinoma and MS.
• Similar illnesses -CMV, toxoplasmosis, acute HIV (test if at risk).

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Scarlet Fever and Invasive Group A Strep

• Scarlet fever -group A streptococcal infection (usually sore throat) with a toxin-mediated rash; mostly children aged 2–10.
  • Features: Sore throat, fever, headache; fine "sandpaper" pink-red rash starting on the chest and spreading, flushed cheeks with a pale area around the mouth, strawberry tongue; skin peeling later (fingers and toes).
  • Treatment: Phenoxymethylpenicillin for 10 days (clarithromycin or azithromycin if allergic).
  • Notifiable to UKHSA.
  • Children can return to school or nursery 24 hours after starting antibiotics.
• Invasive group A streptococcal infection (iGAS):
  • Rare but serious -necrotising fasciitis, streptococcal toxic shock syndrome, pneumonia, empyema, bone and joint infection, sepsis.
  • Higher risk after chickenpox, influenza, in older people and in people who inject drugs.
  • Red flags -severe pain out of proportion, spreading redness, high fever, low BP, confusion.
  • Treatment -urgent IV antibiotics (e.g. benzylpenicillin with clindamycin to switch off toxin production), IVIG in toxic shock, surgical debridement.
  • Close contacts may need antibiotic prophylaxis (UKHSA).
• Other complications of strep throat -quinsy, rheumatic fever (rare in the UK), post-streptococcal glomerulonephritis.

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Tonsillectomy

• Indications for recurrent tonsillitis (SIGN 117) -sore throats due to tonsillitis that are disabling and affect normal life, and:
  • 7 or more well-documented episodes in the past year, or
  • 5 or more per year for 2 years, or
  • 3 or more per year for 3 years.
• Other indications:
  • Recurrent quinsy (two or more).
  • Obstructive sleep apnoea in children (adenotonsillectomy -the main treatment).
  • Suspected cancer -a one-sided enlarged tonsil, especially in adults (lymphoma, HPV-related squamous cell carcinoma).
• Risks:
  • Bleeding -primary (first 24 hours) or secondary (5–10 days); a small percentage need a return to theatre.
  • Pain for 1–2 weeks (often with ear pain); infection; dental damage; anaesthetic risks.
• After surgery -regular analgesia, eat normally (helps healing), return to hospital for any bleeding.

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Snoring and Obstructive Sleep Apnoea

• Obstructive sleep apnoea (OSA) -the upper airway collapses repeatedly during sleep, causing pauses in breathing, falling oxygen, and broken sleep.
• Risk factors:
  • Obesity (neck size over 43 cm in men).
  • Male sex; older age; menopause.
  • Alcohol and sedatives at night.
  • Smoking.
  • Large tonsils (children); small jaw (retrognathia).
  • Hypothyroidism, acromegaly, Down syndrome.
• Features:
  • Loud snoring; partner sees pauses in breathing and gasping.
  • Excessive daytime sleepiness; unrefreshing sleep; morning headaches; poor concentration; low mood.
  • Nocturia.
  • Associations -hypertension (resistant), atrial fibrillation, heart failure, stroke, type 2 diabetes, road traffic accidents.
  • Children -snoring, restless sleep, behaviour problems, poor growth.
• Assessment (NICE NG202):
  • Epworth Sleepiness Scale (score over 10 = excessive sleepiness) and STOP-Bang questionnaire.
  • Refer to a sleep service; urgent referral if sleepy and a professional driver or in a safety-critical job, or with significant other illness (e.g. respiratory failure) or pre-operative assessment.
  • Home sleep study (respiratory polygraphy) -apnoea–hypopnoea index (AHI): 5–14 mild, 15–29 moderate, 30 or more severe.
• Treatment:
  • Weight loss; reduce alcohol and sedatives; stop smoking; sleep on side.
  • CPAP (continuous positive airway pressure) -for moderate to severe OSA, or mild OSA with symptoms affecting daily life. Improves sleepiness, BP and quality of life.
  • Mandibular advancement splint -mild OSA or if CPAP isn't tolerated.
  • Surgery -tonsillectomy in children; selected adults (hypoglossal nerve stimulation, airway surgery).
• Driving (DVLA):
  • People with excessive sleepiness from suspected or confirmed OSA must not drive until symptoms are controlled.
  • Must tell the DVLA if they have moderate or severe OSA with excessive sleepiness (or mild OSA with sleepiness not controlled within 3 months).
  • Group 2 drivers need evidence of treatment adherence.
• Simple snoring without apnoea -weight loss, alcohol reduction, side sleeping; splints.
• Obesity hypoventilation syndrome -obesity with daytime high CO2; needs NIV. See the Respiratory chapters.

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Hoarseness

• Hoarseness (dysphonia) -a change in voice quality. Most is from short-lived laryngitis, but persistent hoarseness can be laryngeal cancer.
• Causes:
  • Acute laryngitis -viral, with a cold; voice overuse. Settles within 2–3 weeks.
  • Vocal nodules ("singer's nodules") -both cords, from voice overuse (teachers, singers). Voice therapy.
  • Vocal cord polyp -usually one side; surgery.
  • Reinke's oedema -swollen, floppy cords in smokers (and hypothyroidism); low, gravelly voice (especially in women).
  • Muscle tension dysphonia -no structural problem; voice therapy.
  • Laryngopharyngeal reflux.
  • Inhaled steroids -laryngeal candida or weak cords; rinse mouth, use a spacer.
  • Vocal cord palsy -weak, breathy voice and weak cough (see below).
  • Laryngeal cancer -smokers, alcohol.
  • Recurrent respiratory papillomatosis -HPV 6 and 11 warts on the cords.
  • Hypothyroidism; acromegaly.
  • Neurological -Parkinson's (quiet voice), myasthenia, MND (bulbar), stroke, spasmodic dysphonia.
• Refer (NICE NG12):
  • Age 45 or over with persistent unexplained hoarseness -consider a suspected cancer pathway referral (laryngeal cancer).
  • Also consider an urgent chest X-ray in smokers and those over 40 (lung cancer can cause hoarseness via the recurrent laryngeal nerve).
  • Any age -hoarseness lasting over 3 weeks, or with stridor, neck lump, swallowing problems, ear pain, haemoptysis, or weight loss.
• Assessment: Flexible nasendoscopy (laryngoscopy) by ENT.
• Voice care -hydration, avoid shouting and whispering, stop smoking, treat reflux; speech and language therapy.

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Vocal Cord Palsy

• Nerve supply: The recurrent laryngeal nerve (branch of the vagus) moves most of the vocal cord muscles. The left nerve loops under the aortic arch, so it has a longer course in the chest and is affected more often.
• Features (one-sided):
  • Weak, breathy voice.
  • Weak "bovine" cough.
  • Choking or coughing on drinks (aspiration).
  • Breathlessness on talking.
• Bilateral palsy -cords stuck near the midline: stridor and airway obstruction (often after thyroid surgery) -emergency.
• Causes:
  • Surgery -thyroid and parathyroid surgery (the commonest), cardiothoracic surgery, carotid surgery, oesophagectomy.
  • Cancer:
    • Lung cancer (left apex, mediastinal nodes).
    • Thyroid cancer.
    • Oesophageal cancer.
    • Mediastinal lymphoma.
    • Skull base tumours (with other cranial nerve palsies -jugular foramen syndrome).
  • Thoracic aortic aneurysm; enlarged left atrium (mitral stenosis -Ortner syndrome).
  • Prolonged intubation; viral neuritis; idiopathic.
  • Central -stroke (lateral medullary syndrome), MND, MS, syringobulbia.
• Investigation: Laryngoscopy; CT from the skull base to the aortic arch (to follow the whole nerve); chest X-ray.
• Treatment: Treat the cause; speech and language therapy; injection medialisation of the cord or thyroplasty; bilateral palsy may need tracheostomy.

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Globus and Laryngopharyngeal Reflux

• Globus pharyngeus -a feeling of a lump or tightness in the throat when there is nothing there.
  • Reassuring features -felt in the midline, between meals (often better when eating), comes and goes, worse with stress, no difficulty swallowing food.
  • Management -explanation and reassurance; treat reflux if present; speech and language therapy; manage anxiety.
• Red flags (refer -could be cancer):
  • Difficulty swallowing food (true dysphagia) or painful swallowing.
  • Weight loss.
  • One-sided or localised throat pain, referred ear pain.
  • Hoarseness; neck lump; haemoptysis.
  • Smoker or heavy drinker; age over 45.
• Laryngopharyngeal reflux (LPR) -acid or pepsin reaching the throat:
  • Throat clearing, hoarseness, chronic cough, globus, postnasal drip feeling -often without heartburn.
  • Treatment -lifestyle (avoid late meals, alcohol, caffeine; raise the bed head; lose weight), alginates (e.g. Gaviscon Advance) after meals and at bedtime; a PPI trial is often used but evidence is mixed.

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Pharyngeal Pouch and ENT Dysphagia

• Pharyngeal pouch (Zenker's diverticulum):
  • A pouch of the pharynx pushes out through a weak area at the back (Killian's dehiscence) above the cricopharyngeus muscle.
  • Who: Older men (over 70).
  • Features:
    • Dysphagia with food sticking high in the throat.
    • Regurgitation of undigested food, sometimes hours later.
    • Bad breath (halitosis).
    • Gurgling noises in the neck; neck swelling on the left after drinking.
    • Cough and aspiration pneumonia; weight loss.
  • Diagnosis: Barium swallow (contrast swallow). Take care at endoscopy (perforation risk).
  • Treatment: Endoscopic stapling of the wall between the pouch and oesophagus, or open surgery; watch if mild.
• High (oropharyngeal) dysphagia -difficulty starting a swallow, coughing or choking, nasal regurgitation:
  • Neurological -stroke, Parkinson's, MND, myasthenia, dementia.
  • Structural -pouch, head and neck cancer, cervical osteophytes, post-radiotherapy stricture.
  • Assessment -speech and language therapy swallow assessment, videofluoroscopy or fibreoptic endoscopic evaluation of swallowing (FEES).
• Oesophageal dysphagia -food sticking behind the sternum: see the Oesophagus and Stomach chapter. Any new dysphagia needs urgent investigation (NICE NG12).

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Mouth Ulcers

• Aphthous ulcers -the commonest:
  • Small, round, painful ulcers with a yellow-grey base and red rim; heal in 1–2 weeks; recur.
  • Triggers -stress, minor trauma, hormonal changes, stopping smoking, sodium lauryl sulfate toothpaste.
  • Treatment -chlorhexidine mouthwash, benzydamine spray, topical steroids (e.g. hydrocortisone mucoadhesive buccal tablets, beclometasone inhaler sprayed onto ulcers).
• Systemic causes (recurrent or severe ulcers) -check FBC, ferritin, B12, folate, coeliac serology:
  • Iron, B12 or folate deficiency.
  • Coeliac disease; Crohn's disease (also lip swelling, cobblestone mucosa).
  • Behçet's disease -with genital ulcers, uveitis, skin lesions.
  • SLE (painless palatal ulcers); reactive arthritis.
  • HIV; neutropenia.
  • Drugs -nicorandil, methotrexate, NSAIDs, chemotherapy, mycophenolate.
  • Erosive lichen planus; pemphigus vulgaris; mucous membrane pemphigoid.
• Infections:
  • Primary herpes simplex (gingivostomatitis) -young children, fever, many ulcers, swollen gums; fluids, analgesia, aciclovir if early and severe.
  • Hand, foot and mouth disease (coxsackie) -children; mouth ulcers with hand and foot blisters.
  • Herpangina -ulcers on the soft palate.
  • Syphilis (painless chancre); TB.
• Cancer -a single ulcer that doesn't heal, often painless, hard edge, on the side of the tongue or floor of mouth; smokers and drinkers.
  • NICE NG12 -refer via a suspected cancer pathway anyone with unexplained mouth ulceration lasting more than 3 weeks.

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White and Red Patches in the Mouth

• Oral candida (thrush):
  • White patches that wipe off, leaving a red surface; or red, sore areas under dentures; cracks at the mouth corners (angular cheilitis).
  • Risk factors -inhaled steroids, dentures, antibiotics, diabetes, dry mouth, immunosuppression (HIV, chemotherapy), smoking, infancy.
  • Treatment -miconazole oral gel (avoid with warfarin -raises INR), nystatin, or oral fluconazole; denture hygiene; rinse after inhalers.
• Leukoplakia -a white patch that can't be wiped off and has no other cause. Potentially malignant -refer for biopsy; stop smoking and reduce alcohol.
• Erythroplakia -a red velvety patch; higher cancer risk than leukoplakia -refer urgently.
• Oral lichen planus -white lacy (Wickham's) streaks on the inner cheeks, sometimes with erosions; small cancer risk; topical steroids; review.
• Oral hairy leukoplakia -white ridged patches on the side of the tongue; EBV in HIV or immunosuppression.
• Geographic tongue -smooth red patches with white borders that move around; harmless.
• Black hairy tongue -antibiotics, smoking, poor hygiene; harmless.
• Burning mouth syndrome -burning with a normal-looking mouth; postmenopausal women; exclude deficiencies, candida, diabetes, dry mouth, drugs; low-dose clonazepam or tricyclics (specialist).
• Dry mouth (xerostomia) -drugs (anticholinergics, antidepressants, diuretics), Sjögren's syndrome, radiotherapy, dehydration, diabetes; saliva substitutes, sugar-free gum, dental care.
• NICE NG12 -refer (cancer pathway, or urgent dental assessment) a lump on the lip or in the mouth, or a red or red-and-white patch consistent with cancer.

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Drug Reference Table

Drug	Key points
Mometasone / fluticasone nasal spray	Most effective treatment for allergic rhinitis and chronic rhinosinusitis; high dose (mometasone 200 micrograms twice daily for 14 days) for sinusitis over 10 days.
Cetirizine / loratadine / fexofenadine	Non-sedating oral antihistamines for allergic rhinitis.
Azelastine nasal spray	Intranasal antihistamine; fast onset; bitter taste.
Xylometazoline	Decongestant spray -maximum 5–7 days (rebound rhinitis).
Ipratropium nasal spray	Watery rhinorrhoea in vasomotor rhinitis.
Phenoxymethylpenicillin	Strep throat 5–10 days; scarlet fever 10 days; sinusitis 5 days (500 mg four times daily).
Clarithromycin	Penicillin allergy (sore throat, sinusitis); interactions (statins, warfarin).
Doxycycline	Sinusitis in penicillin allergy; not under 12 or in pregnancy.
Co-amoxiclav	Sinusitis if systemically very unwell or high risk.
Benzylpenicillin + clindamycin IV	Invasive group A strep and toxic shock.
CPAP	Moderate to severe OSA, or mild OSA with symptoms.
Alginate (Gaviscon Advance)	Laryngopharyngeal reflux after meals and at bedtime.
Benzydamine / chlorhexidine mouthwash	Symptomatic relief of mouth ulcers.
Miconazole oral gel / nystatin / fluconazole	Oral candida; miconazole raises INR with warfarin.

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Spot the Diagnosis

Clue	Diagnosis
Sneezing, itchy nose and eyes every June	Seasonal allergic rhinitis
Worsening blockage after weeks of xylometazoline	Rhinitis medicamentosa
Asthma, nasal polyps and wheeze after ibuprofen	Aspirin-exacerbated respiratory disease
Grey, insensitive "grapes" in both nostrils and no sense of smell	Chronic rhinosinusitis with nasal polyps
Nasal polyps in a 7-year-old	Cystic fibrosis -sweat test
Carpenter with one-sided blockage, bloody discharge and cheek numbness	Sinonasal adenocarcinoma
Adolescent boy with recurrent heavy one-sided nosebleeds	Juvenile angiofibroma
Crusting, septal perforation, haematuria and positive PR3-ANCA	GPA
Anosmia with delayed puberty	Kallmann syndrome
FeverPAIN 1	No antibiotic
Sore throat, posterior neck nodes, splenomegaly, rash after amoxicillin	Glandular fever
Sandpaper rash, strawberry tongue and sore throat in a 5-year-old	Scarlet fever
One-sided enlarged tonsil in a 55-year-old	Tonsil cancer or lymphoma -urgent referral
Snoring, witnessed pauses, Epworth 16, BMI 38	Obstructive sleep apnoea
Deep gravelly voice in a heavy-smoking woman	Reinke's oedema
Breathy voice and weak cough in a smoker with a left hilar mass	Left recurrent laryngeal nerve palsy (lung cancer)
Stridor after total thyroidectomy	Bilateral vocal cord palsy (or haematoma)
Lump in the throat between meals, better when eating	Globus pharyngeus
Older man regurgitating undigested food, bad breath and gurgling neck	Pharyngeal pouch
Painful mouth ulcers on nicorandil	Drug-induced ulceration
Painless tongue ulcer for 5 weeks in a smoker	Oral cancer -suspected cancer referral
White patch on the tongue that won't wipe off	Leukoplakia

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Exam-style Scenarios

1. A 22-year-old has had a sore throat for 2 days with fever and pus on swollen tonsils. No cough or cold symptoms.
Answer: Probable streptococcal tonsillitis (FeverPAIN 5).

• Analgesia and fluids.
• Immediate (or back-up) phenoxymethylpenicillin for 5–10 days; clarithromycin if allergic.
• Safety-net for quinsy (one-sided pain, trismus, drooling).

2. A 34-year-old has had nasal blockage, discoloured discharge and facial pressure for 12 days, with no improvement. She is otherwise well.
Answer: Acute sinusitis lasting over 10 days.

• Consider high-dose nasal steroid (mometasone 200 micrograms twice daily for 14 days).
• No antibiotic or a back-up prescription (phenoxymethylpenicillin 5 days).
• Safety-net for eye swelling, severe headache, or neurological symptoms.

3. A 52-year-old lorry driver has loud snoring, falls asleep at traffic lights, and his wife sees him stop breathing at night. BMI 37, BP 162/98.
Answer: Suspected obstructive sleep apnoea with excessive sleepiness -a safety-critical driver.

• Advise not to drive until assessed and treated; tell the DVLA if OSA is confirmed with sleepiness.
• Urgent sleep service referral; home sleep study.
• CPAP if moderate to severe; weight loss; treat BP; check thyroid.

4. A 63-year-old smoker has had a hoarse voice for 6 weeks. He has no cold symptoms.
Answer: Persistent unexplained hoarseness over 45 -possible laryngeal (or lung) cancer.

• Suspected cancer pathway referral to ENT for laryngoscopy.
• Urgent chest X-ray.
• Stop smoking support.

5. A 66-year-old has a painless ulcer on the side of his tongue for 4 weeks. He smokes and drinks heavily.
Answer: Suspected oral cancer.

• Suspected cancer pathway referral (unexplained mouth ulcer over 3 weeks).
• Examine the neck for lymph nodes.
• Smoking and alcohol support.

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Key Points

• Intranasal steroids are the most effective treatment for allergic rhinitis and chronic rhinosinusitis.
• Decongestant sprays for no more than 5–7 days.
• Acute sinusitis: no antibiotics for 10 days or less; over 10 days consider high-dose nasal steroid and a back-up antibiotic.
• One-sided nasal symptoms or polyps -exclude a tumour; polyps in children -test for cystic fibrosis.
• Use FeverPAIN or Centor to target antibiotics for sore throat; phenoxymethylpenicillin first line; avoid amoxicillin.
• Sore throat on carbimazole or clozapine -urgent FBC for neutropenia.
• Glandular fever: avoid contact sports for at least 4 weeks (splenic rupture).
• Scarlet fever is notifiable; penicillin for 10 days; iGAS needs penicillin with clindamycin.
• Tonsillectomy criteria: 7 in 1 year, 5 a year for 2 years, or 3 a year for 3 years; also recurrent quinsy and childhood OSA.
• OSA: Epworth and STOP-Bang, sleep study, CPAP; sleepy drivers must not drive.
• Persistent hoarseness over 45 needs a suspected cancer referral; consider a chest X-ray.
• Left recurrent laryngeal nerve palsy -think lung cancer, thyroid surgery or aortic aneurysm; image skull base to aortic arch.
• Globus is better when eating; dysphagia, pain, weight loss or one-sided symptoms are red flags.
• Mouth ulcer over 3 weeks, leukoplakia or erythroplakia -refer for possible cancer.

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Guidelines and Further Reading

• NICE NG84: Sore throat (acute) -antimicrobial prescribing
• NICE NG79: Sinusitis (acute) -antimicrobial prescribing
• NICE NG202: Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s
• NICE NG12: Suspected cancer -recognition and referral (head and neck, oral)
• SIGN 117: Management of sore throat and indications for tonsillectomy
• EPOS 2020: European Position Paper on Rhinosinusitis and Nasal Polyps
• BSACI guideline for the management of allergic and non-allergic rhinitis
• UKHSA: Group A streptococcal infections -guidance
• DVLA: Assessing fitness to drive (sleep disorders)
• BNF -for current doses

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