ENT: #2 Common Nose and Throat disorders

• Nose and sinuses: Allergic Rhinitis | Non-allergic and Drug-induced Rhinitis | Acute Sinusitis | Chronic Rhinosinusitis and Nasal Polyps | Loss of Smell | Septal Problems and Nasal Blockage | Sinonasal Tumours
• Throat: Sore Throat and Tonsillitis | Glandular Fever | Scarlet Fever and Invasive Group A Strep | Tonsillectomy | Snoring and Obstructive Sleep Apnoea
• Voice and swallowing: Hoarseness | Vocal Cord Palsy | Globus and Laryngopharyngeal Reflux | Pharyngeal Pouch and ENT Dysphagia
• Mouth: Mouth Ulcers | White and Red Patches in the Mouth
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

👃 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?

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):

• 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

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Spot the Diagnosis