NECK

Difficulty swallowing

Hoarseness

Neck lumps

Sore throat

Stiff neck

Stridor in children

DIFFICULTY SWALLOWING

The GP overview

This symptom can mean several things, and a careful history is necessary to tease out the precise problem: difficulty in initiating swallowing; a sensation of food sticking somewhere; painful swallowing; also included here is the sensation of ‘something in the throat’ even when not trying to swallow anything.

Differential diagnosis

COMMON

   globus hystericus

   any painful pharyngeal condition, e.g. pharyngitis

   GORD

   benign stricture

   oesophageal carcinoma

OCCASIONAL

   pharyngeal pouch

   pharyngeal carcinoma

   compression by mediastinal tumours (e.g. lymphoma, bronchial carcinoma)

   oesophageal achalasia

   gastric carcinoma

   xerostomia (the elderly, post-parotidectomy and Sjögren’s syndrome)

   foreign body

   drugs: NSAID-associated oesophagitis, failure to take bisphosphonate tablets correctly

RARE

   Plummer–Vinson syndrome

   Chagas’s disease (South American trypanosomal infection)

   scleroderma (CREST syndrome), polymyositis and dermatomyositis

   neurological disorders, e.g. myasthenia gravis, bulbar palsy

   motor neurone disease

Ready reckoner

Possible investigations

LIKELY: (unless obvious globus or local pharyngeal cause) FBC, ESR/CRP, barium swallow or endoscopy.

POSSIBLE: CXR, LFT.

SMALL PRINT: pharyngeal swab, CT scan thorax.

   FBC and ESR/CRP: may reveal evidence of malignancy or iron-deficiency anaemia.

   LFT if malignancy suspected: abnormality suggests hepatic spread.

   Barium swallow useful in the frail and to safely demonstrate stricture or motility problems if no absolute dysphagia for liquids (risk of aspiration).

   Flexible upper GI endoscopy allows visualisation and biopsy of suspicious lesions.

   Throat swab occasionally helpful in painful pharyngeal lesions.

   CXR if suspicion of mediastinal tumour of any cause.

   CT scan or further imaging may be arranged by the specialist to further define mediastinal tumours.

TOP TIPS

   A young patient under stress who can swallow food and drink without problems but who feels there is ‘something stuck’ almost certainly has globus. Reassurance usually resolves the situation.

   Remember to ask about medication – recent onset of painful dysphagia may be caused by severe oesophagitis secondary to drugs such as alendronate, NSAIDs and slow-release potassium supplements.

   Take time with the history: difficulty in swallowing can mean a number of different things, and the diagnosis is much more likely to be revealed by careful questioning than by examination.

   Recent onset of progressive dysphagia with weight loss in an elderly patient is caused by oesophageal carcinoma until proved otherwise.

   A palpable hard lymph node in the left supraclavicular fossa (Troisier’s sign) is strongly associated with gastric carcinoma.

   Beware of patients who have a long history of oesophagitis but who complain of increasing or unusual dysphagia: they may have developed a stricture, or even a carcinoma.

   If endoscopy does not reveal a cause but the symptom continues, remember rarer causes, such as extrinsic compression on the oesophagus or a neurological problem. Consider a barium swallow, or referral to a neurologist if there are other neurological symptoms or signs.

HOARSENESS

The GP overview

Hoarseness may start suddenly and last a few days (acute), or arise gradually and continue for weeks or months (chronic). The history will clarify this and point the way forward in management. Acute hoarseness rarely causes any diagnostic problem or concern; the less common chronic case raises more worrying possibilities and usually requires referral.

Differential diagnosis

COMMON

   acute viral laryngitis

   voice overuse (shouting, screaming)

   hypothyroidism

   smoking

   sinusitis

OCCASIONAL

   GORD

   benign tumours: singer’s nodes, polyps

   crico-arytenoid rheumatoid arthritis

   functional (hysterical) aphonia

RARE

   acute epiglottitis

   laryngeal carcinoma

   recurrent laryngeal nerve palsy

   physical trauma (e.g. after intubation)

   chemical inhalation trauma

   rare inflammatory lesions (e.g. TB, syphilis)

Ready reckoner

Possible investigations

LIKELY: none.

POSSIBLE: TFT, CXR, direct or indirect laryngoscopy.

SMALL PRINT: throat swab.

   TFT: in chronic hoarseness to exclude hypothyroidism.

   CXR: to check for thoracic lesions causing recurrent laryngeal nerve palsy.

   Indirect laryngoscopy: useful for a GP with the necessary skills; most will refer to an ENT specialist.

   Direct laryngoscopy: using a flexible fibre-optic endoscope. This is a specialist investigation allowing close-up views and biopsy of suspicious lesions.

   Throat swab: useful, very rarely, if hoarseness is associated with a persisting pharyngitis.

TOP TIPS

   In acute laryngitis, don’t forget to tell the patient to rest the voice, and remember that occupational factors are important: use of voice (e.g. by telephonists) or working in smoky environment (e.g. a pub) will aggravate and prolong symptoms, causing diagnostic confusion.

   If you suspect a malignancy, arrange an urgent CXR immediately prior to referral. The referral can then be made to the correct specialist (chest rather than ENT) if a lung lesion is present, thus expediting appropriate management.

   Don’t forget transient hoarseness caused by intubation – GPs are seeing this increasingly often as patients spend less post-operative time in hospital.

   Every adult patient with hoarseness for 3 weeks or more showing no signs of improvement has carcinoma of the larynx until proved otherwise.

   GORD is a common cause in the elderly, but beware of making this diagnosis without specialist investigation first.

   Epiglottitis is rare but if you suspect it in any patient, admit immediately – and don’t examine the throat.

   Hypothyroidism is easily overlooked – prompt diagnosis can save unnecessary anxiety and investigation.

NECK LUMPS

The GP overview

A lump in the neck usually means just one thing to a patient: cancer. This is rarely the cause in practice, and a careful examination and explanation can be more anxiolytic than a bucket-load of benzodiazepines. Occasionally further investigation is needed.

Differential diagnosis

COMMON

   reactive lymphadenitis due to a local infection

   prominent normal lymph nodes

   goitre

   sebaceous cyst

   thyroglossal cyst

OCCASIONAL

   branchial cyst

   pharyngeal pouch

   cervical rib

   actinomycosis

   primary lymphoma or secondary neoplastic metastasis

RARE

   tuberculosis of cervical lymph nodes (king’s evil; scrofula)

   thyroid carcinoma

   carotid body tumour or aneurysm

   sarcoidosis

   cystic hygroma

Ready reckoner

Possible investigations

LIKELY: TFTs if thyroid swelling.

POSSIBLE: FBC, ESR, CXR.

SMALL PRINT: thyroid ultrasound, radioisotope studies, barium swallow, biopsy.

   TFT in all cases of thyroid enlargement: may reveal hypo- or hyperthyroidism.

   FBC and ESR in persistent enlarged nodes: check WCC and investigate further if abnormal or if ESR high.

   CXR: may reveal primary lung carcinoma, lymphoma, or other more obscure pathologies.

   Thyroid ultrasound and/or radioiodine studies if lump felt within the thyroid – usually arranged by endocrinologist after referral.

   Barium swallow: to confirm and outline a pharyngeal pouch.

   Biopsy: specialist procedure to establish nature of a persistent, suspicious neck lump.

TOP TIPS

   Establish the patient’s concerns: cancer fear is common with this symptom.

   Unless the lump is obviously suspicious, employ the ‘diagnostic use of time’ – a judicious delay often resolves the problem, or it may reveal the true diagnosis.

   Suspicious lymphadenopathy usually involves a single, gradually enlarging and non-tender lymph node.

   Children with normal or reactive neck glands are often presented by anxious parents. Take time to explain the nature of the problem to properly allay fears and prevent inappropriate repeat attendances.

   A neoplastic-type lymph node enlargement without any obvious cause should be referred urgently for detailed ENT assessment.

   A neck lump fixed to skin and without a punctum should arouse suspicion: urgent biopsy should be done once a primary ENT tumour is ruled out.

   Dysphagia with a neck lump is a serious symptom unless associated with a transient sore throat. Further investigation by endoscopy is necessary.

   Beware of a hard swelling developing rapidly in the thyroid – carcinoma must be excluded.

SORE THROAT

The GP overview

This presenting symptom is the king of superlatives in general practice. It is the commonest – the average GP will see about 120 cases each year – the most over-treated, the most controversial and usually the most mundane. It is also probably the most welcome, as consultations are often short, even when self-management is explained rather than a prescription given.

Differential diagnosis

COMMON

   mild viral pharyngitis (with URTI)

   tonsillitis/streptococcal pharyngitis (‘strep throat’)

   glandular fever

   quinsy (peritonsillar abscess)

   oropharyngeal candidiasis

OCCASIONAL

   GORD

   glossopharyngeal neuralgia and cervicogenic nerve root pain

   trauma: foreign body or scratch from badly chewed crispy food

   other viral or bacterial infections, e.g. Vincent’s angina, herpangina, herpes simplex, gonorrhoea

   aphthous ulceration

   acute or subacute thyroiditis

RARE

   cardiac angina

   carotidynia

   blood dyscrasia (including iatrogenic)

   epiglottitis

   diphtheria

   oropharyngeal carcinoma

   retropharyngeal abscess

Ready reckoner

Possible investigations

LIKELY: none.

POSSIBLE: throat swab, FBC, Paul–Bunnell test.

SMALL PRINT: upper GI endoscopy, biopsy, cardiac investigation (all secondary care).

   Throat swab: use is controversial, mainly because of low specificity and sensitivity. Practical use only in persistent sore throat or treatment failure.

   FBC: may show atypical lymphocytes in glandular fever; also will reveal any underlying blood dyscrasia.

   Paul–Bunnell test for glandular fever if malaise and fatigue persist.

   Upper GI endoscopy may be necessary to diagnose GORD.

   X-ray/laryngoscopy: if suspicion of foreign body.

   Cardiac investigation: in rare case when referred symptoms cause pain in throat.

   Biopsy of suspicious lesions important to investigate possible malignancy.

TOP TIPS

   Consultations for severe sore throats usually boil down to a decision whether or not to prescribe antibiotics. There is no easy or reliable way to distinguish clinically between bacterial and viral causes, so the situation becomes an exercise in pragmatism, though the Centor criteria may help. Even in ‘true’ streptococcal throats, antibiotic treatment probably only reduces the duration of symptoms by about 24 hours and is unlikely to influence the likelihood of complications.

   Mild sore throat with an URTI is usually just one of a ‘package’ of symptoms presented, along with rhinorrhoea, cough, headache and so on. The cause is invariably viral and antibiotics have no role to play.

   Throat swabs only help management in obscure or persistent cases (and even then usually contribute little).

   In adolescents and young adults whom you decide to treat with antibiotics for ‘strep throat’, explain that the symptoms can also be caused by other infections such as glandular fever. This will help maintain the patients’ confidence in you if they return with the sore throat persisting after the course of antibiotics.

   Remember that this apparently trivial symptom can occasionally herald a serious problem. In particular, enquire about medication (the first sign of drug-induced agranulocytosis may be a sore throat).

   A true foreign body stuck in the throat will lodge in the supraglottic area and may not be seen orally. Refer if in doubt.

   Admit if any suspicion of epiglottitis – and do not examine the throat.

   Consider a possible underlying problem (such as diabetes or immunosuppression) in the younger patient with oropharyngeal candidiasis which has no obvious cause.

   Quinsy can cause a respiratory obstruction. Never attempt conservative management, but admit for surgical drainage.

   Florid ‘tonsillitis’ is unusual in the middle-aged or elderly – consider investigations for a blood disorder or oropharyngeal carcinoma.

STIFF NECK

The GP overview

The most common causes of acute neck stiffness are benign and easily managed in general practice. However, this symptom causes disproportionate panic in parents of febrile children thanks to extensive media coverage of meningitis. This anxiety can spill over into adult illness behaviour, with the result that a troublesome but harmless symptom may be misinterpreted as the harbinger of serious pathology.

Differential diagnosis

COMMON

   acute torticollis (positional, draughts)

   cervical spondylosis

   viral URTI with cervical lymphadenitis

   whiplash injury

   meningism due to systemic infection (e.g. pneumonia)

OCCASIONAL

   other forms of arthritis, e.g. rheumatoid (RA) and ankylosing spondylitis

   abscess in the neck

   hysteria

   intracerebral haemorrhage

   cerebral tumour (primary or secondary)

RARE

   meningitis

   vertebral fracture

   bone tumour (primary or secondary)

   atypical infections: tetanus, leptospirosis, sandfly fever, psittacosis

   brain abscess

Ready reckoner

Possible investigations

LIKELY: none.

POSSIBLE: FBC, Paul–Bunnell test, ESR/CRP, rheumatoid factor, HLA-B27.

SMALL PRINT: bone biochemistry, X-ray cervical spine, bone scan, other hospital-based tests.

   FBC and Paul–Bunnell: in unresolved or resistant URTI, check these parameters if glandular fever suspected.

   ESR/CRP, rheumatoid factor and HLA-B27: will help in the diagnosis of possible RA and ankylosing spondylitis in the young and middle-aged with unresolving neck stiffness.

   Neck X-ray: for possible fracture (at hospital); of limited value in cervical spondylosis – symptoms do not correlate well with X-ray findings. May reveal serious bone pathology, but bone scan more useful for this.

   Bone biochemistry: consider this if bony secondaries or myeloma are possible diagnoses.

   Hospital-based tests: these might include lumbar puncture (for meningitis) and scans for cerebral lesions.

TOP TIPS

   Neck tenderness due to cervical lymphadenopathy in an URTI is infinitely more common than meningitis, but is often misreported as ‘neck stiffness’.

   Only advise soft collars in the majority of stiff necks for a maximum of 48 hours. Though comfortable, they tend to delay resolution. Instead, suggest adequate analgesia, heat and mobilisation.

   Warn patients with whiplash injury that symptoms may take many months to settle completely – this saves repeated futile and frustrating consultations.

   Meningococcal petechiae are usually a late sign and can be missed unless the febrile child with a stiff neck is undressed and examined.

   Pain and stiffness may be the only symptoms of vertebral fracture or subluxation, which can occur without cord involvement – significant trauma merits A&E referral.

   Thunderclap headache preceding neck stiffness suggests subarachnoid haemorrhage: admit straight away.

   Consider serious bony pathology if pain and stiffness are relentless and wake the patient at night – especially if there are other worrying symptoms, or the patient has a past history of carcinoma.

STRIDOR IN CHILDREN

The GP overview

Acute stridor is a very frightening experience for both child and parents. The respiratory effort can lead to hyperventilation, making things worse. ‘Difficult’ or ‘noisy’ breathing in a child quite commonly leads to a request for an out-of-hours visit in winter. The usual cause is viral croup, producing mild, harmless stridor – but serious cases do occur. A calm exterior and a methodical approach are the keys to effective management.

Differential diagnosis

COMMON

   viral croup (laryngotracheobronchitis)

   acute epiglottitis

   acute laryngitis

   acute airways obstruction: foreign body (small toy, peanut)

   laryngeal paralysis (congenital: accounts for 25% of infants with stridor)

OCCASIONAL

   laryngomalacia

   laryngeal trauma

   bacterial tracheitis

   pseudomembranous croup (staphylococcal)

   upper airway burn

RARE

   laryngeal stenosis

   laryngeal tumours (papilloma, haemangioma) and mediastinal tumours

   laryngeal oedema (angioneurotic: oedema also present in other tissues)

   anomalous blood vessels, e.g. double aortic arch

   diphtheria

   retropharyngeal abscess

Ready reckoner

Possible investigations

There are no investigations likely to be performed in primary care. The following might be performed in hospital: FBC (WCC raised in infection), lateral X-ray of pharynx (enlarged epiglottis in epiglottitis), CXR (may show foreign body, distal collapse or external compression of larynx or trachea) and laryngoscopy (for direct visualisation of the larynx).

TOP TIPS

   In practice, the first step is to exclude those conditions requiring immediate admission (epiglottitis or inhaled foreign body), leaving a probable diagnosis of viral croup. Management then depends on the child’s general condition – in particular, the level of respiratory distress.

   Children with viral croup may have marked stridor and some recession when crying. It is reasonable to observe such children at home provided these signs disappear when the child is settled.

   When managing a child at home, make absolutely sure that the parents understand the signs of deterioration. If in doubt, arrange review.

   The toxic child with low-pitched stridor (often not marked), severe sore throat or difficulty in swallowing, and respiratory distress has epiglottitis until proved otherwise. Admit immediately and do not examine the throat (this can provoke respiratory obstruction).

   Restlessness, rising pulse and respiratory rate, increasing intercostal recession, fatigue and drowsiness are ominous signs: admit urgently regardless of precise diagnosis.

   Consider an inhaled foreign body if the onset is very sudden and there are no other symptoms or signs of respiratory infection.