16th February 2025

The upper respiratory tract

The mouth and pharynx

Pharyngitis and tonsillitis

These are usually caused by viruses but can also be caused by beta-haemolytic streptococci, H. influenzae, M. pneumoniae or C. pneumoniae. Local spread of infection may lead to quinsy (peritonsillar abscess) or otitis media. Beta-haemolytic streptococci (Streptococcus pyogenes) tend to cause severe infection and may rarely lead to various systemic complications, including glomerulonephritis, rheumatic fever, scarlet fever and toxic shock syndrome. The antibiotic of choice is phenoxymethylpenicillin.

Infectious mononucleosis 

Also called glandular fever, this is caused by the Epstein-Barr virus (EBV). In addition to pharyngitis, it may cause fatigue, fever, lymphadenopathy and splenomegaly. Patients have a positive heterophile antibody (Monospot) test, and the blood film shows atypical mononuclear cells. The patient may develop a rash if given certain antibiotics, particularly amoxicillin and ampicillin. Treatment is usually supportive unless there are severe rare complications; these include airway compromise, Guillain-Barré syndrome and splenic rupture.

Ludwig’s angina

This is a rapidly spreading cellulitis that originates in the floor of the mouth, most commonly from a dental infection and spreads to the submandibular space. Causative organisms include viridans streptococci, staphylococci, and oral anaerobes such as Peptostreptococcus, Fusobacterium and Bacteroides. Presenting features include sepsis, airway compromise, drooling, dysphagia and difficulty speaking.

Oropharyngeal candidiasis

Also known as thrush, this occurs most frequently in the immunosuppressed, those who have had recent antibiotics, or those on oral or inhaled steroids. Mild disease is managed with topical antifungals (e.g. nystatin). Oral fluconazole is used for moderate-to-severe disease or with immunocompromise.

Diphtheria

Caused by the Gram-positive bacillus Corynebacterium diphtheriae, respiratory diphtheria has its onset 2 to 5 days after exposure and presents with sore throat, low-grade fever and purulent nasal discharge. Pharyngeal exudates are often noted, and in one third of cases an oral or nasal “pseudomembrane” forms.

The larynx

Disorders of the larynx may present with hoarseness, change in voice, difficulty breathing and chronic aspiration. The investigation may require flexible nasendoscopy (FNE) to visualise the larynx, which can be conducted in the ENT clinic.

Laryngitis

May be acute or chronic (lasting more than four weeks). Acute laryngitis is a common self-limiting illness causing hoarseness, usually caused by respiratory viruses. Chronic laryngitis is caused by irritants such as smoking, alcohol, gastro-oesophageal reflux, and chronic sinusitis with post-nasal drip. Chronic laryngitis can also complicate systemic diseases such as rheumatoid arthritis, pemphigoid, SLE and sarcoid.

Acute epiglottitis

This severe disease is most commonly caused by H. influenzae type B. It can cause life-threatening airway compromise, with a mortality of 7% in adults, but is now rare thanks to widespread vaccination. Presenting features include sepsis, sore throat, drooling, painful dysphagia, respiratory distress and stridor. Support should be sought from ENT and Anaesthetics, and the airway should only be examined where there are facilities to undertake endotracheal intubation. Treatment involves airway management and a third-generation cephalosporin such as ceftriaxone or cefotaxime.

Laryngeal cancer

This is predominantly squamous cell carcinoma related to smoking and alcohol and commonly presents with hoarseness. Flexible nasendoscopy (FNE) typically shows a white plaque-like lesion. Management is usually one or both of radiotherapy and surgery. Following a laryngectomy, it is important to be aware that the patient has no patent upper airway, as the trachea opens directly to the anterior neck.

Polypoid corditis (Reinke’s oedema)

This inflammatory, smoking-related condition of the larynx most commonly affects middle-aged women, presenting with a husky, low-pitched voice.

Vocal cord paralysis

This results from palsy of the vagus or recurrent laryngeal nerve. It presents with hoarseness and carries a risk of aspiration. It may be caused by multiple sclerosis, Lyme disease, Epstein-Barr virus, Herpes Simplex virus, and malignancy on the course of the nerves.

Systemic disease

Rheumatoid arthritis can give rise to vocal cord nodules and may also involve the cricoarytenoid joints, leading to vocal cord immobility. Tuberculosis involving the larynx may also give rise to vocal cord nodules.

References

• Chapman SJ, Robinson GV, Shrimanker R, Turnbull CD, Wrightson JM. Oxford handbook of respiratory medicine. 4th ed. London, England: Oxford University Press; 2021
• Bourke SJ. Respiratory medicine: Lecture notes, 10th edition: Lecture Notes. 10th ed. Hoboken, NJ: Wiley-Blackwell; 2022
• Bruch JM. Hoarseness in adults [Internet]. Kamani DV, editor. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/hoarseness-in-adults
• Woods CR. Epiglottitis (supraglottitis): Clinical features and diagnosis [Internet]. Edwards MS, Isaacson GC, Neuman MI, editors. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/epiglottitis-supraglottitis-clinical-features-and-diagnosis
• Pichichero ME. Complications of streptococcal tonsillopharyngitis [Internet]. Sexton DJ, Kaplan SL, editors. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/complications-of-streptococcal-tonsillopharyngitis
• Wald ER. Peritonsillar cellulitis and abscess [Internet]. Edwards MS et al., editors. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/peritonsillar-cellulitis-and-abscess
• Chow AW. Ludwig angina [Internet]. Durand ML, editor. UpToDate. 2022 [cited 2022 Dec 9]. Available from: https://www.uptodate.com/contents/submandibular-space-infections-ludwig-angina
• Barraso LF, Samuel Pegram P. Clinical manifestations, diagnosis, and treatment of diphtheria [Internet]. Sexton DJ, editor. UpToDate. 2022 [cited 2022 Dec 17]. Available from: https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-treatment-of-diphtheria