Causes of Throat cancer

• Inflammatory
  –Allergy
  –Gastroesophageal reflux disease
  –Sinusitis resulting in postnasal drainage
• Tumors
  –Leukemia
  –Rhabdosarcomas
  –Squamous cell carcinoma secondary to oral ulcerations
• Trauma
  –Foreign body ingestion
  –Caustic ingestion
  –Soft tissue injury from accidental and nonaccidental trauma
• Systemic/rheumatologic disorders
  –Kawasaki disease: Mucocutaneous lymph node syndrome may have sore throat at presentation (other oral findings include strawberry tongue, fissured lips, mucosal erythema, fever, and lymphadenopathy)
  –Behçet syndrome
  –Reiter syndrome
  • Others
    –Cigarette smoke
    –Environmental pollutants
    –Pharyngeal drying: Mouth and pharynx can be dry from mouth breathing, more common in the winter months

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Dysphagia: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Achalasia

Airway obstruction

Amyotrophic lateral sclerosis (ALS)

Bulbar paralysis

Esophageal cancer

Esophageal compression (external)

Esophageal diverticulum

Esophageal obstruction by foreign body.

Esophageal spasm.

Esophageal stricture.

Esophagitis.

Candidal esophagitis causes phase 2 dysphagia, a sore throat and, possibly, retrosternal pain on swallowing. With reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid.

Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.

Gastric carcinoma

Laryngeal cancer (extrinsic)

Lead poisoning

Myasthenia gravis

Oral cavity tumor

Plummer-Vinson syndrome

Rabies.

Systemic lupus erythematosus (SLE).

Tetanus

Other causes

Procedures

Radiation therapy

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Mouth lesions: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Acquired immunodeficiency syndrome (AIDS)

Oral lesions may be an early indication of the immunosuppression that’s characteristic of AIDS. Fungal infections can occur, with oral candidiasis being the most common. Bacterial or viral infections of the oral mucosa, tongue, gingivae, and periodontal tissue may also occur.

The primary oral neoplasm associated with AIDS is Kaposi’s sarcoma. The tumor is usually found on the hard palate and may appear initially as an asymptomatic, flat or raised lesion, ranging in color from red to blue to purple. As these tumors grow, they may ulcerate and become painful.

Actinomycosis (cervicofacial)

Actinomycosis is a chronic fungal infection that typically produces small, firm, flat, and usually painless swellings on the oral mucosa and under the skin of the jaw and neck. Swellings may indurate and abscess, producing fistulas and sinus tracts with a characteristic purulent yellow discharge.

Behçet’s syndrome

Behçet’s syndrome is a chronic, progressive syndrome that generally affects young males and produces small, painful ulcers on the lips, gums, buccal mucosa, and tongue. In severe cases, the ulcers also develop on the palate, pharynx, and esophagus. The ulcers typically have a reddened border and are covered with a gray or yellow exudate. Similar lesions appear on the scrotum and penis or labia majora; small pustules or papules on the trunk and limbs; and painful erythematous nodules on the shins. Ocular lesions may also develop.

Candidiasis

Candidiasis is a common fungal infection that characteristically produces soft, elevated plaques on the buccal mucosa, tongue, and sometimes the palate, gingivae, and floor of the mouth; the plaques may be wiped away. The lesions of acute atrophic candidiasis are red and painful. The lesions of chronic hyperplastic candidiasis are white and firm. Localized areas of redness, pruritus, and a foul odor may be present.

Discoid lupus erythematosus

Oral lesions are common, typically appearing on the tongue, buccal mucosa, and palate as erythematous areas with white spots and radiating white striae. Associated findings include skin lesions on the face, possibly extending to the neck, ears, and scalp; if the scalp is involved, alopecia may result. Hair follicles are enlarged and filled with scale.

Gender Cue:This chronic, recurrent disease is most common in women ages 30 to 40.

Erythema multiforme

Erythema multiforme is an acute inflammatory skin disease that produces a sudden onset of vesicles and bullae on the lips and buccal mucosa. Also, erythematous macules and papules form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia. Lymphadenopathy may also occur. With visceral involvement, other findings include a fever, malaise, a cough, throat and chest pain, vomiting, diarrhea, myalgia, arthralgia, fingernail loss, blindness, hematuria, and signs of renal failure.

Gingivitis (acute necrotizing ulcerative)

Gingivitis is a recurring periodontal condition that causes a sudden onset of gingival ulcers covered with a grayish white pseudomembrane. Other findings include tender or painful gingivae, intermittent gingival bleeding, halitosis, enlarged lymph nodes in the neck, and a fever.

Herpes simplex I

With primary infection, a brief period of prodromal tingling and itching, which is accompanied by a fever and pharyngitis, is followed by eruption of small and irritating vesicles on part of the oral mucosa, especially the tongue, gums, and cheeks. Vesicles form on an erythematous base and then rupture, leaving a painful ulcer, followed by a yellowish crust. Other findings include submaxillary lymphadenopathy, increased salivation, halitosis, anorexia, and keratoconjunctivitis.

Herpes zoster

Herpes zoster is a common viral infection that may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small red nodules typically erupt unilaterally around the thorax or vertically on the arms and legs, and rapidly become vesicles filled with clear fluid or pus; vesicles dry and form scabs about 10 days after eruption. A fever and general malaise accompany pruritus, paresthesia or hyperesthesia, and tenderness along the course of the involved sensory nerve.

Inflammatory fibrous hyperplasia

Inflammatory fibrous hyperplasia is a painless nodular swelling of the buccal mucosa that typically results from cheek trauma or irritation and is characterized by pink, smooth, pedunculated areas of soft tissue.

Leukoplakia, erythroplakia

Leukoplakia is a white lesion that can’t be removed simply by rubbing the mucosal surface — unlike candidiasis. It may occur in response to chronic irritation from dentures or from tobacco or pipe smoking, or it may represent dysplasia or early squamous cell carcinoma.

Erythroplakia is red and edematous and has a velvety surface. About 90% of all cases of erythroplakia are either dysplasia or cancer.

Pemphigoid (benign mucosal)

Pemphigoid is a rare autoimmune disease that’s characterized by thick-walled vesicles on the oral mucous membranes, the conjunctiva and, less commonly, the skin. Mouth lesions typically develop months or even years before other manifestations and may occur as desquamative patchy gingivitis or as a vesicobullous eruption. Secondary fibrous bands may lead to dysphagia, hoarseness, and blindness. Recurrent skin lesions include vesicobullous eruptions, usually on the inguinal area and extremities, and an erythematous, vesicobullous plaque on the scalp and face near the affected mucous membranes.

Pemphigus

Pemphigus is a chronic skin disease that’s characterized by thin-walled vesicles and bullae that appear in cycles on skin or mucous membranes that otherwise appear normal. On the oral mucosa, bullae rupture, leaving painful lesions and raw patches that bleed easily. Associated findings include bullae anywhere on the body, denudation of the skin, and pruritus.

Pyogenic granuloma

Typically the result of injury, trauma, or irritation, pyogenic granuloma — a soft, tender nodule, papule, or polypoid mass of excessive granulated tissue — usually appears on the gingivae, but can also erupt on the lips, tongue, or buccal mucosa. The lesions bleed easily because they contain many capillaries. The affected area may be smooth or have a warty surface; erythema develops in the surrounding mucosa. The lesions may ulcerate, producing a purulent exudate.

Squamous cell carcinoma

Squamous cell carcinoma is typically a painless ulcer with an elevated, indurated border. It may erupt in areas of leukoplakia and is most common on the lower lip, but it may also occur on the edge of the tongue or floor of the mouth. High risk factors include chronic smoking and alcohol intake.

Stomatitis (aphthous)

Stomatitis, a common disease, is characterized by painful ulcerations of the oral mucosa, usually on the dorsum of the tongue, gingivae, and hard palate.

With recurrent aphthous stomatitis minor, the ulcer begins as one or more erosions covered by a gray membrane and surrounded by a red halo. It’s commonly found on the buccal and lip mucosa and junction, tongue, soft palate, pharynx, gingivae, and all places not bound to the periosteum.

With recurrent aphthous stomatitis major, large, painful ulcers commonly occur on the lips, cheek, tongue, and soft palate; they may last up to 6 weeks and leave a scar.

Syphilis

Primarysyphilis typically produces a solitary painless, red ulcer (chancre) on the lip, tongue, palate, tonsil, or gingivae. The ulcer appears as a crater with undulated, raised edges and a shiny center; lip chancres may develop a crust. Similar lesions may appear on the fingers, breasts, or genitals, and regional lymph nodes may become enlarged and tender.

During the secondary stage, multiple painless ulcers covered by a grayish white plaque may erupt on the tongue, gingivae, or buccal mucosa. A macular, papular, pustular, or nodular rash appears, usually on the arms, trunk, palms, soles, face, and scalp; genital lesions usually subside. Other findings include generalized lymphadenopathy, a headache, malaise, anorexia, weight loss, nausea, vomiting, a sore throat, a low-grade fever, metrorrhagia, and postcoital bleeding.

At the tertiarystage, lesions (usually gummas — chronic, painless, superficial nodules or deep granulomatous lesions) develop on the skin and mucous membranes, especially the tongue and palate.

Systemic lupus erythematosus

Oral lesions are common and appear as erythematous areas associated with edema, petechiae, and superficial ulcers with a red halo and a tendency to bleed. Primary effects include nondeforming arthritis, a butterfly rash across the nose and cheeks, and photosensitivity.

Other causes

Drugs

Various chemotherapeutic agents can directly produce stomatitis. Also, allergic reactions to penicillin, sulfonamides, gold, quinine, streptomycin, phenytoin, aspirin, and barbiturates commonly cause lesions to develop and erupt. Inhaled steroids used for pulmonary disorders can also cause oral lesions.

Radiation therapy

Radiation therapy may cause oral lesions.

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Throat pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Agranulocytosis

With agranulocytosis, sore throat may accompany other signs and symptoms of infection, such as fever, chills, and headache. Typically, it follows progressive fatigue and weakness. Other findings include nausea and vomiting, anorexia, and bleeding tendencies. Rough-edged ulcers with gray or black membranes may appear on the gums, palate, or perianal area.

Bronchitis (acute)

Acute bronchitis may produce lower throat pain associated with fever, chills, cough, and muscle and back pain. Auscultation reveals rhonchi, wheezing and, at times, crackles.

Chronic fatigue syndrome

Chronic fatigue syndrome is a nonspecific symptom complex that’s characterized by incapacitating fatigue. Associated findings besides sore throat include myalgia and cognitive dysfunction.

Common cold

Sore throat may accompany cough, sneezing, nasal congestion, rhinorrhea, fatigue, headache, myalgia, and arthralgia.

Contact ulcers

Common in men with stressful jobs, contact ulcers appear symmetrically on the posterior vocal cords, resulting in sore throat. The pain is aggravated by talking and may be accompanied by referred ear pain and, occasionally, hemoptysis. Typically, the patient also has a history of chronic throat clearing or acid reflux.

Foreign body

A foreign body lodged in the palatine or lingual tonsil and pyriform sinus may produce localized throat pain. The pain may persist after the foreign body is dislodged until mucosal irritation resolves.

Gastroesophageal reflux disease (GERD)

With GERD, an incompetent gastroesophageal sphincter allows gastric juices to enter the hypopharynx and irritate the larynx, causing chronic sore throat and hoarseness. The arytenoids may also appear red and swollen, resulting in a sensation of a lump in the throat.

Influenza

Patients with the flu commonly complain of sore throat, fever with chills, headache, weakness, malaise, muscle aches, cough and, occasionally, hoarseness and rhinorrhea.

Laryngeal cancer

With extrinsic laryngeal cancer, the chief symptom is pain or burning in the throat when drinking citrus juice or hot liquids or a lump in the throat; with intrinsic laryngeal cancer, the chief symptom is hoarseness that persists for longer than 3 weeks. Later signs and symptoms of metastasis include dysphagia, dyspnea, a cough, enlarged cervical lymph nodes, and pain that radiates to the ear.

Mononucleosis (infectious)

Sore throat is one of the three classic findings in this infection. The other two classic signs are cervical lymphadenopathy and fluctuating temperature with an evening peak of 101° to 102° F (38.3° to 38.9° C). Splenomegaly and hepatomegaly may also develop.

Necrotizing ulcerative gingivitis (acute)

Also known as trench mouth, necrotizing ulcerative gingivitis usually begins abruptly with sore throat and tender gums that ulcerate and bleed. A gray exudate may cover the gums and pharyngeal tonsils. Related signs and symptoms include a foul taste in the mouth, halitosis, cervical lymphadenopathy, headache, malaise, and fever.

Peritonsillar abscess

A complication of bacterial tonsillitis, this abscess typically causes severe throat pain that radiates to the ear. Accompanying the pain may be dysphagia, drooling, dysarthria, halitosis, fever with chills, malaise, and nausea. The patient usually tilts his head toward the side of the abscess. Examination may also reveal a deviated uvula, trismus, and tender cervical lymphadenopathy.

Pharyngitis

Whether bacterial, fungal, or viral, pharyngitis may cause sore throat and localized erythema and edema. Bacterial pharyngitis begins abruptly with a unilateral sore throat. Associated signs and symptoms include dysphagia, fever, malaise, headache, abdominal pain, myalgia, and arthralgia. Inspection reveals an exudate on the tonsil or tonsillar fossae, uvular edema, soft palate erythema, and tender cervical lymph nodes.

Also known as thrush, fungal pharyngitis causes diffuse sore throat — commonly described as a burning sensation — accompanied by pharyngeal erythema and edema. White plaques mark the pharynx, tonsil, tonsillar pillars, base of the tongue, and oral mucosa; scraping these plaques uncovers a hemorrhagic base.

With viral pharyngitis, findings include diffuse sore throat, malaise, fever, and mild erythema and edema of the posterior oropharyngeal wall. Tonsillary enlargement may be present along with anterior cervical lymphadenopathy.

Sinusitis (acute)

Sinusitis may cause sore throat with purulent nasal discharge and postnasal drip, resulting in halitosis. Other effects include headache, malaise, cough, fever, and facial pain and swelling associated with nasal congestion.

Tongue cancer

With tongue cancer, the patient experiences localized throat pain that may occur around a raised white lesion or ulcer. The pain may radiate to the ear and be accompanied by dysphagia.

Tonsillar cancer

Sore throat is the presenting symptom in tonsillar cancer. Unfortunately, the cancer is usually quite advanced before the appearance of this symptom. The pain may radiate to the ear and is accompanied by a superficial ulcer on the tonsil or one that extends to the base of the tongue.

Tonsillitis

With acute tonsillitis, mild to severe sore throat is usually the first symptom. The pain may radiate to the ears and be accompanied by dysphagia and headache. Related findings include malaise, fever with chills, halitosis, myalgia, arthralgia, and tender cervical lymphadenopathy. Examination reveals edematous, reddened tonsils with a purulent exudate.

Chronic tonsillitis causes mild sore throat, malaise, and tender cervical lymph nodes. The tonsils appear smooth, pink and, possibly, enlarged, with purulent debris in the crypts. Halitosis and a foul taste in the mouth are other common findings.

Unilateral or bilateral throat pain just above the hyoid bone occurs with lingual tonsillitis. The lingual tonsils appear red and swollen and are covered with exudate. Other findings include a muffled voice, dysphagia, and tender cervical lymphadenopathy on the affected side.

Uvulitis

Uvulitis may cause throat pain or a sensation of something in the throat. The uvula is usually swollen and red but, in allergic uvulitis, it’s pale.

Other causes

Treatments

Endotracheal intubation and local surgery, such as tonsillectomy and adenoidectomy, commonly cause sore throat.

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Introduction: Malignant Neoplasms: What causes cancer?
(Professional Guide to Diseases (Eighth Edition))

Researchers have found that cancer develops from mutations within the genes of cells. Thus, cancer is a genetic disease. Cancer susceptibility genes are of two types. Some are oncogenes, which activate cell division and influence embryonic development, and some are tumor suppressor genes, which halt cell division.

These genes are typically found in normal human cells, but certain kinds of mutations may transform the normal cells. Inherited defects may cause a genetic mutation, whereas exposure to a carcinogen may cause an acquired mutation. Current evidence indicates that carcinogenesis results from a complex interaction of carcinogens and accumulated mutations in several genes.

In animal studies of the ability of viruses to transform cells, some human viruses exhibit carcinogenic potential. For example, the Epstein-Barr virus, the cause of infectious mononucleosis, has been linked to Burkitt's lymphoma and nasopharyngeal cancer.

High-frequency radiation, such as ultraviolet and ionizing radiation, damages the genetic material known as deoxyribonucleic acid (DNA), possibly inducing genetically transferable abnormalities. Other factors, such as a person's tissue type and hormonal status, interact to potentiate radiation's carcinogenic effect. Examples of substances that may damage DNA and induce carcinogenesis include:

❑alkylating agents — leukemia

❑aromatic hydrocarbons and benzopyrene (from polluted air) — lung cancer

❑asbestos — mesothelioma of the lung

❑tobacco — cancer of the lung, oral cavity and upper airways, esophagus, pancreas, kidneys, and bladder

❑vinyl chloride — angiosarcoma of the liver.

Diet has also been implicated, especially in the development of GI cancer as a result of a high animal fat diet. Additives composed of nitrates and certain methods of food preparation — particularly charbroiling — are also recognized factors.

The role of hormones in carcinogenesis is still controversial, but it seems that excessive use of some hormones, especially estrogen, produces cancer in animals. Also, the synthetic estrogen diethylstilbestrol causes vaginal cancer in some daughters of women who were treated with it. It's unclear, however, whether changes in human hormonal balance retard or stimulate cancer development.

Some forms of cancer and precancerous lesions result from genetic predisposition either directly (as in Wilms' tumor and retinoblastoma) or indirectly (in association with inherited conditions such as Down syndrome or immunodeficiency diseases). Expressed as autosomal recessive, X-linked, or autosomal dominant disorders, their common characteristics include:

❑early onset of malignant disease

❑increased incidence of bilateral cancer in paired organs (breasts, adrenal glands, kidneys, and eighth cranial nerve [acoustic neuroma])

❑increased incidence of multiple primary malignancies in nonpaired organs

❑abnormal chromosome complement in tumor cells.

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Malignant spinal neoplasms: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Primary tumors of the spinal cord may be extramedullary (occurring outside the spinal cord) or intramedullary (occurring within the cord itself). Extramedullary tumors may be intradural (meningiomas and schwannomas), which account for 60% of all primary malignant spinal cord neoplasms, or extradural (metastatic tumors from breasts, lungs, prostate, leukemia, or lymphomas), which account for 25% of these malignant neoplasms.

Intramedullary tumors, or gliomas (astrocytomas or ependymomas), are comparatively rare, accounting for only about 10%. In children, they're low-grade astrocytomas.

Spinal cord tumors are rare compared with intracranial tumors (ratio of 1:4). They occur equally in men and women, with the exception of meningiomas, which occur mostly in women. Spinal cord tumors can occur anywhere along the length of the cord or its roots.

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Throat abscesses: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Peritonsillar abscess is a complication of acute tonsillitis, usually after streptococcal or staphylococcal infection. It occurs more commonly in adolescents and young adults than in children.

Acute retropharyngeal abscess results from infection in the retropharyngeal lymph glands, which may follow an upper respiratory tract bacterial infection. Most common pathogens are beta-hemolytic Streptococcus and Staphylococcus aureus. These lymph glands begin to atrophy after age 2. Acute retropharyngeal abscess most commonly affects infants and children younger than age 2.

Chronic retropharyngeal abscess may result from tuberculosis of the cervical spine (Pott’s disease) and may occur at any age.

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Dysphagia: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Achalasia

Most common in patients ages 20 to 40, this disorder produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it’s preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.

Airway obstruction

Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.

Amyotrophic lateral sclerosis

Besides dysphagia, this disorder causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes, and emotional lability.

Botulism

This type of food poisoning causes phase 1 dysphagia and dysuria, usually within 36 hours of toxin ingestion. Other early findings include blurred or double vision, dry mouth, sore throat, nausea, vomiting, and diarrhea. Symmetrical descending weakness or paralysis occurs gradually.

Bulbar paralysis

Phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation in this disorder. Dysphagia for both solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.

Dysphagia lusoria

This disorder is caused by compression of the esophagus by a congenital vascular abnormality (usually an aberrant right subclavian artery arising from the left side of the aortic arch). Phase 3 dysphagia symptoms may start in childhood or may develop later from changes in the aberrant vessel such as arteriosclerosis.

Esophageal cancer

Phase 2 or 3 dysphagia is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, cough with hemoptysis, hoarseness, and sore throat. He may also develop nausea and vomiting, fever, hiccups, hematemesis, melena, and halitosis.

Esophageal compression (external)

Usually caused by a dilated carotid or aortic aneurysm, this rare condition causes phase 3 dysphagia as the primary symptom. Other features depend on the cause of the compression.

Esophageal diverticulum

This disorder causes phase 3 dysphagia when the enlarged diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, chronic cough, hoarseness, chest pain, and halitosis.

Esophageal leiomyoma

A relatively rare benign tumor, esophageal leiomyoma may cause phase 3 dysphagia along with retrosternal pain or discomfort. In addition, the patient experiences weight loss and a feeling of fullness.

Esophageal obstruction by foreign body

Sudden onset of phase 2 or 3 dysphagia, gagging, coughing, and esophageal pain characterize this potentially life-threatening condition. Dyspnea may occur if the obstruction compresses the trachea.

Esophageal spasm

The most striking symptoms of this disorder are phase 2 dysphagia for solids and liquids and dull or squeezing substernal chest pain. The pain may last up to an hour and may radiate to the neck, arm, back, or jaw; however, it may be relieved by drinking a glass of water. Bradycardia may also occur.

Esophageal stricture

Usually caused by scar tissue or ingestion of a chemical, this condition causes phase 3 dysphagia. Drooling, tachypnea, and gagging may also be evident.

Esophagitis

Corrosive esophagitis, resulting from ingestion of alkalies or acids, causes severe phase 3 dysphagia. Accompanying it are marked salivation, hematemesis, tachypnea, fever, and intense pain in the mouth and anterior chest that’s aggravated by swallowing. Signs of shock, such as hypotension and tachycardia, may also occur.

Candidal esophagitis causes phase 2 dysphagia, sore throat and, possibly, retrosternal pain on swallowing. In reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid.

Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.

Gastric carcinoma

Infiltration of the cardia or esophagus by gastric carcinoma causes phase 3 dysphagia along with nausea, vomiting, and pain that may radiate to the neck, back, or retrosternum. In addition, perforation causes massive bleeding with coffee-ground vomitus or melena.

Hypocalcemia

Although tetany is its primary sign, severe hypocalcemia may cause neuromuscular irritability, producing phase 1 dysphagia associated with numbness and tingling in the nose, ears, fingertips, and toes and around the mouth. Carpopedal spasms, muscle twitching, and laryngeal spasms may also occur.

Laryngeal cancer (extrinsic)

Phase 2 dysphagia and dyspnea develop late in this disorder. Accompanying features include muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, chronic cough, and cachexia. Palpation reveals enlarged cervical nodes.

Laryngeal nerve damage

Commonly the result of radical neck surgery, superior laryngeal nerve damage may produce painless phase 2 dysphagia.

Lower esophageal ring

Narrowing of the lower esophagus can cause an attack of phase 3 dysphagia that may recur several weeks or months later. During the attack, the patient complains of a foreign body sensation in the lower esophagus, which may be relieved by drinking water or vomiting. Esophageal rupture produces severe lower chest pain followed by a feeling of something giving way.

Mediastinitis

Varying with the extent of esophageal perforation, mediastinitis can cause insidious or rapid onset of phase 3 dysphagia. The patient displays chills, fever, and severe retrosternal chest pain that may radiate to the epigastrium, back, or shoulder. The pain may be aggravated by breathing, coughing, or sneezing. Other findings include tachycardia, subcutaneous crepitation in the suprasternal notch, and falling blood pressure.

Myasthenia gravis

Fatigue and progressive muscle weakness characterize this disorder and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.

Oral cavity tumor

Painful phase 1 dysphagia is accompanied by hoarseness and ulcerating lesions in patients with this type of tumor.

Parkinson’s disease

Usually a late symptom, phase 1 dysphagia is painless but progressive and may cause choking. Other signs and symptoms include bradykinesia, tremors, muscle rigidity, dysarthria, masklike facies, muffled voice, increased salivation and lacrimation, constipation, stooped posture, a propulsive gait, incontinence, and sexual dysfunction.

Pharyngitis (chronic)

This condition causes painful phase 2 dysphagia for solids and liquids. Rarely serious, it’s accompanied by a dry, sore throat; a cough; and thick mucus in the throat.

Plummer-Vinson syndrome

This syndrome causes phase 3 dysphagia for solids in some women with severe iron deficiency anemia. Related features include upper esophageal pain; atrophy of the oral or pharyngeal mucous membranes; tooth loss; a smooth, red, sore tongue; dry mouth; chills; inflamed lips; spoon-shaped nails; pallor; and splenomegaly.

Rabies

Severe phase 2 dysphagia for liquids results from painful pharyngeal muscle spasms occurring late in this rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling and, in 50% of patients, hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.

Scleroderma (progressive systemic sclerosis)

Typically, dysphagia is preceded by Raynaud’s phenomenon in patients with this disorder. The dysphagia may be mild at first and described as a feeling of food sticking behind the breastbone. The patient also complains of heartburn after meals that’s aggravated by lying down. As the disease progresses, dysphagia worsens until only liquids can be swallowed. It may be accompanied by other GI effects, including weight loss, abdominal distention, diarrhea, and malodorous, floating stools. Other characteristic late features include joint pain and stiffness, masklike facies, and thick, taut, shiny skin.

Syphilis

Rarely, tertiary-stage syphilis causes ulceration and stricture of the upper esophagus, resulting in phase 3 dysphagia. The dysphagia may be accompanied by regurgitation after meals and heartburn that’s aggravated by lying down or bending over.

Systemic lupus erythematosus

This disorder may cause progressive phase 2 dysphagia. However, its primary signs and symptoms include nondeforming arthritis, a characteristic butterfly rash, and photosensitivity.

Tetanus

Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics include marked muscle hypertonicity, hyperactive deep tendon reflexes, tachycardia, diaphoresis, drooling, and low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.

Other causes

Lead poisoning

Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and fever. The patient may be depressed and display severe mental impairment and seizures.

Procedures

A recent tracheostomy or repeated or prolonged intubation may cause temporary dysphagia.

Radiation therapy

When usd to treat oral cancer, radiation therapy may cause scant salivation and temporary dysphagia.

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Mouth lesions: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acquired immunodeficiency syndrome (AIDS)

Oral lesions may be an early indication of the immunosuppression that’s characteristic of this disease. Fungal infections can occur, with oral candidiasis being the most common. Bacterial or viral infections of oral mucosa, tongue, gingivae, and periodontal tissue may also occur.

The primary oral neoplasm associated with AIDS is Kaposi’s sarcoma. The tumor is usually found on the hard palate and may appear initially as an asymptomatic, flat or raised lesion, ranging in color from red to blue to purple. As these tumors grow, they may ulcerate and become painful.

Actinomycosis (cervicofacial)

This chronic fungal infection typically produces small, firm, flat, usually painless swellings on the oral mucosa and under the skin of the jaw and neck. Swellings may indurate and abscess, producing fistulas and sinus tracts with a characteristic purulent yellow discharge.

Behçet’s syndrome

This chronic, progressive syndrome that generally affects young males produces small, painful ulcers on the lips, gums, buccal mucosa, and tongue. In severe cases, the ulcers also develop on the palate, pharynx, and esophagus. The ulcers typically have a reddened border and are covered with a gray or yellow exudate. Similar lesions appear on the scrotum and penis or labia majora; small pustules or papules on the trunk and limbs; and painful erythematous nodules on the shins. Ocular lesions may also develop.

Candidiasis

This common fungal infection characteristically produces soft, elevated plaques on the buccal mucosa, tongue, and sometimes the palate, gingivae, and floor of the mouth; the plaques may be wiped away. The lesions of acute atrophic candidiasis are red and painful. The lesions of chronic hyperplastic candidiasis are white and firm. Localized areas of redness, pruritus, and foul odor may be present.

Discoid lupus erythematosus

Oral lesions are common, typically appearing on the tongue, buccal mucosa, and palate as erythematous areas with white spots and radiating white striae. Associated findings include skin lesions on the face, possibly extending to the neck, ears, and scalp; if the scalp is involved, alopecia may result. Hair follicles are enlarged and filled with scale.

Gender Cue: This chronic, recurrent disease is most common in women ages 30 to 40.

Epulis (giant cell)

This rare tumor or growth occurs on the gingival or alveolar process, anterior to the molars. Dark red, pedunculated or sessile, and 0.5 to 1.5 cm in diameter, it commonly ulcerates to produce a concave defect in the underlying bone. Gingivae bleed easily with slight trauma.

Erythema multiforme

This acute inflammatory skin disease produces sudden onset of vesicles and bullae on the lips and buccal mucosa. Also, erythematous macules and papules form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia. Lymphadenopathy may also occur. With visceral involvement, other findings include fever, malaise, cough, throat and chest pain, vomiting, diarrhea, myalgias, arthralgias, fingernail loss, blindness, hematuria, and signs of renal failure.

Gingivitis (acute necrotizing ulcerative)

This recurring periodontal condition causes a sudden onset of gingival ulcers covered with a grayish white pseudomembrane. Other findings include tender or painful gingivae, intermittent gingival bleeding, halitosis, enlarged lymph nodes in the neck, and fever.

Gonorrhea

Painful lip ulcerations may occur, along with rough, reddened, bleeding gingivae (possibly necrotic and covered by a yellowish pseudomembrane), and a swollen, ulcerated tongue. Related effects vary. Most men develop dysuria, purulent urethral discharge, and a reddened, edematous urinary meatus. Most women remain asymptomatic, but others develop inflammation and a greenish yellow cervical discharge.

Herpes simplex 1

With primary infection, a brief period of prodromal tingling and itching, which is accompanied by fever and pharyngitis, is followed by eruption of small and irritating vesicles on any part of the oral mucosa, especially the tongue, gums, and cheeks. Vesicles form on an erythematous base and then rupture, leaving a painful ulcer, followed by a yellowish crust. Other findings include submaxillary lymphadenopathy, increased salivation, halitosis, anorexia, and keratoconjunctivitis.

Herpes zoster

This common viral infection may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small red nodules often erupt unilaterally around the thorax or vertically on the arms and legs, and rapidly become vesicles filled with clear fluid or pus; vesicles dry and form scabs about 10 days after eruption. Fever and general malaise accompany pruritus, paresthesia or hyperesthesia, and tenderness along the course of the involved sensory nerve.

Inflammatory fibrous hyperplasia

This painless nodular swelling of the buccal mucosa typically results from cheek trauma or irritation and is characterized by pink, smooth, pedunculated areas of soft tissue.

Leukoplakia, erythroplakia

Leukoplakia is a white lesion that cannot be removed simply by rubbing the mucosal surface—unlike candidiasis. It may occur in response to chronic irritation from dentures or tobacco or pipe smoking, or it may represent dysplasia or early squamous cell carcinoma.

Erythroplakia is red and edematous and has a velvety surface. About 90% of all cases of erythroplakia are either dysplasia or cancer.

Lichen planus

Oral lesions develop on the buccal mucosa or, less commonly, on the tongue as painless, white or gray, velvety, threadlike papules. These precede the eruption of violet papules with white lines or spots, usually on the genitalia, lower back, ankles, and anterior lower legs; pruritus; nails with longitudinal ridges; and alopecia.

Mucous duct obstruction

Obstruction produces a ranula—a painless, slow-growing mucocele on the floor of the mouth near the ducts of the submandibular and sublingual glands.

Pemphigoid (benign mucosal)

This rare autoimmune disease is characterized by thick-walled vesicles on the oral mucous membranes, the conjunctiva and, less often, the skin. Mouth lesions typically develop months or even years before other manifestations and may occur as desquamative patchy gingivitis or as a vesicobullous eruption. Secondary fibrous bands may lead to dysphagia, hoarseness, and blindness. Recurrent skin lesions include vesicobullous eruptions, usually on the inguinal area and extremities, and an erythematous, vesicobullous plaque on the scalp and face near the affected mucous membranes.

Pemphigus

This chronic skin disease is characterized by thin-walled vesicles and bullae that appear in cycles on skin or mucous membranes that otherwise appear normal. On the oral mucosa, bullae rupture, leaving painful lesions and raw patches that bleed easily. Associated findings include bullae anywhere on the body, denudation of the skin, and pruritus.

Pyogenic granuloma

Commonly the result of injury, trauma, or irritation, this soft, tender nodule, papule, or polypoid mass of excessive granulation tissue usually appears on the gingivae but can also erupt on the lips, tongue, or buccal mucosa. The lesions bleed easily because they contain many capillaries. The affected area may be smooth or have a warty surface; erythema develops in the surrounding mucosa. The lesions may ulcerate, producing a purulent exudate.

Squamous cell carcinoma

This is typically a painless ulcer with an elevated, indurated border. It may erupt in areas of leukoplakia and is most common on the lower lip, but it may also occur on the edge of the tongue or the floor of the mouth. High risk factors include chronic smoking and alcohol intake.

Stomatitis (aphthous)

This common disease is characterized by painful ulcerations of the oral mucosa, usually on the dorsum of the tongue, gingivae, and hard palate.

With recurrent aphthous stomatitis minor, the ulcer begins as one or more erosions covered by a gray membrane and surrounded by a red halo. It’s commonly found on the buccal and lip mucosa and junction, tongue, soft palate, pharynx, gingivae, and all places not bound to the periosteum.

With recurrent aphthous stomatitis major, large, painful ulcers commonly occur on the lips, cheek, tongue, and soft palate; they may last up to 6 weeks and leave a scar.

Syphilis

Primary syphilis typically produces a solitary painless, red ulcer (chancre) on the lip, tongue, palate, tonsil, or gingivae. The ulcer appears as a crater with undulated, raised edges and a shiny center; lip chancres may develop a crust. Similar lesions may appear on the fingers, breasts, or genitals, and regional lymph nodes may become enlarged and tender.

During the secondary stage, multiple painless ulcers covered by a grayish white plaque may erupt on the tongue, gingivae, or buccal mucosa. A macular, papular, pustular, or nodular rash appears, usually on the arms, trunk, palms, soles, face, and scalp; genital lesions usually subside. Other findings include generalized lymphadenopathy, headache, malaise, anorexia, weight loss, nausea, vomiting, sore throat, low fever, metrorrhagia, and postcoital bleeding.

At the tertiarystage, lesions (often chronic, painless, superficial nodules or deep granulomatous lesions, called gummas) develop on the skin and mucous membranes, especially the tongue and palate.

Systemic lupus erythematosus

Oral lesions are common and appear as erythematous areas associated with edema, petechiae, and superficial ulcers with a red halo and a tendency to bleed. Primary effects include nondeforming arthritis, butterfly rash across the nose and cheeks, and photosensitivity.

Trauma

The most common cause of oral lesions, trauma can produce ulcers anywhere in the mouth, especially on the tongue and buccal mucosa.

Tuberculosis (oral mucosal)

This rare disorder produces a painless ulcer (usually on the tongue) and, sometimes, caseation. Other findings include lymphadenopathy, fatigue, weakness, anorexia, weight loss, cough, low fever, and night sweats.

Other causes

Drugs

Various chemotherapeutic agents can directly produce stomatitis. Also, allergic reactions to penicillin, sulfonamides, gold, quinine, streptomycin, phenytoin, aspirin, and barbiturates commonly cause lesions to develop and erupt. Inhaled steroids used for pulmonary disorders can also cause oral lesions.

Orthodontics

The rubbing of orthodontic equipment or prosthesis on the buccal mucosa may cause eroded, tender areas.

Radiation therapy

Radiation therapy may cause oral lesions.

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Throat pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Agranulocytosis

In this disorder, sore throat may accompany other signs and symptoms of infection, such as fever, chills, and headache. Typically, it follows progressive fatigue and weakness. Other findings include nausea and vomiting, anorexia, and bleeding tendencies. Rough-edged ulcers with gray or black membranes may appear on the gums, palate, or perianal area.

Allergic rhinitis

Occurring seasonally or year-round, this disorder may produce sore throat as well as nasal congestion with a thin nasal discharge, postnasal drip, paroxysmal sneezing, decreased sense of smell, frontal or temporal headache, and itchy eyes, nose, and throat. Examination reveals pale and glistening nasal mucosa with edematous nasal turbinates, watery eyes, reddened conjunctivae and eyelids and, possibly, swollen eyelids.

Avian influenza

Throat pain, muscle aches, cough, and fever are common early symptoms of avian influenza. The most virulent of these viruses, avian influenza A (H5N1), may also cause pneumonia, acute respiratory distress, and other life-threatening complications. A recent outbreak of the H5N1 virus among domesticated birds (chickens, turkeys, geese) in Asian countries has caused human sickness and death in those who contracted the virus from infected poultry and contaminated surfaces. Studies are underway to investigate the effectiveness of antiviral medications and vaccines.

Bronchitis (acute)

This disorder may produce lower throat pain, fever, chills, cough, and muscle and back pain. Auscultation reveals rhonchi, wheezing, and sometimes crackles.

Chronic fatigue syndrome

This nonspecific symptom complex is characterized by incapacitating fatigue. Associated findings include sore throat, myalgia, and cognitive dysfunction.

Common cold

Sore throat may accompany cough, sneezing, nasal congestion, rhinorrhea, fatigue, headache, myalgia, and arthralgia.

Contact ulcers

Common in men with stressful jobs, contact ulcers appear symmetrically on the posterior vocal cords, resulting in sore throat. The pain is aggravated by talking and may be accompanied by referred ear pain and occasionally hemoptysis. Typically, the patient also has a history of chronic throat clearing or acid reflux.

Foreign body

A foreign body lodged in the palatine or lingual tonsil and pyriform sinus may produce localized throat pain. The pain may persist after the foreign body is dislodged until mucosal irritation resolves.

Gastroesophageal reflux disease

In this disorder, an incompetent gastroesophageal sphincter allows gastric juices to enter the hypopharynx and irritate the larynx, causing chronic sore throat and hoarseness. The arytenoid cartilage may also appear red and swollen, resulting in a sensation of a lump in the throat.

Glossopharyngeal neuralgia

Triggered by a specific pharyngeal movement, such as yawning or swallowing, this condition causes unilateral, knifelike throat pain in the tonsillar fossa that may radiate to the ear.

Herpes simplex virus

Sore throat may result from lesions on the oral mucosa, especially the tongue, gingivae, and cheeks. After causing brief prodromal discomfort, lesions erupt into erythematous vesicles that eventually rupture and leave a painful ulcer, followed by a yellowish crust. In generalized infection, the vesicles accompany submaxillary lymphadenopathy, halitosis, increased salivation, anorexia, and fever of up to 105° F (40.6° C).

Influenza

Patients with the flu commonly complain of sore throat, fever with chills, headache, weakness, malaise, myalgia, cough and, occasionally, hoarseness and rhinorrhea.

Laryngeal cancer

In extrinsic laryngeal cancer, the chief symptom is pain or burning in the throat when drinking citrus juice or hot liquids, or a lump in the throat; in intrinsic laryngeal cancer, it’s hoarseness that persists for longer than 3 weeks. Later signs and symptoms of metastasis include dysphagia, dyspnea, a cough, enlarged cervical lymph nodes, and pain that radiates to the ear.

Laryngitis (acute)

This disorder produces sore throat, but its cardinal sign is mild to severe hoarseness, perhaps with temporary loss of voice. Other findings are malaise, low-grade fever, dysphagia, dry cough, and tender, enlarged cervical lymph nodes.

Monkeypox

Early symptoms of this rare viral disease include sore throat, fever, lymphadenopathy, chills, myalgia, and rash. The virus exhibits some similarities to smallpox, but its symptoms tend to be milder. Monkeypox is spread primarily through contact with lesions or body fluids of infected animals. Although it occurs primarily in central and western Africa, the virus has also been reported in the United States since 2003. There’s no specific treatment for monkeypox, which typically lasts 2 to 4 weeks.

Mononucleosis (infectious)

Sore throat is one of the three classic findings in this infection. The other two classic signs are cervical lymphadenopathy and fluctuating temperature with an evening peak of 101° to 102° F (38.3° to 38.9° C). Splenomegaly and hepatomegaly may also develop.

Necrotizing ulcerative gingivitis (acute)

Also known as trench mouth, this disorder usually begins abruptly with sore throat and tender gums that ulcerate and bleed. A gray exudate may cover the gums and pharyngeal tonsils. Related signs and symptoms include a foul taste in the mouth, halitosis, cervical lymphadenopathy, headache, malaise, and fever.

Peritonsillar abscess

Pharyngeal burns

First- or second-degree burns of the posterior pharynx may cause throat pain and dysphagia.

Pharyngitis

Whether bacterial, fungal, or viral, pharyngitis may cause sore throat and localized erythema and edema. Bacterial pharyngitis begins abruptly with a unilateral sore throat. Associated signs and symptoms include dysphagia, fever, malaise, headache, abdominal pain, myalgia, and arthralgia. Inspection reveals an exudate on the tonsil or tonsillar fossa, uvular edema, soft palate erythema, and tender cervical lymph nodes.

Also known as thrush, fungal pharyngitis causes diffuse sore throat—commonly described as a burning sensation—accompanied by pharyngeal erythema and edema. White plaques mark the pharynx, tonsil, tonsillar pillars, base of the tongue, and oral mucosa; scraping these plaques uncovers a hemorrhagic base.

Viral pharyngitis produces a diffuse sore throat, malaise, fever, and mild erythema and edema of the posterior oropharyngeal wall. Tonsil enlargement and anterior cervical lymphadenopathy may be present.

Pharyngomaxillary space abscess

A complication of untreated pharyngeal or tonsillar infection or tooth extraction, pharyngomaxillary space abscess causes mild throat pain. Inspection reveals a bulge in the medial wall of the pharynx accompanied by swelling of the neck and at the jaw angle on the affected side. Other signs and symptoms include fever, dysphagia, trismus and, possibly, signs of respiratory distress or toxemia.

Sinusitis (acute)

This disorder may cause sore throat with a purulent nasal discharge and postnasal drip, resulting in halitosis. Other effects include headache, malaise, cough, fever, and facial pain and swelling associated with nasal congestion.

Tongue cancer

The patient with tongue cancer experiences localized throat pain that may occur around a raised white lesion or ulcer. The pain may radiate to the ear and be accompanied by dysphagia.

Tonsillar cancer

Sore throat is the presenting symptom in tonsillar cancer. Unfortunately, the cancer is usually quite advanced before this symptom appears. The pain may radiate to the ear and is accompanied by a superficial ulcer on the tonsil or one that extends to the base of the tongue.

Tonsillitis

Mild to severe sore throat is usually the first symptom of acute tonsillitis. The pain may radiate to the ears and be accompanied by dysphagia and headache. Related findings include malaise, fever with chills, halitosis, myalgia, arthralgia, and tender cervical lymph nodes. Examination reveals edematous, reddened tonsils with a purulent exudate.

Chronic tonsillitis causes a mild sore throat, malaise, and tender cervical lymph nodes. The tonsils appear smooth, pink and, possibly, enlarged, with purulent debris in the crypts. Halitosis and a foul taste in the mouth are other common findings.

Unilateral or bilateral throat pain occurs just above the hyoid bone in lingual tonsillitis. The lingual tonsils appear red and swollen and are covered with exudate. Other findings include a muffled voice, dysphagia, and tender cervical lymph nodes on the affected side.

Uvulitis

This inflammation may cause throat pain or a sensation of something in the throat. The uvula is usually swollen and red but, in allergic uvulitis, it’s pale.

Other causes

Treatments

Endotracheal intubation and local surgery, such as tonsillectomy and adenoidectomy, commonly cause sore throat.

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Sore Throat: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Rhinovirus

❑ Group A streptococci

❑ Ebstein-Barr virus

❑ Adenovirus

❑ Influenza

❑ Candida/thrush

❑ Herpes simplex virus

❑ Peritonsillar abscess

❑ Mycoplasma pneumoniae

❑ Coxsackievirus

❑ Primary HIV

❑ Neisseria gonorrhea

❑ Epiglottitis

❑ Corynebacterium diphtheriae

❑ Leukemia

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dysphagia/Heartburn: Differential Overview
(Field Guide to Bedside Diagnosis)

Dysphagia

❑ Infectious esophagitis

❑ Reflux stricture

❑ Zenker diverticulum

❑ Transfer dysphagia

❑ Diffuse esophageal spasm

❑ Foreign body

❑ Esophageal cancer

❑ Achalasia

❑ External compression

❑ Scleroderma

❑ Myasthenia gravis

❑ Radiation injury

❑ Globus hystericus

❑ Esophageal web

❑ Botulism

Heartburn

❑ Reflux esophagitis

❑ Drugs

❑ Gastritis

❑ Pregnancy

❑ Aerophagia

❑ Infectious esophagitis

❑ Scleroderma

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Dysphagia: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Achalasia

Most common in patients ages 20 to 40, achalasia produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it’s preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.

Airway obstruction

Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.

Amyotrophic lateral sclerosis (ALS)

Besides dysphagia, ALS causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes, and emotional lability.

Botulism

Bulbar paralysis

Phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation. Dysphagia for both solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.

Dysphagia lusoria

Esophageal cancer

Phases 2 and 3 dysphagia is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, cough with hemoptysis, hoarseness, and sore throat. He may also develop nausea and vomiting, fever, hiccups, hematemesis, melena, and halitosis.

Esophageal compression (external)

Usually caused by a dilated carotid or aortic aneurysm, external esophageal compression — a rare condition — causes phase 3 dysphagia as the primary symptom. Other features depend on the cause of the compression.

Esophageal diverticulum

Esophageal leiomyoma

A relatively rare benign tumor, esophageal leiomyoma may cause phase 3 dysphagia along with retrosternal pain or discomfort. In addition, the patient experiences weight loss and a feeling of fullness.

Esophageal obstruction by foreign body

Sudden onset of phase 2 or 3 dysphagia, gagging, coughing, and esophageal pain characterize esophageal obstruction by foreign body — a potentially life-threatening condition. Dyspnea may occur if the obstruction compresses the trachea.

Esophageal spasm

The most striking symptoms of esophageal spasm are phase 2 dysphagia for solids and liquids and dull or squeezing substernal chest pain. The pain may last up to an hour and may radiate to the neck, arm, back, or jaw; however, it may be relieved by drinking a glass of water. Bradycardia may also occur.

Esophageal stricture

Usually caused by a chemical ingestion or scar tissue, esophageal stricture causes phase 3 dysphagia. Drooling, tachypnea, and gagging may also be evident.

Esophagitis

Candidal esophagitis causes phase 2 dysphagia, sore throat and, possibly, retrosternal pain on swallowing. With reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid.

Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.

Gastric carcinoma

Infiltration of the cardia or esophagus by gastric carcinoma causes phase 3 dysphagia along with nausea, vomiting, and pain that may radiate to the neck, back, or retrosternum. In addition, perforation causes massive bleeding with coffee-ground vomitus or melena.

Hypocalcemia

Although tetany is its primary sign, severe hypocalcemia may cause neuromuscular irritability, producing phase 1 dysphagia associated with numbness and tingling in the nose, ears, fingertips, and toes and around the mouth. Carpopedal spasms, muscle twitching, and laryngeal spasms may also occur.

Laryngeal cancer (extrinsic)

Phase 2 dysphagia and dyspnea develop late in extrinsic laryngeal cancer. Accompanying features include muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, chronic cough, and cachexia. Palpation reveals enlarged cervical nodes.

Laryngeal nerve damage

Commonly the result of radical neck surgery, superior laryngeal nerve damage may produce painless phase 2 dysphagia.

Lead poisoning

Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and fever. The patient may be depressed and display severe mental impairment and seizures.

Lower esophageal ring

Narrowing of the lower esophagus can cause an attack of phase 3 dysphagia that may recur several weeks or months later. During the attack, the patient complains of a foreign body in the lower esophagus, a sensation that may be relieved by drinking water or vomiting. Esophageal rupture produces severe lower chest pain followed by a feeling of something giving way.

Mediastinitis

Myasthenia gravis

Fatigue and progressive muscle weakness characterize myasthenia gravis and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.

Oral cavity tumor

Painful phase 1 dysphagia develops along with hoarseness and ulcerating lesions.

Parkinson’s disease

Pharyngitis (chronic)

Chronic pharyngitis causes painful phase 2 dysphagia for solids and liquids. Rarely serious, it’s accompanied by a dry, sore throat; a cough; and thick mucus in the throat.

Plummer-Vinson syndrome

Plummer-Vinson syndrome causes phase 3 dysphagia for solids in some females with severe iron deficiency anemia. Related features include upper esophageal pain; atrophy of the oral or pharyngeal mucous membranes; tooth loss; smooth, red, sore tongue; dry mouth; chills; inflamed lips; spoon-shaped nails; pallor; and splenomegaly.

Progressive systemic sclerosis

Typically, dysphagia is preceded by Raynaud’s phenomenon in patients with progressive systemic sclerosis. The dysphagia may be mild at first and described as a feeling of food sticking behind the breastbone. The patient also complains of heartburn after meals that’s aggravated by lying down. As the disease progresses, dysphagia worsens until only liquids can be swallowed. It may be accompanied by other GI effects, including weight loss, abdominal distention, diarrhea, and malodorous, floating stools. Other characteristic late features include joint pain and stiffness and thickening of the skin that progresses to taut, shiny skin. The patient usually has masklike facies.

Rabies

Severe phase 2 dysphagia for liquids results from painful pharyngeal muscle spasms occurring late in rabies — a rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling, and in 50% of patients it’s responsible for hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.

Syphilis

Rarely, tertiary-stage syphilis causes ulceration and stricture of the upper esophagus, resulting in phase 3 dysphagia. The dysphagia may be accompanied by regurgitation after meals and heartburn that’s aggravated by lying down or bending over.

Systemic lupus erythematosus (SLE)

SLE may cause progressive phase 2 dysphagia. However, its primary signs and symptoms include nondeforming arthritis, a characteristic butterfly rash, and photosensitivity.

Tetanus

Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics include marked muscle hypertonicity, hyperactive deep tendon reflexes, tachycardia, diaphoresis, drooling, and low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.

Other causes

Medical procedures

Recent tracheostomy or repeated or prolonged intubation may cause temporary dysphagia.

Radiation therapy

When directed against oral cancer, this therapy may cause scant salivation and temporary dysphagia.

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Dysphagia: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Achalasia

Most common in patients ages 20 to 40, achalasia produces phase 3 dysphagia for solids and liquids. The dysphagia develops gradually and may be precipitated or exacerbated by stress. Occasionally, it’s preceded by esophageal colic. Regurgitation of undigested food, especially at night, may cause wheezing, coughing, or choking as well as halitosis. Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.

Airway obstruction

Life-threatening upper airway obstruction is marked by signs of respiratory distress, such as crowing and stridor. Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in onset. When inflammation causes the obstruction, dysphagia may be painful and develop slowly.

Amyotrophic lateral sclerosis

In addition to dysphagia, amyotrophic lateral sclerosis (ALS), which is also known as Lou Gehrig disease, causes muscle weakness and atrophy, fasciculations, dysarthria, dyspnea, shallow respirations, tachypnea, slurred speech, hyperactive deep tendon reflexes, and emotional lability.

Botulism

Botulism causes phase 1 dysphagia and dysuria, usually within 36 hours of toxin ingestion. Other early findings include blurred or double vision, dry mouth, sore throat, nausea, vomiting, and diarrhea. Symmetrical descending weakness or paralysis occurs gradually.

Bulbar paralysis

In bulbar paralysis, phase 1 dysphagia occurs along with drooling, difficulty chewing, dysarthria, and nasal regurgitation. Dysphagia for solids and liquids is painful and progressive. Accompanying features may include arm and leg spasticity, hyperreflexia, and emotional lability.

Esophageal cancer

Dysphagia (phases 2 and 3) is the earliest and most common symptom of esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid weight loss. As the cancer advances, dysphagia becomes painful and constant. In addition, the patient complains of steady chest pain, cough with hemoptysis, hoarseness, and sore throat. He may also develop nausea and vomiting, fever, hiccups, hematemesis, melena, and halitosis.

Esophageal diverticulum

Esophageal diverticulum causes phase 3 dysphagia when the enlarged diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, chronic cough, hoarseness, chest pain, and halitosis.

Esophageal obstruction by foreign body

Esophageal obstruction by foreign body is characterized by sudden onset of dysphagia (phase 2 or 3) as well as gagging, coughing, and esophageal pain. Dyspnea may occur if the obstruction compresses the trachea.

Esophageal spasm

The most striking symptoms of esophageal spasm are phase 2 dysphagia for solids and liquids and dull or squeezing substernal chest pain. The pain may last up to 1 hour; radiate to the neck, arm, back, or jaw; and be relieved by drinking a glass of water. Bradycardia may also occur.

Esophageal stricture

Usually caused by a chemical ingestion or scar tissue, esophageal stricture causes phase 3 dysphagia. Drooling, tachypnea, and gagging also may be evident. In chemical ingestion, dysphagia may be accompanied by burns, ulcers, or erythema of the lips and mouth.

Esophagitis

Corrosive esophagitis, resulting from ingestion of alkalies or acids, causes severe phase 3 dysphagia. Dysphagia is accompanied by marked salivation, hematemesis, tachypnea, fever, and intense pain in the mouth and anterior chest that’s aggravated by swallowing. Signs of shock, such as hypotension and tachycardia, may also occur.

Candidal esophagitis causes phase 2 dysphagia, sore throat and, possibly, retrosternal pain on swallowing.

With reflux esophagitis, phase 3 dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by strenuous exercise, bending over, or lying down and is relieved by sitting up or taking an antacid. Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates, signs of bleeding, such as melena and hematemesis, may occur along with weakness and fatigue.

Hypocalcemia

Although tetany is its primary sign, severe hypocalcemia may cause neuromuscular irritability, producing phase 1 dysphagia associated with numbness and tingling in the nose, ears, fingertips, and toes and around the mouth. Carpopedal spasms, muscle twitching, and laryngeal spasms also may occur.

Laryngeal cancer (extrinsic)

Phase 2 dysphagia and dyspnea develop late in laryngeal cancer. Accompanying features include muffled voice, stridor, pain, halitosis, weight loss, ipsilateral otalgia, chronic cough, and cachexia. Palpation reveals enlarged cervical lymph nodes.

Lead poisoning

Painless, progressive dysphagia may result from lead poisoning. Related findings include a lead line on the gums, metallic taste, papilledema, ocular palsy, footdrop or wristdrop, and signs of hemolytic anemia, such as abdominal pain and fever. The patient may be depressed and display severe mental impairment and seizures.

Lower esophageal ring

Narrowing of the lower esophagus can cause an attack of phase 3 dysphagia that may recur several weeks or months later. During the attack, the patient complains of a foreign body in the lower esophagus, a sensation that may be relieved by drinking water or vomiting. Esophageal rupture produces severe lower chest pain followed by a feeling of something giving way.

Mediastinitis

Varying with the extent of esophageal perforation, mediastinitis can cause insidious or rapid onset of phase 3 dysphagia. The patient displays chills, fever, and severe retrosternal chest pain that may radiate to the epigastrium, back, or shoulder. The pain may be aggravated by breathing, coughing, or sneezing. Other findings include tachycardia, subcutaneous crepitation in the suprasternal notch, and falling blood pressure.

Myasthenia gravis

Fatigue and progressive muscle weakness characterize myasthenia gravis and account for painless phase 1 dysphagia and possibly choking. Typically, dysphagia follows ptosis and diplopia. Other features include masklike facies, nasal voice, frequent nasal regurgitation, and head bobbing. Shallow respirations and dyspnea may occur with respiratory muscle weakness. Signs and symptoms worsen during menses and with exposure to stress, cold, or infection.

Oral cavity tumor

With an oral cavity tumor, painful phase 1 dysphagia develops along with hoarseness and ulcerating lesions. The patient may report an abnormal taste in the mouth, abnormal bleeding from the mouth, or a feeling that dentures no longer fit properly.

Parkinson’s disease

Usually a late symptom of Parkinson’s disease, phase 1 dysphagia is painless but progressive and may cause choking. Other signs and symptoms include bradykinesia, tremors, muscle rigidity, dysarthria, masklike facies, muffled voice, increased salivation and lacrimation, constipation, stooped posture, propulsive gait, incontinence, and sexual dysfunction.

Pharyngitis (chronic)

Pharyngitis causes painful phase 2 dysphagia of solids and liquids. Rarely serious, it’s accompanied by a dry, sore throat; a cough; and thick mucus in the throat. The patient may report the sensation of a lump in his throat.

Progressive systemic sclerosis

Typically, dysphagia is preceded by Raynaud’s phenomenon in patients with progressive systemic sclerosis. The dysphagia may be mild at first and described as a feeling of food sticking behind the breastbone. The patient also complains of heartburn after meals that’s aggravated by lying down. As the disease progresses, dysphagia worsens until only liquids can be swallowed. It may be accompanied by other GI effects, including weight loss, abdominal distention, diarrhea, and malodorous, floating stools. Other characteristic late features include joint pain and stiffness and thickening of the skin that progresses to taut, shiny skin. The patient usually has masklike facies.

Rabies

Severe phase 2 dysphagia of liquids results from painful pharyngeal muscle spasms occurring late in this rare, life-threatening disorder. In fact, the patient may become dehydrated and possibly apneic. Dysphagia also causes drooling, and in 50% of patients it’s responsible for hydrophobia. Eventually, rabies causes progressive flaccid paralysis that leads to peripheral vascular collapse, coma, and death.

Tetanus

Phase 1 dysphagia usually develops about 1 week after the patient receives a puncture wound. Other characteristics of tetanus include marked muscle hypertonicity, hyperactive deep tendon reflexes, tachycardia, diaphoresis, drooling, and low-grade fever. Painful, involuntary muscle spasms account for lockjaw (trismus), risus sardonicus, opisthotonos, boardlike abdominal rigidity, and intermittent tonic seizures.

Other causes

Procedures

Recent tracheostomy or repeated or prolonged intubation may cause temporary dysphagia.

Radiation therapy

When directed against oral cancer, radiation therapy may cause scant salivation and temporary dysphagia.

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Mouth lesions: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Acquired immunodeficiency syndrome

Oral lesions may be an early indication of the immunosuppression that’s characteristic of acquired immunodeficiency syndrome (AIDS). Fungal infections can occur, with oral candidiasis being the most common. Bacterial or viral infections of oral mucosa, tongue, gingivae, and periodontal tissue may also occur.

The primary oral neoplasm associated with AIDS is Kaposi’s sarcoma. The tumor is usually found on the hard palate. Initially producing no symptoms, it may appear as a flat or raised lesion, ranging in color from red to blue to purple. As these tumors grow, they may ulcerate and become painful.

Candidiasis

Candidiasis, a common fungal infection, characteristically produces soft, elevated plaques on the buccal mucosa, tongue, and sometimes the palate, gingivae, and floor of the mouth; the plaques may be wiped away. The lesions of acute atrophic candidiasis are red and painful. The lesions of chronic hyperplastic candidiasis are white and firm. Localized areas of redness, pruritus, and foul odor may be present.

Discoid lupus erythematosus

Oral lesions are common in discoid lupus erythematosus. They typically appear on the tongue, buccal mucosa, and palate as erythematous areas with white spots and radiating white striae. Associated findings include skin lesions on the face, possibly extending to the neck, ears, and scalp; if the scalp is involved, alopecia may result. Hair follicles are enlarged and filled with scale.

Erythema multiforme

Erythema multiforme, an acute inflammatory skin disease, produces sudden onset of vesicles and bullae on the lips and buccal mucosa. Also, erythematous macules and papules form symmetrically on the hands, arms, feet, legs, face, and neck and, possibly, in the eyes and on the genitalia. Lymphadenopathy may also occur. With visceral involvement, other findings include fever, malaise, cough, throat and chest pain, vomiting, diarrhea, myalgia, arthralgia, fingernail loss, blindness, hematuria, and signs of renal failure.

Gingivitis (acute necrotizing ulcerative)

Gingivitis, a recurring periodontal condition, causes a sudden onset of gingival ulcers covered with a grayish white pseudomembrane. Other findings include tender or painful gingivae, intermittent gingival bleeding, halitosis, enlarged lymph nodes in the neck, and fever.

Gonorrhea

With gonorrhea, painful lip ulcerations may occur, along with rough, reddened, bleeding gingivae (possibly necrotic and covered by a yellowish pseudomembrane), and a swollen, ulcerated tongue. Related effects vary. Most men develop dysuria, purulent urethral discharge, and a reddened, edematous urinary meatus. Most women remain asymptomatic, but others develop inflammation and a greenish yellow cervical discharge.

Herpes simplex 1

With primary herpes simplex infection, a brief period of prodromal tingling and itching, which is accompanied by fever and pharyngitis, is followed by eruption of small and irritating vesicles on any part of the oral mucosa, especially the tongue, gums, and cheeks. Vesicles form on an erythematous base and then rupture, leaving a painful ulcer, followed by a yellowish crust. Other findings include submaxillary lymphadenopathy, increased salivation, halitosis, anorexia, and keratoconjunctivitis.

Herpes zoster

Herpes zoster is a common viral infection that may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small, red nodules usually erupt unilaterally around the thorax or vertically on the arms and legs and rapidly become vesicles filled with clear fluid or pus; vesicles dry and form scabs about 10 days after eruption. Fever and general malaise accompany pruritus, paresthesia or hyperesthesia, and tenderness along the course of the involved sensory nerve.

Leukoplakia, erythroplakia

Leukoplakia is a white lesion that can’t be removed simply by rubbing the mucosal surface — unlike candidiasis. It may occur in response to chronic irritation from dentures or tobacco or pipe smoking, or it may represent dysplasia or early squamous cell carcinoma.

Erythroplakia is red and edematous and has a velvety surface. About 90% of erythroplakia cases are either dysplasia or cancer.

Lichen planus

With lichen planus, oral lesions develop on the buccal mucosa or, less commonly, on the tongue as painless, white or gray, velvety, threadlike papules. These precede the eruption of violet papules with white lines or spots, usually on the genitalia, lower back, ankles, and anterior lower legs; pruritus; nails with longitudinal ridges; and alopecia.

Squamous cell carcinoma

A squamous cell carcinoma is typically a painless ulcer with an elevated, indurated border. It may erupt in areas of leukoplakia and is most common on the lower lip, but it may also occur on the edge of the tongue or the floor of the mouth. High risk factors include chronic smoking and alcohol intake.

Stomatitis (aphthous)

Aphthous stomatitis is a common disease characterized by painful ulcerations of the oral mucosa, usually on the dorsum of the tongue, gingivae, and hard palate.

With recurrent aphthous stomatitis minor, the ulcer begins as one or more erosions covered by a gray membrane and surrounded by a red halo. It’s commonly found on the buccal and lip mucosa and junction, tongue, soft palate, pharynx, gingivae, and all places not bound to the periosteum.

With recurrent aphthous stomatitis major, large, painful ulcers commonly occur on the lips, cheek, tongue, and soft palate; they may last up to 6 weeks and leave a scar.

Syphilis

Primarysyphilis typically produces a solitary painless, red ulcer (chancre) on the lip, tongue, palate, tonsil, or gingivae. The ulcer appears as a crater with undulated, raised edges and a shiny center; lip chancres may develop a crust. Similar lesions may appear on the fingers, breasts, or genitals, and regional lymph nodes may become enlarged and tender.

During the secondary stage, multiple painless ulcers covered by a grayish white plaque may erupt on the tongue, gingivae, or buccal mucosa. A macular, papular, pustular, or nodular rash appears, usually on the arms, trunk, palms, soles, face, and scalp; genital lesions usually subside. Other findings include generalized lymphadenopathy, headache, malaise, anorexia, weight loss, nausea, vomiting, sore throat, low fever, metrorrhagia, and postcoital bleeding.

At the tertiarystage, lesions (usually gummas — chronic, painless, superficial nodules or deep granulomatous lesions) develop on the skin and mucous membranes, especially the tongue and palate.

Systemic lupus erythematosus

Oral lesions are common with systemic lupus erythematosus (SLE) and appear as erythematous areas associated with edema, petechiae, and superficial ulcers with a red halo and a tendency to bleed. Primary effects include nondeforming arthritis, butterfly rash across the nose and cheeks, and photosensitivity.

Other causes

Drugs

Various chemotherapeutic agents can directly produce stomatitis. Also, allergic reactions to penicillin, sulfonamides, gold, quinine, streptomycin, phenytoin, aspirin, and barbiturates commonly cause lesions to develop and erupt. Inhaled steroids used for pulmonary disorders can also cause oral lesions.

Treatments

Radiation therapy may cause oral lesions.

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Throat pain: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Agranulocytosis