Acute and Chronic Sore Throat Bay Area Sore Throat Treatment with Jerome Hester, MD

Most of us have experienced a sore throat at some point in our lives. Commonly this occurs with an upper respiratory tract infection or a cold, is relatively mild, and resolves in a reasonable amount of time either by just allowing it to run its course or occasionally with antibiotics.  

However, there are times when the situation is more significant- either because of the severity of the discomfort or because the symptoms persist for a prolonged period of time. In times like these, we recommend you speak with a physician or otolaryngologist.

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In these cases, a thorough history and examination are necessary to confirm the correct diagnosis and therefore be able to outline the correct treatment. As will be discussed below, the incorrect diagnosis can not only lead to prescribing the wrong medications but can result in a potentially dangerous delay of treatment.  

It is perhaps most convenient to divide symptoms into acute-present for 3 weeks or less- or chronic- those cases lasting greater than 3 weeks.  

Acute Sore Throat

An acute sore throat is most likely to have an infectious cause. The typical viral sore throat will be mild to moderate and resolve in under 7-10 days. Commonly there are other symptoms such as congestion, cough, and possibly a low-grade fever. An acute infectious sore throat can also be caused by bacteria. Determining whether a sore throat present for a few days is viral or bacterial can be difficult. If a patient has not had their tonsils removed, there may be a slightly higher chance of a bacterial cause. Also, the physical examination can reveal white areas (known as exudate) on the tonsils, which would suggest a bacteria. This differentiation between viral or bacterial causes is important for the physician to know whether antibiotics are appropriate.  

Certain other symptoms are important in the history. An acute sore throat that is only on one side raises the possibility of a peritonsillar abscess. This is a severe infection of the area around the tonsil, and if not recognized and treated can become a serious or even fatal infection. Increasing difficulty swallowing, a change in one’s voice, or difficulty breathing all demand urgent evaluation as they suggest an infection that has gone beyond the normal confines of the throat. For example, epiglottitis is an infection of the epiglottis- a structure that normally helps prevent solids or fluids from entering the breathing tube. Such an infection can lead to increased swelling that itself can obstruct breathing. Rapid identification and treatment are necessary to stop this potentially life-threatening situation.  

There are also noninfectious causes for an acute sore throat. Perhaps the most common would be reflux esophagitis. Although this more commonly produces a chronic, low-grade irritation, even a single large reflux event can leave the back of one’s throat sore for a few days.  

The reflux can occur during sleep, leaving the patient unaware until they experience a sore throat. Other non-infectious causes can be allergies or the ingestion of a foreign body, although allergies themselves do not actually commonly result in a sore throat.  

Chronic Sore Throat

The incidence of infection-causing a chronic sore throat is low. Occasionally chronic tonsillitis can lead to this. In this condition, even repeated or prolonged antibiotic treatment may not be successful. This is due to the fact that the bacteria can form biofilms, which can be thought of as protective coatings that encase the bacteria, protecting them from both the body’s natural defenses, but also from antibiotic therapy.  

However, in chronic situations, other causes should be considered. Perhaps the most common cause for a long-standing sore throat is reflux esophagitis. Specifically, a type of reflux known as laryngopharyngeal reflux can be an insidious etiology. Rather than being a result of simply too much acid in the stomach, it is caused by the valve at the top of the stomach allowing acid to regurgitate back up into the throat. This can especially be true during the first few hours of laying flat at night. By the time one awakens, the actual reflux has stopped, but the irritation and inflammation caused by the stomach acid is left behind. The patient may also experience slight hoarseness and even a feeling of something stuck in their throat. This known as a “globus” sensation and is due to the swelling in the region.  

Chronic postnasal drip can also lead to a low grade chronic sore throat, although this is probably over-diagnosed as a cause. Typically, the patient will be able to identify the feeling of this discharge and can experience a need to clear their throat. The postnasal drip can certainly be from allergies, but just as frequently can be caused by non-allergic rhinitis or chronic sinusitis.  

Finally, as part of a thorough evaluation, the physician must rule out the possibility of a more serious cause, such as a tumor. Cancers in this part of the body occur at a much higher rate in those individuals who smoke and drink alcohol, but must be suspected in patients with a chronic sore throat, especially when accompanied by hoarseness, true difficulty swallowing, weight loss, or ear pain (otalgia).  

Treatment of a Sore  Throat

It can not be stressed enough that before treatment can begin, a thorough history and examination must be performed. After listening to your description of the symptoms, the examination starts by carefully looking at your ears, nose, and throat. Each one of these areas can contribute vital information as to the cause of the symptoms. Depending on the history and findings on this examination, further study may be indicated. Commonly a fiber optic laryngoscopy is an important part of the evaluation. After placing a small cotton ball with topical anesthetic in one nostril, a thin, flexible scope attached to a camera is passed through your nose and down into the throat. Placing the scope through the nose causes minimal or no discomfort and avoids the “gag reflex” that would prevent being able to examine the lower aspects of the area behind the tongue and all the way to the vocal cords. This procedure only takes minutes and allows a very accurate evaluation of this region.  

Depending on the exact symptoms, other tests may also be ordered to confirm the diagnosis. In some cases, this can include a CT scan or MRI scan of the neck, or special X-rays that are done as a patient swallows a dye that will look at the function of the swallowing tube.  

Dr. Hester will use the appropriate testing to determine the cause of your sore throat in order to direct the appropriate treatment and start your recovery.  

In cases of an acute sore throat, it is sometimes difficult to assess whether the cause is viral or bacterial. The duration of the symptoms along with the severity of the discomfort and the presence of other symptoms such as fever or hoarseness can help. In most viral infections, supportive care and medicines to help with the pain or fever are the only treatments.  

Antibiotics can be added if the information supports a bacterial cause. The commonly performed “strep test” can be used to specifically identify one type of bacteria- a form of streptococcus. If some individuals, streptococcus infections, especially of the tonsils, can become repetitive and can raise the possibility of performing tonsillectomy to end this cycle and return the patient to health. However, it should be noted that the strep test has its limitations. Other bacteria can cause infections of the tonsils and throat, therefore a negative strep test does not rule out the possible need for antibiotics or ultimately even tonsillectomy.  

Other acute infections such as epiglottitis can present with a significant sore throat and difficulty breathing. It may be difficult for the patient to even swallow their own saliva. In children, this is a medical emergency that must be correctly diagnosed quickly and commonly requires the child to be hospitalized and steps are taken to protect their ability to breathe. In an older patient, treatment with antibiotics and steroids (to reduce swelling) are instituted immediately to resolve this potentially serious infection.  

A significant sore throat that is located only on one side suggests the possibility of a peritonsillar abscess. Symptoms may also include a “hot potato voice” and ear pain. The ear pain is due to inflammation of a nerve in the throat which then causes the brain to perceive this referred pain to the ear. If recognized early, antibiotics alone can provide successful treatment for a peritonsillar abscess. However, in many cases, drainage of the abscess is necessary. This can be done even in the office setting, by locally anesthetizing the area just above the tonsil and making a small incision to drain the infection.  

If the sore throat is chronic, the history and physical examination are again paramount in making the diagnosis.  

In cases of laryngopharyngeal reflux (LPR), treatment may start with lifestyle changes. Since one of the goals Is to limit the amount of material in the stomach before one lays down to go to sleep, keeping approximately 3 hours between the time of one’s last meal or beverage and bedtime will be helpful. Paying attention to what is consumed especially at night is also part of the treatment as fatty foods, alcohol, and caffeine can slow the emptying of the stomach and increase the chance of reflux. Elevating the head of one’s bed, even just slightly, will allow gravity to help prevent the passive regurgitation that can occur. Finally, the addition of certain medications such as proton pump inhibitors can be used. If these conservative treatments are not successful, Dr. Hester can work with your gastroenterologist, or refer you to an excellent one if you do not have one of your own, to further evaluate the situation and provide more advanced treatments.  

The treatment of postnasal drip due to chronic sinusitis and rhinitis are reviewed in their specific sections on this website. Newly developed office-based treatments such as RhinAer can be very useful for these conditions.  

Finally, if in fact a tumor is found as the cause of the sore throat, Dr. Hester will perform a comprehensive evaluation of the type and extent of the disease to determine the best course of action, including referral to experts in even the rarest of conditions.