Sore Throat

Tonsillitis

Peritonsillar Abscess (Quinsy)

Glandular Fever (Infectious mononucleosis)

Throat Pain

Bad Breath (Halitosis)

Tongue Tie

Lumps in the Throat

Difficulty Swallowing

Globus Pharyngeus

Hoarseness (Loss of Voice)

Vocal Cord Nodules

Sore throat

Sore throats are often viral or bacterial in origin. Most commonly they are viral and settle on their own account. However persistent sore throat sometimes needs a course of antibiotic in order to speed up recovery. A common antibiotic to use would be Penicillin (or Erythromycin if you are allergic to Penicillins). Mouth washes such as Difflam can be useful to help treat the discomfort/pain. Salt water mouth washes can also be helpful. Short term use of mouth washes such as Chlorhexidene can be helpful. However long term use of mouth washes such as these can sometimes cause sore throat.

Tonsillitis

This is inflammation of the tonsils. Again commonly this is viral in origin, but if prolonged can be due to bacterial infection. Acute episodes are again best treated with antibiotics such as Penicillin, along with a mouth wash. If you are having multiple episodes of tonsillitis (greater than 5 episodes per year) or are having significant time off work or school, then tonsillectomy is advised. This is a safe (although sore) operation. Your immune system is not compromised at all by this surgery.

Peritonsillar Abscess (Quinsy)

When tonsillitis gets very bad, the infection can spread from the tonsil to the surrounding tissue (peritonsillar cellulitis). If an abscess forms in this area then this is called a peritonsillar abscess. The old fashioned name for this is Quinsy (quinsy: Etymology: 14c: from Latin quinancia, from Greek kyon dog + anchein to strangle) although why it is called this is truly beyond me! A quinsy (peritonsillar abscess) is not just enlarged infected tonsils.

Cardinal features of a peritonsillar abscess are:

1. unilateral bulging out (convex swelling) of the soft palate (sometimes this makes the tonsil itself hard to see
2. unilateral sore throat
3. unilateral earache
4. Trismus (pain on jaw opening): due to spasm of the muscles responsible for chewing.
5. ‘Hot potato’ speech. (this is where the word quinsy may have come from, if you think patients with this condition sound like a dog being strangled!

If you do not have these features then whilst you may well have bad tonsillitis, it is unlikely you have a peritonsillar abscess. Treatment is admission to hospital, aspiration, incision and drainage of the abscess. Intravenous antibiotics are given (Penicillin). Metronidazole is not given as first line treatment. Pain relief and iv fluids is important also.

Glandular fever (Infectious Mononucleosis)

This is an infection caused by the Epstein Barr Virus (EBV). It commonly presents with fever, sore throat, enlarged neck glands (lymphadenopathy) and lethargy (tiredness). Because it is a viral infection antibiotics are not effective. However up to 30% of glandular fever infections may have a super added bacterial infection and for this reason antibiotics are often given. Amoxill should be avoided as it can provoke a severe rash in patients with glandular fever.  It is important to remember that the ‘monospot’ test, used to diagnose glandular fever, may be negative in up to 50% of children and 10% of adults with glandular fever. The ‘gold standard’ test is a blood test to look for the antibodies to the EBV virus. If you have glandular fever it is important to avoid contact sports, as there is a very low, but real risk of rupture of the spleen with severe body blows. The illness resolves by itself, but it can take several weeks to return to normal fitness. Pain relief tablets, fluids and rest is the best treatment.

Throat Pain

Throat pain can have many causes. Ordinary sore throat occurring with a ‘cold’ is very common. Viral and bacterial tonsillitis and peritonsillar abscesses can also cause sore throat. Trauma to the throat caused by burns (hot food) or injury (eg fish bones) are other causes.  Sometimes viral ‘cold sore’ like infections can cause sore throat. It can also be caused by acid reflux, smoking, chronic cough and voice strain. If your throat pain is single sided, or associated with difficulty swallowing, or earache, it is very important to get your throat checked, as sometimes you have serious underlying problems causing this throat pain. This is particularly so if the sore throat has not occurred following or with a ‘cold’ and if the throat pain lasts longer that 4 weeks. 

The best treatment therefore is a tongue scraper with good attention to oral hygiene.  There are people however who are concerned they have bad breath when they do not have bad breath at all: Psychosomatic Halitosis (Halitophobia, Imaginary Halitosis, Olfactory Reference Syndrome). Psychotherapy is the approach in the management of this problem in these people.  

Tongue tie occurs when the lingual frenulum (attaching from the under surface of the mid-tongue to the alveolar ridge) is shortened, allowing only the side  edges to lift to the mid-mouth when crying. It also does not allow tongue to rise from the floor of the mouth. It can cause problems with breast feeding, in which case division of the thin membrane will release the tongue. Adults may also request division of a tongue tie. This can be performed under local anaesthesia. In very very young babies the tongue tie can be divided/released in clinic, with a very quick procedure in clinic. In older children this needs to be performed under general anaesthesia.

Lumps in the throat

These can cause localised pain (ie pain on one side of the throat only). Sometimes this pain can be referred to the ear. If there is a problem with swallowing, this is worse with solid food rather than liquids.  Sometimes the tonsils may appear asymmetrical. This is not uncommon and can be normal. Obviously if this change is new, or if the lump is changing in size, or is large, then it needs to be investigated.

Occasionally you can see little cysts on the tonsil. They are common and if they are small they often do not cause symptoms and do not require removal. Larger cysts that cause a sensation of a "lump in the throat" may require removal.

Little warts (Squamous papillomas) are commonly seen hanging from a small stalk on the soft palate or the tonsils. They are little warts.

Larger throat lumps, or lumps associated with pain, or pain on swallowing, or earache, or rapidly growing lumps, need to be seen urgently to rule out or manage any throat cancers.

Difficulty swallowing

This is called dysphagia. Painful swallowing is called odynophagia. Problems can be caused by globus pharyngeus. Difficulty with swallowing can also be caused by food or fish bone stuck in the throat. Increasing difficulty swallowing solid food must be investigated, as growths in the swallowing passage can cause these symptoms. Of course difficulty with swallowing can be caused by sore throats and throat infection.

Globus Pharyngeus

This is an awareness of a lump or tightness in the throat (when in fact no lump or blockage is present). The feeling is similar to the lump in the throat felt when you are sad or emotional. It is due to tightening, failure of relaxation on swallowing and uncoordinated contraction of the muscles of the throat. It can be brought on by acid reflux, stress and anxiety and can last for several months. Patients may also repeatedly ‘dry swallow’ to check how the throat feels, resulting in further tight feelings of the throat. Patients are often concerned that “something is going on” in the throat and are concerned about throat cancer.

Characteristically however patients have no difficulty in swallowing food (either solids or liquids), do not have pain or earache when swallowing food, do not have weight loss nor do they have any change in voice. The feeling is most noticeable when only swallowing saliva between meals.

Investigations and Treatment

• Full ENT history and examination by a Head and Neck surgeon, including flexible nasendoscopy.
• A barium swallow is often arranged to exclude any problems that are futher down the throat than what is seen with flexible nasendoscopy.
• A 6 week course of antacid treatment (proton pump inhibitors), on the basis that acid reflux can exacerbate the spasm of the muscles of the throat. It is important to realise that it can take up to three weeks on treatment before you will notice an improvement in your symptoms.
• Trying to consciously ignore this feeling in the throat and trying to  reduce your stress and anxiety levels can be helpful.
• Often the feeling goes away.
• It is very unlikely any other investigations will alter the diagnosis, although sometimes a pharyngoscopy and oesophagoscopy is performed to further inspect the lower throat area.
  
  

Hoarseness (Loss of Voice)

This commonly occurs with voice overuse like your voice after shouting/singing at a rock concert. It can also occur with teachers, professional singers/actors and other professional voice users. This is called muscular tension dysphonia. It is exacerbated by smoking and acid reflux. Management involves taking of a patient history and examination of the voice box with the flexible nasendoscope. Assuming the vocal cords are normal in movement and appearance, then speech language therapy is indicated. Voice rest is important, and may require time off work. Smoking should be avoided. Caffeine (tea, coffee etc) should be avoided. Drinking plenty of water is important. Commonly a six week course of antacids (proton pump inhibitors) such as lansoprazole is given.